Blunt Vertebral Artery Injury Research Articles

431 The Role of Stroke Prophylaxis in Traumatic Vertebral Artery Injury: A Literature-Based Cohort Study

INTRODUCTION: Vertebral artery injury (VAI) can precipitate posterior circulation strokes acutely following blunt trauma. VAI severity is conventionally classified by the Denver grading system, but at present, there remain no guidelines that translate Denver injury grade to antiplatelet or anticoagulant recommendations. METHODS: Four databases (Ovid MEDLINE, Ovid Embase, Cochrane Central, and Scopus) were queried to identify all studies evaluating stroke risk following blunt VAI. Stroke rates following VAI were compared for patients managed with observation only or antiplatelets. Sub-analyses stratifying outcomes by injury severity (Denver grade) were performed. Effectiveness of antiplatelet use was summarized by the number needed to prevent (NNP) post-VAI stroke. RESULTS: Of 2,256 unique studies identified, 34 comprising 1,138 patients were incluced. Overall VAI-related stroke risk was 1.75% before admission and 3.40% after admission. Grades I and II had a cumulative stroke risk of 2.43% (95% CI: 0.98-4.94), which differed significantly (p < 0.01) from Grade IV-associated risk (10.10%; 95% CI: 4.95-17.79). Overall stroke risk in patients without prophylactic treatment was 10.00% (95% CI: 9.07-10.9), and 0.43% (95% CI: 0.01-1.06) in their counterparts who received antiplatelets (NNP = 10). Patients with grade I-II VAI receiving no treatment had 5.19% (95% CI: 1.43-12.77) stroke risk compared to 0.55% (95% CI: 0.01-3.02) treated with antiplatelet agents (NNP = 22). Among grade IV VAI, the stroke risk among patients that received no treatment was 21.21% (95% CI: 8.98-38.91), while none of the patients that received antiplatelet therapy developed stroke (NNP = 5). CONCLUSIONS: The majority of VAI-related stroke occurs after initial presentation, suggesting a potential for prevention of post-VAI stroke. Antiplatelet treatment was associated with significantly lower odds of post-VAI stroke among patients with Grade I, II, or IV injury, with the impact increasing within injury grade. The results suggest the positive impact of antiplatelet therapy with increasing VAI injury severity.

Operative V2 decompression for traumatic vertebrobasilar insufficiency: illustrative case.

Blunt vertebral artery injuries after cervical trauma due to the close anatomical relationship of the vertebral artery to the cervical spine may have fatal consequences because of posterior circulation ischemia and vertebrobasilar insufficiency. While the standard of care remains medical treatment by anticoagulation or antiplatelet therapy, surgical decompression of the vertebral artery is rarely indicated. The authors present a case of selective decompression of a traumatically constricted vertebral artery within the transverse foramen of C2 presenting with vertebrobasilar insufficiency due to bilateral aplasia of the posterior communicating arteries and contralateral hypoplasia of the vertebral artery. Because of their close relationship to the cervical spine, the vertebral arteries are at risk for blunt injury, which may present asymptomatically or with symptoms of posterior circulation ischemia or vertebrobasilar insufficiency either immediately or after a latency phase. The anatomical variability of (1) the vertebral arteries, (2) collateral brainstem perfusion, and (3) the individual injury pattern demands individualized treatment strategies. If endovascular treatment of hemodynamically relevant stenosis of the V2 segment of the vertebral artery poses too high a risk for vessel injury, decompression of the transverse foramen can be performed safely and without risk to the biomechanical stability of the cervical spine.

