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Blunt traumatic vertebral artery injury

Vertebral artery injury can be spontaneous or traumatic.

Blunt traumatic vertebral artery injury is a type of blunt cerebrovascular injury.

Traumatic vertebral artery injury (TVAI) presents a clinical challenge since it is hard to detect, has a diverse presentation and there are no widely accepted guidelines on diagnosis and management. Most evidence available on TVAI is class 3, based on case series from individual institutions. Spontaneous vertebral artery dissection is well described and typically managed by anticoagulation 1).

Blunt TVAI tends to occur where vessels are exposed to shearing forces, principally at junctions between fixed and mobile segments. The vertebral artery V2 segment is the most commonly affected in adult TVAI 2) 3).

In infants and children, the V3 and upper V2 segment are more commonly affected 4) 5).


There is still debate regarding the optimal screening criteria, diagnostic imaging modality and treatment methods. In 2012 the American College of Surgeons proposed criteria for investigating patients with suspected TVAI and subsequent treatment methods, caveated with the statement that evidence is limited and still evolving 6).

Following the introduction of a Diagnostic Imaging Pathway in Department of Health of Western Australia reports a significant increase in the diagnosis of Blunt Carotid Artery and Vertebral Artery Injury (BCVI) in 2007. The previously low incidence of BCVI compared with other centres' reports indicated possible previous under-screening and diagnosis of this injury 7).

MRA has a moderate diagnostic accuracy in the diagnosis of blunt vertebral artery injuries. Further studies on high-field magnetic resonance scanners are recommended 8).

Grading of Blunt traumatic cerebrovascular injury (TCVI) with CTA using the Biffl Scale is reliable 9).

Case reports

Weber et al. report the life- and limb-saving management in a 57-year-old hemodynamically unstable trauma patient. The individual developed hemorrhagic shock, and other major complications, including cortical blindness, related to a posterior circulation stroke. Full recovery was achieved by immediate endovascular prosthesis for subclavian artery (SA) rupture and stenting of a traumatic vertebral artery occlusion. Endovascular and alternative treatment options are discussed and the management of subsequent sequelae associated with aggressive anticoagulation in trauma patients is reviewed, including intracranial, abdominal and other sites of secondary hemorrhage 10).

A 72-year-old woman was found at the bottom of the stairs by her family. She was immediately transferred to our hospital. She was, in spite of being in a state of shock, alert and oriented with normal respiration. A curvilinear laceration at the right suboccipital region was noticed. On neurological examination, she was diagnosed as having tetraparesis. Roentgenograms confirmed fractures of a vertebral body at C 6 and a transverse process at C 7. Head CT scan demonstrated a small low density area in the left putaminal region with cortical atrophy. As subcutaneous swelling of the left lower cervical portion was gradually taking place, vertebral arteriography was performed. Through left vertebral arteriography, extravasation of the contrast medium was demonstrated at the C6-7 level. Eighteen hours after admission, direct operation on the torn vessel was carried out through a supraclavicular linear skin incision. On operation, there was active bleeding from the lacerated vertebral artery at its point of entrance into the foramen transversarium. The bleeding point of the vertebral artery was trapped at the C 6 level. Postoperatively, the symptoms of the tetraparesis were improving. Two days after the operation, she had some food by herself. Suddenly, she had cardiac arrest five days after admission, and soon expired. It was 13 days since she had been admitted. Traumatic tear of a vertebral artery is very rare. Fourteen cases of intra-and extracranial vertebral artery rupture in closed head injury have been reported in previous writings 11).

Kim YK, Schulman S. Cervical artery dissection: pathology, epidemiology and management. Thromb Res. 2009 Apr;123(6):810-21. doi: 10.1016/j.thromres.2009.01.013. Epub 2009 Mar 9. Review. PubMed PMID: 19269682.
Taneichi H, Suda K, Kajino T, Kaneda K. Traumatically induced vertebral artery occlusion associated with cervical spine injuries: prospective study using magnetic resonance angiography. Spine (Phila Pa 1976). 2005 Sep 1;30(17):1955-62. PubMed PMID: 16135985.
Herrera DA, Vargas SA, Dublin AB. Endovascular treatment of traumatic injuries of the vertebral artery. AJNR Am J Neuroradiol. 2008 Sep;29(8):1585-9. doi: 10.3174/ajnr.A1123. Epub 2008 May 22. PubMed PMID: 18499790.
Wang H, Orbach DB. Traumatic dissecting aneurysm at the vertebrobasilar junction in a 3-month-old infant: evaluation and treatment strategies. Case report. J Neurosurg Pediatr. 2008 May;1(5):415-9. doi: 10.3171/PED/2008/1/5/415. PubMed PMID: 18447682.
Hasan I, Wapnick S, Tenner MS, Couldwell W. Vertebral artery dissection in children: a comprehensive review. Pediatr Neurosurg. 2002 Oct;37(4):168-77. Review. PubMed PMID: 12372909.
Shafafy R, Suresh S, Afolayan JO, Vaccaro AR, Panchmatia JR. Blunt vertebral vascular injury in trauma patients: ATLS(®) recommendations and review of current evidence. J Spine Surg. 2017 Jun;3(2):217-225. doi: 10.21037/jss.2017.05.10. Review. PubMed PMID: 28744503; PubMed Central PMCID: PMC5506306.
Sinnathamby M, Rao SV, Weber DG. Increased detection of blunt carotid and vertebral artery injury after implementation of diagnostic imaging pathway in level 1 trauma centre in Western Australia. Injury. 2017 Jun 13. pii: S0020-1383(17)30370-4. doi: 10.1016/j.injury.2017.06.006. [Epub ahead of print] PubMed PMID: 28647095.
Karagiorgas GP, Brotis AG, Giannis T, Rountas CD, Vassiou KG, Fountas KN, Kapsalaki EZ. The diagnostic accuracy of magnetic resonance angiography for blunt vertebral artery injury detection in trauma patients: A systematic review and meta-analysis. Clin Neurol Neurosurg. 2017 Jul 21;160:152-163. doi: 10.1016/j.clineuro.2017.07.005. [Epub ahead of print] Review. PubMed PMID: 28759887.
Foreman PM, Griessenauer CJ, Kicielinski KP, Schmalz PGR, Rocque BG, Fusco MR, Sullivan JC 3rd, Deveikis JP, Harrigan MR. Reliability assessment of the Biffl Scale for blunt traumatic cerebrovascular injury as detected on computer tomography angiography. J Neurosurg. 2017 Jul;127(1):32-35. doi: 10.3171/2016.7.JNS16849. Epub 2016 Oct 21. PubMed PMID: 27767400; PubMed Central PMCID: PMC5446307.
Weber CD, Kobbe P, Herren C, Mahnken AH, Hildebrand F, Pape HC. Endovascular Management of a Combined Subclavian and Vertebral Artery Injury in an Unstable Polytrauma Patient: Case Report and Literature Review. Bull Emerg Trauma. 2017 Jan;5(1):53-57. PubMed PMID: 28246625; PubMed Central PMCID: PMC5316138.
Okuyama T, Niwa J, Shimizu K, Hirai H, Kubota T. [Traumatic rupture of the vertebral artery associated with fracture of the cervical spine: a case report]. No Shinkei Geka. 1989 Oct;17(10):973-7. Japanese. PubMed PMID: 2812260.
blunt_traumatic_vertebral_artery_injury.txt · Last modified: 2018/08/04 11:38 by administrador