Limited Clinical Relevance of Vertebral Artery Injury in Blunt Trauma

Lytle, Mark E.; West, James A.; Burkes, Jason N.; Beteck, Besem; Fisher, Tammy; Daoud, Yahya; Gable, Dennis; Shutze, William P.

doi:10.1016/j.avsg.2018.05.034

Cited by 12 publications

(8 citation statements)

References 30 publications

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“…On multivariate analysis, lack of AT therapy for Grade IV injuries conferred a 4.4Â increased risk of poor outcomes. In contrast to the conclusions of other studies, 21,22 our analysis would indicate that all Grade IV injuries pose a clinically significant risk of stroke and death and should warrant treatment.…”

Section: Occlusion (Grade Iv)contrasting

confidence: 99%

Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry

Russo

Davidson

Alam

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations. METHODS:Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis.Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants. RESULTS:Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2Â increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies. CONCLUSION:Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option. (

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Section: Occlusion (Grade Iv)contrasting

confidence: 99%

Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry

Russo

Davidson

Alam

et al. 2021

J Trauma Acute Care Surg

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“…Most BCVIs were on the level of the upper cervical spine with a strong association to cervical spine fractures, as previously documented [ 1 , 4 , 5 , 7 , 10 – 12 , 29 – 31 , 33 ]. The cranially distributed location corresponded to BCVIs of carotid arteries in general blunt trauma populations [ 12 , 28 ].…”

Section: Discussionsupporting

confidence: 65%

“…Although grade IV BCVI of the carotid arteries represents a small sample, the outcome tends to be high morbidity and mortality, as demonstrated by the present and previous data [ 2 , 6 , 25 ]. In the general trauma population, the stroke rate as a result of VAI is 0% to 24%, although Lytle et al reported a rate of only 3% [ 6 , 29 – 33 ]. Combining VAI patients with regular anticoagulation and those without, resulted in a stroke rate of 15%, in line with previous results [ 32 ].…”

Section: Discussionmentioning

confidence: 99%

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Ankylosis of the cervical spine increases the incidence of blunt cerebrovascular injury (BCVI) in CTA screening after blunt trauma

et al. 2022

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Purpose To examine the incidence, location, and grade of blunt cerebrovascular injury (BCVI), as well as associated strokes in patients with ankylosis of the cervical spine, imaged with CT angiography (CTA) after blunt trauma. The related etiologies of ankylosis had an additional focus. Materials and methods Altogether of 5867 CTAs of the craniocervical arteries imaged after blunt trauma between October 2011 and March 2020 were manually reviewed for a threshold value of ankylosis of at least three consecutive cervical vertebrae. BCVI was the primary outcome and associated stroke as the secondary outcome. Variables were craniofacial and cervical spine fractures, etiology and levels of ankylosis, traumatic brain injury, spinal hematoma, spinal cord injury, and spinal cord impingement, for which correlations with BCVI were examined. Results Of the 153 patients with ankylosis and blunt trauma of the cervical spine, 29 had a total of 36 BCVIs, of whom two had anterior and 4 posterior circulation strokes. Most of the BCVIs (n = 32) were in the vertebral arteries. Injuries were graded according to the Biffl scale: 17 grade II, 4 grade III, 14 grade IV, and 1 grade V. A ground-level fall was the most common trauma mechanism. Cervical spine fracture was the only statistically significant predictor for BCVI (OR 7.44). Degenerative spondylosis was the most prevalent etiology for ankylosis. Conclusion Ankylosis of the cervical spine increases the incidence of BCVI up to sevenfold compared to general blunt trauma populations, affecting especially the vertebral arteries.

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“…Segment IV crosses the dura at the foramen magnum and runs superiorly to meet the proximal basilar artery. Approximately 15% of patients have a unilateral hypoplastic VA that may not be able to provide sufficient collateral flow if the contralateral artery is injured [8]. Although only a small percentage of acute traumatic VAIs present with neurologic deficits, delayed presentations from missed diagnoses have severe consequences if ischemic or embolic phenomenon occurs [9][10][11].…”

Section: Introductionmentioning

confidence: 99%

Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options

Merrill

Clifton

Valero-Moreno

et al. 2020

Cureus

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Limited Clinical Relevance of Vertebral Artery Injury in Blunt Trauma

Cited by 12 publications

References 30 publications

Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry

Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry

Ankylosis of the cervical spine increases the incidence of blunt cerebrovascular injury (BCVI) in CTA screening after blunt trauma

Vertebral Artery Injury with Coinciding Unstable Cervical Spine Trauma: Mechanisms, Evidence-based Management, and Treatment Options

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