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes

A single-center, retrospective review between 2011 and 2018. A total of 156 patients were treated for isolated blunt vertebral artery injuries (16 bilateral) and underwent computed tomography angiography within 24 hours of presentation. Injury location was classified as: V1 = subclavian artery origin to the entrance into the C-6 transverse foramen; V2 = within the C2-C6 transverse foramen; V3 = from the C2 foramen to the foramen magnum dura; V4 = intradural. There were 79 grade I (≤25% luminal stenosis), 39 grade II (>25% luminal stenosis), 5 grade III (pseudoaneurysm), 49 grade IV (occlusion), and 0 grade V (extravasation or arteriovenous fistula) injuries. Three strokes were detected before treatment initiation. Most patients (135) were treated with aspirin alone, 2 with heparin, and 1 with Plavix, and 18 did not receive treatment (grade I injuries or required multiple surgeries for other problems). Only two patients were switched from aspirin to anticoagulation for injury progression. No strokes were detected during hospitalization for any other patient. The risk of stroke after blunt cervical vertebral artery injury is low. Aspirin is efficacious in grade I and IV injuries, but there are limited data regarding grade II and III injuries.

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes.

Blunt cerebrovascular injury (BCVI) is a term for injuries to the carotid and vertebral arteries (blunt vertebral artery injury [BVAI]) caused by blunt trauma. Computed tomographic angiography is currently the best screening test for BCVI. The subsequent management of any identified vessel injury, however, is not clearly defined. To describe one of the largest cohorts of isolated vertebral artery injuries and report the evolution of treated and untreated lesions and clinical outcomes of treatment regimens used to reduce the risk of injury-related stroke. The list included patients who presented to or were transferred to a level 1 trauma center and found to have an isolated BVAI. Patients were included if imaging was performed within 24 hours of presentation. Data collected included location and grade of injury, timing and type of initial therapy, follow-up imaging, evolution of the disease, and associated strokes. A total of 156 patients were included in the analysis. Most patients (135/156) were treated with aspirin alone, 3 with anticoagulation therapy, and 18 did not receive treatment. Three strokes were detected within 24 hours of admission and before treatment initiation. No strokes were detected during the length of the hospitalization for any other patient. Our data demonstrate that the risk of stroke after cervical vertebral artery injury is low, and aspirin as a prophylactic is efficacious in grade I and IV injuries. There are limited data regarding grade II and grade III injuries. The benefit of early interval imaging follow-up is unclear and warrants investigation.

Treatment of Traumatic Blunt Vertebral Artery Injuries: Teikyo University Experience

Treatment of Traumatic Blunt Vertebral Artery Injuries: Teikyo University Experience

Characteristics and Forensic Identification of Blunt Vertebral Artery Injury.

Blunt vertebral artery injury occurs frequently in forensic practice. However, injuries of the vertebral artery are easily ignored or overlooked because of its relatively deep location. Through literatures review, this paper finds that the manners of blunt vertebral artery injury are varied and one or more injury mechanisms may be involved simultaneously. Patients often undergo immediate or delayed cerebral apoplexy as well as compression and injury of surrounding structures, due to direct injury or secondary aneurysm or dissection, resulting in disability or death. Diseases such as, vertebral atherosclerosis and dysplasia can increase the disability and death risk and the difficulty of forensic identification. In forensic identification, the details of the case should be considered. For cases of suspected vertebral artery injury, in addition to routine examination of intracranial segment, attention should be paid to the examination of extracranial segment. If conditions permit, angiography can be used prior to or during the autopsy to improve the identification efficiency and accuracy of opinions.

Minimally displaced unilateral facet fracture of cervical spine can lead to spinal cord injury: a report of two cases

BackgroundAccording to most of the commonly used classification systems for subaxial spine injuries, unilateral and minimally displaced facet fractures without any sign of a spinal cord injury would be directed to non-operative management. However, the failure rate of non-operative treatment varies from 20 to 80%, and no consensus exists with regard to predictors of failure after non-operative management.Case presentationCase 1 is a patient with a unilateral facet fracture. The patient had only numbness in the right C6 dermatome but failed non-operative treatment, which resulted in severe spinal cord injury. Case 2 is a patient who had a similar injury pattern as case 1 but presented with immediate instability and underwent fusion surgery. Both patients had a minimally displaced unilateral facet fracture accompanied by disc injury and blunt vertebral artery injury, which are possible signs indicating significant instability.ConclusionsThis is the first report of an isolated unilateral facet fracture that resulted in catastrophic spinal cord injury. These two cases illustrate that an isolated minimally displaced unilateral facet fracture with disc injury and vertebral artery injury were associated with significant instability that can lead to spinal cord injury.

