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Lee MJ, Weaver DJ, El Dafrawy MH. Extracranial Vertebral Artery Injuries. J Am Acad Orthop Surg 2024; 32:e899-e908. [PMID: 38810231 DOI: 10.5435/jaaos-d-24-00244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/28/2024] [Indexed: 05/31/2024] Open
Abstract
Paired vertebral arteries (VAs) travel from the subclavian artery through the cervical spine and into the intracranial space where they contribute to posterior cerebral circulation. Blunt and penetrating injuries to the cervical spine risk injury to the VA. Among the most feared complications of vertebral artery injury (VAI) is posterior circulation stroke. Appropriate screening and treatment of these injuries in the trauma setting remain vitally important to aid in the prevention of devastating neurologic sequelae. A robust knowledge of the VA anatomy is required for spine surgeons to avoid VAI during cervical spine approaches and instrumentation. Both anterior and posterior cervical spine surgeries can place the VA at risk. Careful preoperative assessment with the appropriate advanced imaging studies is necessary to verify the course of the VA in the cervical spine and thus prevent iatrogenic injury because anatomic variations along the course of the artery can prove hazardous if not properly anticipated. Iatrogenic VAI can be treated successfully with tamponade. However, in some cases, ligation, repair, or endovascular procedures may be indicated.
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Affiliation(s)
- Michael J Lee
- From the Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
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Santangelo G, Wathen C, Pieters T, George DD, Worley L, Macaluso D, Dagli MM, Catanzaro S, Gu B, Welch WC, Petrov D, Vates GE, Ozturk AK, Schuster J, Stone JJ. Multi-institutional review of characteristics and management of gunshot wounds to the spine. Spine J 2024; 24:1553-1560. [PMID: 38740190 DOI: 10.1016/j.spinee.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND CONTEXT Gunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data. PURPOSE To characterize the management and follow-up of GSWs to the spine. STUDY DESIGN/SETTING A multi-institutional retrospective review of the experience of two urban Level 1 trauma centers. PATIENT SAMPLE Patients with GSWs to the spine between 2010-2021. OUTCOME MEASURES Measures included work status, follow-up healthcare utilization, and pain management were collected. METHODS Charts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY). RESULTS A total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score. CONCLUSIONS Given the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.
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Affiliation(s)
- Gabrielle Santangelo
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA.
| | - Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Pieters
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Derek D George
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Logan Worley
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Dominick Macaluso
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mert Marcel Dagli
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandra Catanzaro
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Ben Gu
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dmitry Petrov
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan J Stone
- Department of Neurosurgery, University of Rochester, 601 Elmwood Ave., Rochester, NY 14620, USA
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3
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Wathen C, Santangelo G, Muhammad N, Ellens N, Catanzaro S, Singh A, Dagli MM, Petrov D, Ozturk AK, Bender M, Stone JJ, Schuster J. Management and outcomes of cerebrovascular injuries after gunshot wounds to the cervical spine. Clin Neurol Neurosurg 2024; 243:108376. [PMID: 38865803 DOI: 10.1016/j.clineuro.2024.108376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 06/14/2024]
Abstract
STUDY DESIGN This study was a multicenter retrospective analysis of cervical spine gunshot wound (GSW) patients. OBJECTIVE The present study was conducted to evaluate the management and outcomes of vascular injuries following GSW involving the cervical spine. SUMMARY OF BACKGROUND DATA Gunshot wounds (GSW) injuring the cervical spine are associated with high rates of vascular injury. METHODS Charts of patients with GSW involving the cervical spine at two Level 1 trauma centers were reviewed from 2010 to 2021 for demographics, injury characteristics, management and follow-up. Statistical analysis included T tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables, non-parametric tests were used when indicated. Beta-binomial models were used to estimate the probabilities outcomes. Bayesian regression models were utilized to compute risk ratios (RR) and their 95 % confidence intervals (CI) to enhance the inferential robustness. RESULTS 40 patients with cervical spine GSW and associated cerebrovascular injury were included in our analysis. 15 % of patients had Biffl grade (BG) V injuries, 50 % grade IV, and 35 % grade III-I. Angiography was performed in 35 % of patients. 5 of these patients (BG V-III) required endovascular treatment for pseudoaneurysm obliteration or parent vessel sacrifice. 7 patients (22 %) showed evidence of progression. 