Blunt Vertebral Artery Injuries in the Era of Computed Tomographic Angiographic Screening: Incidence and Outcomes From 8292 Patients

Abstract

Blunt injuries to the vertebral artery (BVI) are rare. Recent improvements in the multidetector computer tomography (MDCT) technology and increased use of screening protocols have led to a greater number of these injuries identified. Well-defined treatment recommendations are still lacking, and it is unclear whether screening and treatment lead to improved outcome. All patients who met predefined screening criteria were screened for BVI with a MDCT angiogram (MDCT-A). All patients identified with BVI were treated based on injury grade and associated injuries. Hospital course, morbidity, mortality, and follow-up were recorded and analyzed. A total of 8,292 patients were admitted for blunt injuries during this time period. Forty-four patients were found to have 47 BVI (three bilateral). Pharmacologic treatment with anticoagulants (AC)-heparin and warfarin-or an antiplatelet agent-clopidogrel and aspirin-was initiated in 37 patients (84%). Angiographic coiling was performed in eight patients (18%), and two (5%) had endovascular stents placed. Four patients developed signs of cerebral ischemia (9%), of whom three died and one recovered completely. Overall mortality rate was 16% (7/44). BVI-related mortality occurred in three patients (7%). Of these, two patients had bilateral vertebral artery occlusion or transaction, and death was considered nonpreventable. One death occurred in a patient with a unilateral vertebral dissection developed a posterior circulation infarct. Anticoagulation was felt to be contraindicated in this patient initially due to intracranial hemorrhage. This was deemed the only potentially preventable BVI-related mortality. Annual BVI-related mortality rate in the 4 years before initiating the screening protocol was 0.75 cases per year. During this study period, it was 0.57 cases per year. Under an aggressive screening and individualized treatment protocol for BVI, we had very few potentially preventable BVI-related strokes and deaths. We are unable to conclude; however, based on historical controls that either screening or treatment improved overall outcome.