Vertebral artery injury in major trauma patients in Saudi Arabia: A retrospective cohort study

Blunt vertebral artery injury (VAI) is associated with severe cervicocephalic trauma and may have devastating consequences. This study aimed to determine the incidence and nature of VAI in polytrauma patients. The secondary objective was to assess the association of VAI with previously suggested risk factors. It was a retrospective observational study of all polytrauma patients admitted to the trauma unit between April 2018 and July 2019, who had CT neck angiography to diagnose blunt VAI according to modified Denver criteria. Out of 1084 admitted polytrauma patients, 1025 (94.6%) sustained blunt trauma. Of these, 120 (11.7%) underwent screening CT neck angiography. VAI was detected in 10 (8.3%; 95% CI 4.1–14.8) patients. There were three patients with Grade I injury, two with Grade II, and five with Grade IV injury. Among all trauma admissions, the incidence of diagnosed VAI was 0.9% (95% CI 0.5–1.8). Among patients suspected of VAI, there was no univariable association of VAI with C-Spine fracture: OR 4.2 (95% CI 0.51–34.4; p = 0.18). There were two (20%) deaths related to VAI. Traumatic VAI was uncommonly detected in this major trauma service in Saudi Arabia. High suspicion and liberal screening by CT angiography in cases where VAI is possible should be considered to avoid missed injuries.

Risk Factors and Outcomes Associated with Blunt Cerebrovascular Injury in Patients with Mild or Moderate Traumatic Brain Injury

Blunt cerebrovascular injury (BCVI) represents a spectrum of traumatic injuries to the carotid and vertebral arteries that is an often-overlooked source of morbidity and mortality. Its incidence, risk factors, and effect on outcomes in patients with mild or moderate traumatic brain injury (mTBI) have not been studied independently. The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with mTBI who suffered blunt injuries. BCVI was identified using abbreviated injury scores and included blunt carotid artery injury (BCAI) and blunt vertebral artery injury (BVAI). A binary logistic regression was used to identify patient-related and injury-related factors associated with BCVI. Binary logistic regressions were also performed to evaluate the effect of BCVI on stroke, in-hospital mortality, nonroutine discharge disposition, total length of stay (LOS), intensive care unit LOS, and number of days mechanically ventilated. Of 485,880 patients with mTBI, there were 4,382 (0.9%) with BCVI. Cervical spine fracture was the strongest factor associated with BCAI (odds ratio [OR], 1.97; 95% confidence interval [95% CI], 1.77-2.19), followed by mandible fracture and basilar skull fracture. Cervical spine fracture also had the strongest association with BVAI (OR, 18.28; 95% CI, 16.47-20.28), followed by spinal cord injury and neck contusion. Stroke was more common in patients with BCAI (OR, 5.50; 95% CI, 4.19-7.21) and BVAI (OR, 7.238; 95% CI, 5.929-8.836). BVAI increased the odds of mortality, but BCAI did not. Both were associated with nonroutine discharge and increased LOS, intensive care unit LOS, and number of days mechanically ventilated. The incidence of BCVI in patients with mTBI is low, and it usually does not require invasive treatment. However, it is associated with greater odds of stroke and negative outcomes. Knowledge of risk factors for BCVI may tailor further investigation to aid prompt diagnosis.

