Asymptomatic Vertebral Artery Injury after Acute Cervical Spine Trauma

Abstract

Two recent cases of vertebral artery injury from cervical fracture-dislocation prompted us to review the literature of these wrongly thought uncommon lesions. Extracranial vertebral artery injury during cervical trauma needs to be suspected not only in the case of vertebrobasilar ischemia, but also in asymptomatic patients presenting serious flexion-distraction deformities. Fracture of a transverse foramen or facet joint dislocation should alert the clinician. Magnetic resonance evaluates blood flow and vessel injury, usually unilateral, localized to the traumatized unstable vertebral segment. A four-stage classification is useful to understand and treat vertebral artery injury, also a standardized therapeutic protocol is not documented. Anterior cervical fusion seems indicated to decompress the injured vessel, and to avoid further damage to both vertebral arteries. Unstable spine conditions may also promote clot mobilization at the traumatized vessel leading to vertebrobasilar embolization. The benefit of antithrombotic therapy in reducing neurological morbidity and improving outcome is not yet established and needs long-term follow-up.

Traumatically Induced Vertebral Artery Occlusion Associated with Cervical Spine Injuries: Prospective Study Using Magnetic Resonance Angiography

“…6,20,21 On the other hand, slow blood flow in the small vessels on MRA can be confused with occlusion as a result of insufficient resolution. 5,22 Although conventional angiography is a much more invasive modality, it is superior to MRA in the detection of nonoccluded intimal disruption, which occasionally causes distal embolization. However, because occlusion is the most common vertebral artery injury, the majority can be successfully detected by noninvasive MRA.…”

Cervical Arterial Injury After Blunt Trauma in Children

“…Although the effects of CVI can be variable, the adult literature demonstrates that many patients with unilateral CVI remain asymptomatic, 18 with only 12% to 20% of unilateral CVI patients initially presenting with symptoms attributable to vertebrobasilar ischemia. 15,16 Bilateral vertebral artery lesions are reported to correspond with a more severe clinical picture and higher rates of mortality.…”

Corrective spinal surgery may be protective against stroke in patients with blunt traumatic vertebral artery occlusion

“…Others hypothesize that operative fixation reduces the risk by stabilizing the spine and decompressing the vessel, thus diminishing the potential for clot propagation. 11,16 Data regarding this issue are limited. The present series of 52 patients is the largest study evaluating the relationship between ischemic stroke from traumatic VA occlusion and cervical spine surgery.…”

“…However, some authors believe that surgical fixation of the cervical spine decompresses the injured vessel and may avoid thrombus propagation, thereby reducing the risk of ischemic stroke. 11,16 A relative lack of data regarding risk of ischemic stroke in the setting of a traumatic VA occlusion with an operative spine injury has led to wide variability in practice ranging from treatment with antiplatelets to prophylactic endovascular occlusion of the occluded VA. A series of 52 patients with traumatic VA occlusions are presented with particular attention to ischemic stroke and cervical spine intervention.abbreviatioNS CTA = CT angiography; TCVI = traumatic cerebrovascular injury; VA = vertebral artery. Submitted November 18, 2014. accepted January 27, 2015. iNclude wheN citiNg Published online July 17, 2015; DOI: 10.3171/2015.1.SPINE141174.…”