Vertebral artery injury--diagnosis and management

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.     

Vertebral artery trauma.

Injury to the vertebral artery is infrequent and poses special problems in exposure if it occurs above the entrance to the transverse foramen. The patients may present with neurologic symptoms. Pulsatile tinnitus and a bruit in the cervical-paravertebral region are constant findings. Permanent occlusion by a balloon catheter offers an unhurried and facile means of control after otherwise life-threatening lesions are stabilized.     

Vertebral artery injuries.

Vertebral artery injuries are identified more frequently now than in the past for both penetrating and blunt trauma. This is as a result of increased suspicion and awareness, liberal use of color flow Doppler, CT angiography, and traditional four-vessel angiography. The vast majority of patients who are not exsanguinating at the time of presentation can be managed nonoperatively or by angiographic embolization. Operative management should be reserved only for patients with severe active bleeding or when interventional radiology fails. The surgical exposure is complex and demands excellent knowledge of the local anatomy.     

Vertebral artery damage complicating cervical manipulation

Cervical manipulation may result in serious neurologic injury arising specifically from trauma to the vertebrobasilar system. The vertebral arteries are susceptible to trauma at three locations: in the transverse foraminae, at the atlantoaxial joint, and at the occipitoatlantal joint. Because of frequent inequality in the size of the two vertebral arteries, damage to the larger artery may lead to ischemia of the brain stem. Vertebral artery obstruction may be produced by extension with rotation, even within normal ranges of motion. Neurologic injury following manipulation requires accurate diagnosis and prompt manipulation requires accurate diagnosis and prompt anticoagulant therapy.     

Vertebral artery loop causing cervical radiculopathy

We report on a 68-year-old woman with an abnormal loop of the extracranial VA enlarging the intervertebral foramen at C4-5 and compressing the C5 root causing radiculopathy. The diagnosis was confirmed on contrast enhanced CT and MR angiography after initial conservative treatment was unsuccessful. Microvascular decompression using an anterior approach was curative.     

Vertebral artery loops in surgical perspective

Purpose

Vertebral artery loop is a congenital or acquired anomaly. Vertebral artery loops are incidentally diagnosed during evaluation of neck problems and trauma. We aimed to present the incidence of VA loops using magnetic resonance angiography in consecutive patients and discuss epidemiological data including the gender, age, location, signs and symptoms, treatment approaches and outcomes of VA loops via analyzing literature.

Methods

In the first leg of our two-legged study, consecutive patients were evaluated using magnetic resonance angiography to detect any medial loop of vertebral arteries. The study period was from October 2015 to March 2016. In the second leg, academic databases about medial loop of vertebral artery were screened. Case reports, case series, abstracts and references of relevant literature were searched manually to avoid any missing cases.

Results

We evaluated 239 consecutive patients using magnetic resonance angiography. Twenty-one patients were excluded from the study due to inadequate image acquisition, aplastic vertebral artery and/or concomitant vertebral artery stenosis. Medial loop of V2 vertebral artery was observed in 13 patients (5.9 %): 9 with left, 2 with right and 2 with bilateral medial V2 loop. Patients with medial V2 loop were significantly older than patients with straight vertebral arteries (70.30 vs. 62.36, p = 0.028). In the literature analysis, VA loops were more commonly observed at V2 segment (90.5 %). Vertebral artery loops were mostly diagnosed at the 5th and 6th decades of life predominantly in females. The most common signs and symptoms were radiculopathy and/or neck pain, and signs and symptoms of vertebrobasilar insufficiency.

Conclusions

Concise pre-operative evaluation of the vertebral arteries is essential to avoid the injury of undiagnosed VA loops during surgery, which might result in catastrophic circumstances. Further evaluation of the vertebral arteries using MR angiography is required, especially in elder age, before cervical spine surgeries.

     

椎－基动脉缺血颅外血管重建进展

椎 基动脉缺血或功能不足 (ｖｅｒｔｅｂｒｏｂａｓｉｌａｒｉｓｃｈｅｍｉａ/ｉｎ ｓｕｆｆｉｃｉｅｎｃｙ ,ＶＢＩ)是脑卒中的主要原因之一 ,后脑循环梗死在急性期的死亡率高达 2 0 %～ 30 %。早在 2 0世纪 6 0年代已用动脉内膜剥除术治疗椎 基动脉狭窄和闭塞 ,至 70年代 ,随着显微外科技术和后来动脉造影、磁共振技术的发展和完善 ,ＶＢＩ颅外血管重建技术得到进一步拓展 ,但本病治疗仍存在许多争议和分歧。1　椎 基动脉 (ＶＡ)的应用解剖ＶＡ是锁骨下动脉的第 1分支 ,从第 6颈椎横突进入ＶＡ孔上行至寰椎枕骨关节 ,离开寰椎后通过枕骨…