Current Outcomes of Blunt Vertebral Artery Injuries

There is no consensus on the treatment of blunt vertebral artery injuries, and studies are limited to small case series. We assessed the natural history and current management of these injuries. We performed a retrospective study of a prospectively collected registry at a level I trauma center over a 5-year period. Additional information was gathered from patient charts and imaging review from electronic medical records. We analyzed demographics, mechanism of injury, Glasgow Coma Score, mortality, length of stay, associated injuries, Denver grading scale, neurological findings, level and laterality of injury, delay in diagnosis, treatment, and follow-up imaging. There were 13,080 trauma admissions during this time period yielding 141 patients with blunt vertebral artery injuries from 2013 to 2018 (1.1% incidence). Mean injury severity score (ISS) was 22 with a 30-day mortality of 14 (9.9%). An ISS of greater than 15 is associated with polytrauma and increased mortality. There were 112 (79.4%) associated cervical fractures. C6 and C7 were both equally the most common locations. There was one symptomatic injury manifesting as a cerebellar ischemic infarct. The degree of arterial injury was classified by the Denver grading scale. There were 61 (43.3%) instances of Denver grade I injuries, followed by grade IV at 36 (25.5%), grade II at 34 (24.1%), grade III at 8 (5.7%), and grade V at 1 (0.7%). The level of injury was recorded as follows: V2=67 (47.5%), V3=56 (39.7%), V1=48 (34%), V4=14 (9.9%). Medical therapy included aspirin in 93 patients (66%), 31 patients (22%) received systemic anticoagulation with heparin drip, and 2 patients (1%) were administered therapeutic Lovenox. A total of 15 patients (11%) received no medical treatment. There was one intervention in our series. Our only grade V injury was coil embolized. A total of 118 patients (84%) had follow-up imaging. Seventy-eight patients (96%) with grade I and grade II injuries did not worsen, and complete radiographic resolution was found in 50 patients (62%). Grade IV injuries persisted in 22 patients (75.9%). Median time to resolution for grade I and grade II injuries was 7 and 8days, respectively. Most follow-up scans for grade I and II injuries occurred within 50days. Posterior circulation stroke due to blunt vertebral artery injury is rare. In our experience, the natural course of blunt vertebral artery injury was benign and neither delay in medical treatment nor choice of antithrombotic had a significant impact on outcomes. In our series, only 3 (3.7%) grade I and II injuries worsened and were without any clinical sequelae. We suggest that routine serial imaging in grade I and II blunt vertebral injuries is not warranted.

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

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.

Pharmacologic Therapy is Not Associated with Stroke Prevention in Patients with Isolated Blunt Vertebral Artery Injury

Vertebral artery injury (VAI) is often grouped with carotid artery injury into a broader classification of blunt cerebrovascular injury, despite fundamental differences in mechanism of injury and outcome. This study seeks to evaluate the efficacy of medical therapy in preventing strokes for isolated VAI. Patients with isolated blunt VAI (2011-2018) were identified from the trauma registry of a level I trauma center. A retrospective chart review was conducted excluding patients with concomitant carotid artery injury. Factors examined included demographics, injury characteristics, anatomic classification, and management strategy. Patients were stratified by whether they received pharmacological (antiplatelet or anticoagulation) therapy. The primary outcome was new posterior circulation stroke within 30days of injury as confirmed by imaging studies. A total of 206 patients with blunt VAI were included. Median Injury Severity Score was 17 and 33 (16.0%) patients presented with Glasgow Coma Scale <8. The most common mechanism of injury was motor vehicle collision (58.7%). The injuries were bilateral in 38 (18.5%) patients and 73 (35.4%) suffered multisegmental injuries. The anatomic severity of injuries was Grade 1=38.8%, Grade 2=25.7%, Grade 3=4.9%, Grade 4=30.6%, and Grade 5=0.5%. There was no correlation between anatomic grade and stroke (P=0.11) or initiation of pharmacologic therapy (P=0.30). In total, 172 (84%) patients received pharmacological therapy with no differences in baseline characteristics between treated and untreated patients. Overall, the 30-day stroke rate was 1.9%. There was no difference in stroke rate between patients who received medical therapy versus those who did not (5.9% vs. 1.2%, P=0.13). In subgroup analysis by injury severity, medical therapy did not improve stroke rates. Among patients treated with aspirin, there was no difference in stroke rate between doses of 81 vs. 325mg (1.1% vs. 0%, P=1). Isolated VAI is associated with a very low risk of stroke and treatment withmedical therapies including antiplatelet or anticoagulation does not improve risk of stroke.

