VAI associated cervical spine injuries

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The incidence of vertebral artery injury (VAI) associated with nonpenetrating cervical spine fractures was reported between 17% and 46%.[11,12,18,20]

Anatomy


The vertebral artery arise from the subclavian arteries and passes through the transverse foramen of C6 to C1. Its close proximity location to osseous structures put the artery at risk after spine fracture. It can be divided into 4 segments:

V1-extraosseous segment

V2-foraminal segment

V3-extraspinal segment

V4-intradural segment

Classification[2]


Grade I: arteriographic appearance of irregularity of the vessel wall or a dissection/intramural hematoma with less than 25% luminal stenosis

Grade II: intraluminal thrombus or raised intimal flap is visualized, or dissection/intramural hematoma with 25% or more luminal narrowing

Grade III: pseudoaneurysms

Grade IV: vessel occlusions

Grade V: transections

Significant risk factors


(1) fractures involving a transverse foramen[9,13,14,19]

(2) subluxations[1,5-10]

(3) fractures involving the upper cervical spine (C1-C3).[9,17]

Symptom


Outcome can range from asymptomatic to posterior circulation stroke and even death, commonly the frequency of ischemia is very low.

Diagnosis


Conventional catheter cerebral angiography is the gold standard but carries complications due to the invasive.[3,6 16] Magnetic resonance angiography(MRA) and computed tomography angiography (CTA) are proved to be effective detection method recently. [3,4,15]

Management


Management is still controversial especially in the asymptomatic patients. A risk-to-benefit ratio must be considered. Treatment options include observation, antiplatelet agents, anticoagulation, and endovascular treatments.

Reference


1. Atar E, Griton I, Bachar GN, et al. Embolization of transected vertebral arteries in unstable trauma patients. Emerg Radiol 2005;11:291-4.

2. Biffl WL, Moore EE, Elliott JP, et al. The devastating potential of blunt vertebral arterial injuries. Annals of Surgery 2000;231:672-81.

3. Biffl WL, Ray CE, Jr., Moore EE, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Annals of Surgery 2002;235:699-706; discussion -7.

4. Biffl WL, Ray CE, Jr., Moore EE, et al. Noninvasive diagnosis of blunt cerebrovascular injuries: a preliminary report. J Trauma 2002;53:850-6.

5. Chimowitz MI, Lynn MJ, Howlett-Smith H, et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 2005;352:1305-16.

6. Citron SJ, Wallace RC, Lewis CA, et al. Quality improvement guidelines for adult diagnostic neuroangiography. Cooperative study between ASITN, ASNR, and SIR. J Vasc Interv Radiol 2003;14:S257-62.

7. Cohen JE, Rajz G, Itshayek E, et al. Endovascular management of exsanguinating vertebral artery transection. Surg Neurol 2005;64:331-4; discussion 4.

8. Cothren CC, Moore EE. Blunt cerebrovascular injuries. Clinics 2005;60:489-96.

9. Cothren CC, Moore EE, Biffl WL, et al. Cervical Spine Fracture Patterns Predictive of Blunt Vertebral Artery Injury. Journal of Trauma - Injury, Infection and Critical Care 2003;55:811-3.

10. Cothren CC, Moore EE, Ray CE, Jr., et al. Screening for blunt cerebrovascular injuries is cost-effective. Am J Surg 2005;190:845-9.

11. Cothren CC, Moore EE, Ray CE, Jr., et al. Cervical spine fracture patterns mandating screening to rule out blunt cerebrovascular injury. Surgery 2007;141:76-82.

12. Eastman AL, Chason DP, Perez CL, et al. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma 2006;60:925-9; discussion 9.

13. Kerwin AJ, Bynoe RP, Murray J, et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 2001;51:308-14.

14. Kral T, Schaller C, Urbach H, et al. Vertebral artery injury after cervical spine trauma: a prospective study. Zentralbl Neurochir 2002;63:153-8.

15. Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: Analysis of diagnostic modalities and outcomes. Annals of Surgery 2002;236:386-95.

16. Rommel O, Niedeggen A, Tegenthoff M, et al. Carotid and vertebral artery injury following severe head or cervical spine trauma. Cerebrovasc Dis 1999;9:202-9.

17. Sawlani V, Behari S, Salunke P, et al. "Stretched loop sign" of the vertebral artery: a predictor of vertebrobasilar insufficiency in atlantoaxial dislocation. Surg Neurol 2006;66:298-304; discussion

18. Taneichi H, Suda K, Kajino T, et al. Traumatically induced vertebral artery occlusion associated with cervical spine injuries: prospective study using magnetic resonance angiography. Spine 2005;30:1955-62.

19. Veras LM, Pedraza-Gutierrez S, Castellanos J, et al. Vertebral artery occlusion after acute cervical spine trauma. Spine 2000;25:1171-7.

20. Willis BK, Greiner F, Orrison WW, et al. The incidence of vertebral artery injury after midcervical spine fracture or subluxation. Neurosurgery 1994;34:435-42.

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