70 % of patients were placed on antiplatelet therapy for stroke prevention. Bayesian regression models with a skeptical prior for cerebral ischemia revealed a mean RR of 4.82 (95 % CI 1.02-14.48) in the BG V group, 0.75 (95 % CI 0.13-2.26) in the BG IV group, and 0.61 (95 % CI 0.06-2.01) in the combined BG III-I group. For demise the mean RR was 3.41 (95 % CI 0.58-10.65) in the BG V group and 1.69 (95 % CI 0.29-5.97) in the BG IV group. In the high BG (V, IV) group, 54.55 % of patients treated with antiplatelet therapy had complications. None of the patients that were treated with antiplatelet therapy in the low BG (III-I) group had complications. CONCLUSIONS Cervical spine GSWs are associated with high-grade vascular injuries and may require early endovascular intervention. Additionally, a high rate of injury progression was seen on follow up imaging, requiring subsequent intervention. Reintervention and demise were common and observed in high BG (V, IV) groups. The incidence of stroke was low, especially in low BG (I-III) groups, suggesting that daily aspirin prophylaxis is adequate for long-term stroke prevention.
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Affiliation(s)
- Connor Wathen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Gabrielle Santangelo
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Najib Muhammad
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Sandra Catanzaro
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Aman Singh
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Mert Marcel Dagli
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dmitry Petrov
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Bender
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Jonathan J Stone
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - James Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Yang SJ, Gu YQ, Cui SJ. Treatment of extracranial vertebral artery aneurysms with covering stents: A case report and literature review. Asian J Surg 2024; 47:1815-1818. [PMID: 38151434 DOI: 10.1016/j.asjsur.2023.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/15/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- Sheng-Jia Yang
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Vascular Surgery, Capital Medical University, Beijing, 100053, China; Institute of Vascular Surgery, Capital Medical University, Beijing, 100053, China.
| | - Yong-Quan Gu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Vascular Surgery, Capital Medical University, Beijing, 100053, China; Institute of Vascular Surgery, Capital Medical University, Beijing, 100053, China.
| | - Shi-Jun Cui
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Department of Vascular Surgery, Capital Medical University, Beijing, 100053, China; Institute of Vascular Surgery, Capital Medical University, Beijing, 100053, China
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Kim M, Subah G, Cooper J, Fortunato M, Nolan B, Bowers C, Prabhakaran K, Nuoman R, Amuluru K, Soldozy S, Das AS, Regenhardt RW, Izzy S, Gandhi C, Al-Mufti F. Neuroendovascular Surgery Applications in Craniocervical Trauma. Biomedicines 2023; 11:2409. [PMID: 37760850 PMCID: PMC10525707 DOI: 10.3390/biomedicines11092409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/12/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.
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Affiliation(s)
- Michael Kim
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Michael Fortunato
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87108, USA
| | - Kartik Prabhakaran
- Department of Surgery, Division of Trauma and Acute Care Surgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children’s Hospital, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Indianapolis, IN 46032, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Alvin S. Das
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
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6
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Wu M, Tay J, Lloyd D. Management of a penetrating vertebral artery injury in a peripheral hospital. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086231160299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Vertebral artery (VA) injuries in penetrating trauma are rare but can be life threatening. Management is often reliant on interventional radiology (IR), although such services may be lacking in peripheral centres. We report a case of a 22-year-old man who sustained a right VA injury from a stab wound to the posterolateral neck that was managed in a rural hospital. On presentation, the patient was initially haemodynamically stable but began exsanguinating heavily whilst undergoing imaging and was subsequently transferred to the operating theatre. Intraoperatively, bleeding was noted from the C5/C6 interforaminal space. Due to difficulty with exposure and lack of specialist surgical services, bimanual pressure was continuously applied to the wound whilst awaiting the arrival of a vascular surgeon and neuro-interventionalist who were transported by air from a tertiary hospital. At the time of angiography, bleeding had ceased and no further intervention was required. This case highlights the importance for surgeons in peripheral centres to be aware of some of the operative manouvres used in managing VA injuries including the utility of continued direct pressure. Moreover, it serves as a reminder that there remains a role for operative intervention in the unstable patient despite increasing reliance on radiological techniques to treat such injuries.