Pharmacologic Therapy Is Not Associated with Stroke Prevention In Patients With Isolated Blunt Vertebral Artery Injury

Vertebral artery injury (VAI) is often grouped with carotid artery injury into a broader classification of blunt cerebrovascular injury, despite fundamental differences in mechanism of injury and outcome. This study seeks to evaluate the efficacy of medical therapy in preventing strokes for isolated VAI.

Current Outcomes of Blunt Vertebral Artery Injuries

Current Outcomes of Blunt Vertebral Artery Injuries

The distance of cervical vertebral dislocation could be a risk factor for blunt vertebral artery injury after traumatic cervical spine injury.

Blunt vertebral artery injury (BVAI) is a well-known potentially fatal complication of cervical spine injury. The condition is reported to be associated with vertebral fractures and cervical hyperextension. However, appropriate patient screening methods remain to be elucidated. This study aimed to identify the risk factors associated with BVAI in patients with cervical spine injury. We conducted a retrospective, observational, single-centered study, including 137 patients with cervical spine injury transferred to our center from April 2007 to December 2016. Evaluation for BVAI was available in 62 patients based on magnetic resonance angiography or multi-detector computed tomography angiography. BVAI was classified using the Biffl grade. Among the 62 patients evaluated, 13 (21%) were diagnosed with BVAI. All injuries were classified as Biffl grade 2 (50%) or 4 (50%). Univariate analysis of patients with and without BVAI showed that cervical dislocation (p = 0.041) and low average hemoglobin level (p = 0.032) were associated with BVAI. On multivariate logistic regression analysis, cervical dislocation (odds ratio 1.189; 95% confidence interval 1.011-1.399, p = 0.036) remained a significant predictor of BVAI. Based on receiver operating characteristic (ROC) analysis, a dislocation > 6.7mm was selected as the optimal cutoff value for prediction of BVAI (sensitivity and specificity, 87.5% and 71.4%, respectively). BVAI frequently occurred in combination with cervical spine dislocation, and the distance of the cervical dislocation was identified as a useful predictor of BVAI.

Follow-up imaging of traumatic vertebral artery dissections is unnecessary in asymptomatic patients

ObjectiveRoutine computed tomography (CT) imaging in trauma patients has led to increased recognition of blunt vertebral artery injuries (BVIs). We sought to determine the prevalence of strokes, injury progression, and need for intervention in patients with BVI. MethodsConsecutive patients presenting with BVI during 2 years were identified from the institutional trauma registry. Inpatient records, imaging studies, and follow-up data were reviewed in detail from the electronic medical record. ResultsThere were 76 BVIs identified in 70 patients (64% male; mean age, 47 ± 19 years); bilateral injuries occurred in 6 patients. Five patients who arrived at the hospital intubated had evidence of posterior circulation infarcts on admission CT, whereas one additional patient had evidence of a posterior circulation infarct attributed to complications of late spinal surgery. Four of the five patients with infarcts on admission CT survived to discharge, but only one had residual stroke symptoms. Minor (grade 1 or grade 2) injuries occurred in 25 (36%) patients; severe (grade 3 or grade 4) injuries occurred in 45 (64%). Twelve patients died of associated injuries (eight with severe BVI, four with minor BVI). Stepwise logistic regression analysis selected age (odds ratio, 1.14; confidence interval, 1.04-1.25; P < .001) and intubation on arrival (odds ratio, 450.4; confidence interval, 17.41-1645.51; P < .001) as independent predictors of hospital stroke and death. Of the 58 surviving to discharge, 31 (53%) returned for follow-up CT scans. Six of 10 (60%) patients with minor injuries had resolution or improvement compared with 3 of 21 (14%) with severe injuries (P = .027). One patient (10%) with a minor BVI and two patients (10%) with severe BVI had radiologic progression, but none were clinically significant. During a mean follow-up of 15 ± 13 months, none of the study patients had treatment (surgical or interventional) for BVI, and there were no delayed strokes. Only five patients in this series had vertebral pseudoaneurysms, which limits conclusions about this type of BVI. ConclusionsThese data suggest that BVI-related strokes are present at the time of admission and do not have clinical sequelae. No late strokes occurred in this series, and no surgical or interventional treatments were required even in the presence of radiographic worsening. The relatively few cases of vertebral pseudoaneurysms in this series limit any conclusions about these specific lesions. However, these data indicate that follow-up imaging of nonaneurysmal BVI is not necessary in adults who are found to be asymptomatic on follow-up.

