Vertebral Artery Injury In The Setting of Cervical Spine Trauma

In general, vertebral artery injury will be asymptomatic and therefore underdiagnosed.

What Are The Consequences of Vertebral Artery Occlusion?

Brain-stem and cerebellar ischemia/infarction with altered consciousness, drowsiness, syncope, dysarthria, limb and trunk ataxia, swallowing difficulties, headache, dizziness, vertigo, tinnitus, visual field defects, blurry vision, ptosis

Mechanism of Injury

most likely involves intimal disruption, either through excessive distraction and stretching of the artery between two adjacent transverse foramen or through direct trauma to the vessel wall by fracture fragments. Primary intimal disruption can lead to thrombus formation which may precipitate thrombotic occlusion or distal embolic events.

How Common Is This Injury? And What is the Relevance?

Louw et al., JBJS(B), Vol 72, No 4., 679-681, 1990
Angiography of five patients with unilateral facet dislocations, and seven patients with bilateral facet dislocations. Four of the unilaterals (80%) and five of the bilaterals (71.4%) had vertebral artery occlusion. Two had transient symptoms which resolved.

Willis et al., Neurosurgery, Vol 34, No. 3, 435-441, 1994
Angiography of 26 patients with acute cervical spine trauma – identified 12 patients (46%) with arterial injury. None had symptoms.

Walsh et al., Canadian Journal of Neurological Sciences, Vol 22, 308-311, 1995
Reported on one case of symptomatic vertebral artery occlusion from a Jefferson fracture after a retrospective review of 174 patients who presented to St. Michael’s Hospital with cervical fractures. (Apparently only one other in the English literature) This patient suffered an inferior cerebellar infarction.

Friedman et al., American Journal of Roentgenology, Vol 164, 443-447. 1995
Magnetic resonance angiography of 37 patients with acute cervical spine trauma – identified abnormal findings in 9 patients (24%). One had bilateral vertebral artery injuries and died of a massive right cerebellar infarction

Vaccaro et al., Spine, Vol 23, No 7, 789-795, 1998
In a long term follow up of 7 patients (some from Friedman’s study) identified to have vertebral artery injury on MR angiography, there was no change in the flow patterns (ie, no recannulization of the vessel and restoration of flow). 3 of the seven had symptoms of vertebral artery occlusion on initial presentation, but all resolved and remained as such at their final follow-up.

Vertebral Artery Injury In The Setting of Cervical Spine Trauma

MR versus Angio?

MR is not as sensitive as conventional angiography in the detection of vertebral artery dissection. But angiography is invasive and carries some risk, and clearly cannot be used as a screening tool.

What other Clues Might There Be?

Displacement of the fracture? Controversial
Fracture into the foramen? Controversial

Treatment of Occluded Vertebral Artery?

Unilateral vertebral artery occlusion does not appear to pose significant risk providing the contralateral side is normal. If collateral flow is adequate, an occlusion on one side will most likely be asymptomatic and intervention is rarely required.

Treatment of Non-Occluded Vertebral Artery?

For intimal disruption, some form of antiplatelet or anticoagulation therapy is recommended if there are no other risks in the truamatized patient.

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