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

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Approximately 10% of patients with blunt traumatic extracranial cerebrovascular injury have a complete occlusion of the vertebral artery (VA). Ischemic stroke due to embolization of thrombus from an occluded VA following cervical spine surgery has been observed. The risk of ischemic stroke with cervical spine surgery in the presence of an occluded VA, however, has never been determined.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A retrospective chart review of 52 patients with a VA occlusion following a blunt trauma was performed. Clinical and radiographic characteristics were collected and analyzed.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Ten patients (19.2%) suffered an ischemic stroke attributable to a traumatic VA occlusion. Univariate analysis demonstrated that patients with ischemic stroke were significantly older (p = 0.042) and had a lower rate of cervical spine surgery (p &lt; 0.005). Multivariate analysis found cervical spine surgery to be protective against ischemic stroke (OR 0.049 [95% CI 0.014–0.167], p = 0.014); increasing age and bilateral VA injury (bilateral occlusion or unilateral occlusion with contralateral dissection) were risk factors for ischemic stroke (OR 1.05 [95% CI1.02–1.07], p = 0.065 and OR 13.2 [95% CI 2.98–58.9], p = 0.084, respectively).</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Traumatic VA occlusion is associated with a risk of ischemic stroke and mortality. Corrective cervical spine surgery potentially decreases the risk of ischemic stroke by stabilizing the spine and thereby reducing motion across the occluded segment of the VA and preventing embolization of thrombus. While a high stoke risk may be inherent to the disease, novel therapies should be investigated.</jats:p></jats:sec>

Blunt Traumatic Extracranial Cerebrovascular Injury and Ischemic Stroke

“…It has become clear in recent years that CTA cannot reliably distinguish type 1, type 2, and type 3 lesions. CTA can, however, reliably identify type 4 lesions (complete arterial occlusion), which are also the least common and carry the highest risk of stroke [ 22 , 33 , 38 , 39 ]. All pieces of evidence indicate that the risk of stroke with traumatic vessel occlusion (type 4) exceeds the risk of stroke with type 1–3 injuries: unilateral occlusion of the vertebral artery (9–20%) [ 10 , 22 , 33 , 39 ], unilateral occlusion of the ICA (>50%) [ 10 , 22 , 33 , 38 ], and bilateral occlusion of the vertebral arteries (50%) [ 22 , 39 ].…”

“…CTA can, however, reliably identify type 4 lesions (complete arterial occlusion), which are also the least common and carry the highest risk of stroke [ 22 , 33 , 38 , 39 ]. All pieces of evidence indicate that the risk of stroke with traumatic vessel occlusion (type 4) exceeds the risk of stroke with type 1–3 injuries: unilateral occlusion of the vertebral artery (9–20%) [ 10 , 22 , 33 , 39 ], unilateral occlusion of the ICA (>50%) [ 10 , 22 , 33 , 38 ], and bilateral occlusion of the vertebral arteries (50%) [ 22 , 39 ]. Therefore, in the present era in which CTA is the most commonly used imaging technique for TCVI [ 20 ], the risk of stroke with initially asymptomatic TCVI can be divided into 3 relative categories: low (arterial injury without occlusion), medium (single vertebral artery occlusion), and high (ICA occlusion and bilateral vertebral artery occlusion).…”

“…5 ). However, an analysis of 52 cases of traumatic vertebral artery occlusions actually found that spine surgery was associated with a lower risk of stroke [ 39 ]. Coil embolization of the ICA [ 22 ] and of the vertebral artery proximal to the TCVI lesion prior to cervical spine surgery [ 32 ] to reduce the theoretical risk of embolization has been reported.…”

Vertebral artery occlusion associated with blunt traumatic cervical spine injury

“…The frequency of complications of stroke in grade IV VAI ranges from 7.1% to 33.3%. 16 Although there is no standard treatment strategy for VAI, several reports suggest that antithrombotic or anticoagulant therapy is effective, 1 , 7 , 8 and it is also recommended for patients without a bleeding tendency in the Advanced Trauma Life Support manual. 15 However, there is not sufficient evidence to make standard recommendation as to whether antithrombotic therapy or anticoagulant therapy is superior for preventing stroke caused by VAI.…”

Temporary vertebral artery occlusion after C3 fracture dislocation injury and spontaneous resolution following reduction and instrumented fusion: case report and literature review

“…In one recent study of patients with blunt traumatic VAI, corrective cervical spinal surgery was found to be significantly associated with fewer vertebrobasilar strokes 29. The authors posit that surgical stabilization of the cervical spine decompresses the artery and prevents further thrombus propagation, and further, serves to protect the contralateral vertebral artery from delayed injury.…”