Vertebral Artery Injuries in Patients with Blunt Cervical Spine Injury

Background: Blunt vertebral artery injury (VAI) is uncommon, but it can cause neurologic deficits. Early diagnosis and treatment before the onset of neurological sequelae are important. The Advanced Trauma Life Support® (ATLS) program has published screening criteria for VAI. The major treatments of VAI are anticoagulation therapy and endovascular therapy, but the management of VAI remains controversial. Methods: We retrospectively investigated the patients with blunt cervical spine injury treated at the trauma and critical care center in Osaka City University Hospital and analyzed the efficiency of the ATLS screening criteria and the treatment of VAI. Results: One hundred fourteen patients were diagnosed as having cervical spine injury. Contrast-enhanced whole-body computed tomography was performed in 82 patients, and 13 patients were diagnosed as having VAI. Among the 114 patients, 73 patients met the ATLS screening criteria for investigating VAI, and 12 of the 13 (92.3%) VAI patients met the ATLS screening criteria. Among these 13 patients, antithrombotic therapy was performed in 9 patients but was not performed in the other 4 patients due to other injuries. Seven patients required urgent surgery. Prophylactic coiling to completely occlude the injured vertebral artery was performed before the operation or reduction in 4 patients. Two of the 13 VAI patients showed subsequent cerebellar infarction; both of them was not received antithrombotic therapy and had bilateral VAIs. Conclusion: ATLS screening criteria have high sensitivity for the diagnosis of VAI. Bilateral VAI and no antithrombotic therapy are risk factors for subsequent cerebellar infarction. Coiling of the obstructed vertebral artery might be effective in preventing infarction, but a randomized controlled study would be required to evaluate the efficacy of this endovascular treatment.

Blunt vertebral artery injury in occipital condyle fractures

OBJECTIVEA shifting emphasis on efficient utilization of hospital resources has been seen in recent years. However, reduced screening for blunt vertebral artery injury (BVAI) may result in missed diagnoses if risk factors are not fully understood. The authors examined the records of blunt trauma patients with fractures near the craniocervical junction who underwent CTA at a single institution to better understand the risk of BVAI imposed by occipital condyle fractures (OCFs).METHODSThe authors began with a query of their prospectively collected trauma registry to identify patients who had been screened for BVAI using ICD-9-CM diagnostic codes. Grade and segment were recorded in instances of BVAI. Locations of fractures were classified into 3 groups: 1) OCFs, 2) C1 (atlas) fractures, and 3) fractures of the C2-6 vertebrae. Univariate and multivariate analyses were performed to identify any fracture types associated with BVAI.RESULTSDuring a 6-year period, 719 patients underwent head and neck CTA following blunt trauma. Of these patients, 147 (20%) had OCF. BVAI occurred in 2 of 43 patients with type I OCF, 1 of 42 with type II OCF, and in 9 of 62 with type III OCF (p = 0.12). Type III OCF was an independent risk factor for BVAI in multivariate modeling (OR 2.29 [95% CI 1.04-5.04]), as were fractures of C1-6 (OR 5.51 [95% CI 2.57-11.83]). Injury to the V4 segment was associated with type III OCF (p < 0.01).CONCLUSIONSIn this study, the authors found an association between type III OCF and BVAI. While further study may be necessary to elucidate the mechanism of injury in these cases, this association suggests that thorough cerebrovascular evaluation is warranted in patients with type III OCF.

