A review of the management of vertebral artery injury

Abstract

attitude of the early surgeons to vertebral artery injury could be summed up in the words of Sanson, who, in 1836 wrote: The vertebral artery cannot be ligated, on account of its great depth, nor compressed, because of the osseous canal which protects it; it can still less be cauterised. wounds of this vessel are beyond the resources of art. first comprehensive report of vertebral artery trauma was published by Matas in 1893.1 He collected 42 cases from the literature reporting an 80% mortality rate. He credited Maisonneuve and Fravot with the first successful ligation of the vertebral artery. They wrote: It was suspected that the haemorrhage came from the vertebralis. In the presence of so grave a contingenc)~ for the relief of which the surgical records suggested no remedy, we hesitated, and for a moment felt uncertain as to the proper plan of action. But the life of the patient was involved and we had to stop the haemorrhage at all hazards. This they did, successfully ligating the inferior thyroid artery and the vertebral artery as it entered the canal of the 6th cervical vertebra. anatomy and relationships of the vertebral arteries are unique. With the exception of the first part, from its origin to the foramen transversarium of the sixth cervical vertebra, the remainder of its course is relatively inaccessible to direct surgical exposure. second part is enclosed in the osseous tunnel of the upper six cervical vertebrae, lying immediately anterior to the anterior primary rami of cervical nerves C2-6, and surrounded by a thin-walled plexus of veins. propensity for penetrating injury to result in an arteriovenous fistula in this portion of the vertebral artery relates to the negative pressure in the vertebral venous plexus and the surrounding osteofascial tunnel which serves to contain haemorrhage and prevent effective external compression. third portion of the artery curves backward deep in the suboccipital triangle, related to the anterior primary ramus of C1 and the lateral portion of the atlas before piercing the dura and arachnoid to form the fourth part which then unites with the opposite vertebral arter)~ forming the basilar artery at the lower border of the pons. While direct surgical approaches to parts 2 and 3 of the vertebral artery have been described, 2 these are generally unfamiliar even to vascular surgeons with considerable trauma experience, and are thus often poorly managed resulting in unnecessary morbidity and mortality. Vertebral artery injur~ due predominantly to penetrating trauma and less commonly blunt injur~ has an incidence which is difficult to establish precisely. Asensio et al., in a review of 26 series and 4193 patients with arterial injuries, reported a 1% incidence of vertebral artery trauma, accounting for 9.5% of all cervical arterial injuries. 3 Meier et aI. reported that vertebral artery injuries accounted for 19.4% of cervical vascular injuries seen over a 3 year period, during which time routine four-vessel angiography was performed in all patients with severe neck trauma. This compared with an incidence of 3% over the preceding 16 years in the same unit when routine angiography was not performed. 4 presence of a vertebral artery injury is frequently missed clinically, particularly when applying a policy of selective neck exploration for penetrating trauma and when routine angiography is not performed. This may account for the well recognised observation that arteriovenous fistulae and false aneurysms may present months or even years after the initial injury. Reid et al. reported that 74% of vertebral