Analysis of Traumatic Vertebral Artery Injury Outcomes: Medical Management Is Safe Despite Severity of Injury

Abstract

Management of traumatic vertebral artery injury (VAI) remains under debate. Traditional teaching reserves surgical management for high-grade injury to prevent stroke. We sought to evaluate the factors that influence posterior fossa stroke outcomes of traumatic VAI. A search of the prospectively maintained PROspective Observational Vascular Injury Treatment (PROOVIT) trauma registry of patients older than 18 years with a diagnosis of VAI was performed at a level I trauma center from 2013 to 2019. Patients’ demographics, type of injury, timing of presentation, Biffl classification of cerebrovascular injury grade, medical management, procedural interventions, and stroke outcomes were analyzed. VAIs from 59 surviving trauma patients were identified. There were more blunt VAIs than penetrating VAIs (91.5% vs 8.5%, respectively). Nine patients presented with clinical posterior circulation strokes visible on imaging. The average Biffl classification grade was similar between the stroke and nonstroke groups (2.0 vs 1.5; P = .39). The average Injury Severity Score (ISS) between the stroke and nonstroke groups was also similar (9.0 vs 14.0; P = .35). All nine patients in the stroke group declared their neurologic change on average within 21.2 hours of presentation. In the nonstroke group, 47 patients (94.0%) underwent medical management and 3 patients (6.0%) underwent medical management and non-vertebral artery endovascular intervention (ie, carotid angiography and embolization). Once patients safely passed through the initial 21.2-hour window from VAI, none had vertebral artery aneurysmal degeneration or experienced a new neurologic deficit secondary to the index vertebral injury (followed up to 9.7 months on average). The severity of VAI or ISS does not predict future stroke outcome. Medical management of VAI appears safe regardless of ISS in the trauma population. Neurologic changes on arrival were most predictive of eventual stroke outcomes. Conservative medical management was sufficient to protect from vertebral artery aneurysmal degeneration or secondary neurologic deficit regardless of index vertebral injury.