Limited Clinical Relevance of Vertebral Artery Injury in Blunt Trauma

Blunt cerebrovascular injury (BCVI), although rare, is more common than previously thought and carries a substantial stroke and mortality risk. The purpose of our study was to evaluate the differences between blunt carotid artery (CA) and vertebral artery (VA) injuries, assess the stroke and death rates related to these injuries, and identify the relationship of Injury Severity Score (ISS) with stroke and mortality in BCVI. Using a retrospective review of the trauma registry at a level I trauma center, we identified patients with BCVI. The study period began in January 2003 and ended in July 2014. Demographics, injuries reported, investigative studies performed, and outcomes data were obtained and analyzed. Radiographic images of both blunt CA and VA injuries were reviewed and graded by an independent radiologist, according to the current classification of blunt CA injuries. BCVI involving 114 vessels was identified in 103 patients. This population consisted of 65 males and 38 females with an average age of 45years (15-92, range). The average ISS was 22 (4-75, range). Cervical spine fracture occurred in 80% of VA injuries (64 total patients). Injuries involved the CA in 33, the VA in 59, and both in 11. The CA group had a higher incidence of traumatic brain injury (61% vs. 46%), ISS (27 vs. 18), and stroke (24% vs. 3%), compared to the VA group. Mortality in the CA group was 30% compared to 3% in the VA group. Patients with high ISS (≥25) had increased stroke rates compared to those with lower (<25) ISS (19% vs. 6.7%). All mortalities occurred with ISS >25. Logistic regression revealed that vessel injured, ISS, and Glasgow Coma Scale (GCS) were significant risk factors for mortality. Multivariate analysis demonstrated carotid injury, and lowest GCS were independently associated with mortality. In this comparison of CA and VA injuries in BCVI, VA injuries were more common and more frequently found with cervical spine fractures than CA injuries. However, VA injuries had a lower incidence of CVA and mortality. A high ISS was associated with stroke and mortality while carotid injury and lowest GCS were independently associated with increased mortality.

PC194. Follow-up Imaging of Blunt Vertebral Artery Injuries Is Unnecessary

Routine computed tomography (CT) imaging in trauma patients has led to increased recognition of blunt vertebral artery injuries (BVI). We sought to determine the prevalence of strokes, injury progression, and need for intervention in patients with BVI. Consecutive patients presenting with BVI over two years were identified from the institutional trauma registry. Inpatient records, imaging studies and follow-up data were reviewed in detail from the electronic medical record. 76 BVI were identified in 70 patients (64% males, mean age 47 ± 19 years); bilateral injuries occurred in 6 patients. Mechanism of injury included MVC (n = 47), fall (n = 16), pedestrian motor vehicle accident (n = 2), chiropractic manipulation (n = 3), and assault (n = 2). 58 (83%) had associated C-spine fractures. 6 (8.5%) patients had CT or magnetic resonance imaging evidence of posterior circulation infarctions during admission, but only one had residual stroke symptoms after discharge. Minor (grade 1 or 2) injuries occurred in 25 patients (36%), while severe (grade 3 or 4) injuries occurred in 45 (64%). Twelve patients died of associated injuries (8 with severe BVI, 4 with minor BVI, NSD). Of the 58 surviving to discharge, 31 (53%) returned for follow-up CT scans. Six of 10 patients (60%) with minor injuries had resolution or improvement, compared with 3 of 21 patients (14%) with severe injuries (P = .027). One patient (10%) with a minor BVI and two patients (10%) with severe BVI had radiologic progression, but none were clinically significant. During a mean follow-up of 15 ± 13 months, there were no vertebral artery interventions, and there were no delayed strokes (Fig). These data suggest that BVI are relatively benign sequela of cervical trauma. BVI-related strokes present at the time of admission and do not often have clinical sequela. No late strokes occurred in this series, and no interventions were required. The majority of grade 1 and 2 injuries should be expected to improve or resolve. Regardless of severity, these data indicate that follow-up imaging of BVI is not necessary in asymptomatic patients.