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Affiliation(s)
- Michael Wu
- Department of General Surgery, Launceston General Hospital, Launceston, Australia
| | - Jia Tay
- Department of General Surgery, Launceston General Hospital, Launceston, Australia
| | - David Lloyd
- Department of General Surgery, Launceston General Hospital, Launceston, Australia
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7
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Ischemic Stroke Secondary to a Stab Wound to the Neck in a Young Adult. Case Rep Med 2022; 2022:9365947. [PMID: 36304568 PMCID: PMC9596234 DOI: 10.1155/2022/9365947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Vertebral artery dissection is a common cause of stroke in young adults without predisposing risk factors for cerebrovascular disease. We describe the case of a 28-year-old patient who presented with an ischemic stroke secondary to a stab wound to the neck that affected the vertebral artery. A physical examination revealed neurological deterioration (Glasgow 8/15), a sutured neck wound, no palpable hematoma, no thrills, and no active bleeding. A computed tomography angiography revealed a left vertebral artery arteriovenous fistula with a component of a pseudoaneurysm, for which a neurointerventional consultation was carried out. Due to neurological compromise, the airway was secured, and because the case involved a posterior fossa infarction with compression of the fourth ventricle and obstructive secondary hydrocephalus, an external ventricular shunt was inserted by neurosurgery. A fistula occlusion was performed with five Axium coils and a vial of Squid 12; the vertebral artery was catheterized, and a craniotomy was performed to manage hydrocephalus with a 12-mm H2O collecting system. The patient was discharged on the tenth day after admission with sequelae of left hemiparesis (predominantly brachial) and no other deficits. There was no hemorrhagic transformation on the control computed tomography scans and no further complications.
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8
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Vertebral artery transection with pseudoaneurysm and arteriovenous fistula requiring antegrade and retrograde embolization. J Vasc Surg Cases Innov Tech 2022; 8:183-186. [PMID: 35434437 PMCID: PMC9006477 DOI: 10.1016/j.jvscit.2022.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/28/2022] [Indexed: 11/24/2022] Open
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Yan J, Guo Y, Lei Z, Yang H, Ma C. Arteriovenous fistula between the left vertebral artery and the inferior thyroid vein: a case report. J Int Med Res 2022; 50:3000605221078217. [PMID: 35139692 PMCID: PMC8841930 DOI: 10.1177/03000605221078217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Arteriovenous fistula between the left vertebral artery and the inferior thyroid vein is a rare entity. This condition can change the blood supply of the basilar artery system, and then lead to an abnormal blood supply of the vertebral body. Therefore, this rare condition may be misdiagnosed in the clinic. We report an arteriovenous fistula between the left vertebral artery, which was found during an interventional operation of a 49-year-old Asian man. He was non-diabetic and an ex-smoker, and presented with a 1-month history of pain in the neck, shoulder, waist, back, and right lower limb. Vascular angiography showed an arteriovenous fistula, and coils were placed in the fistula. In this setting, coil embolization was effective, and a 1-year follow-up suggested that a good long-term result was likely.
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Affiliation(s)
- Jingxin Yan
- Department of Interventional Therapy, 207475Qinghai University, Affiliated Hospital of Qinghai University, Xining, China.,Postgraduate Department, Qinghai University, Xining, China
| | - Yingxing Guo
- Department of Interventional Therapy, 207475Qinghai University, Affiliated Hospital of Qinghai University, Xining, China
| | - Zhenwu Lei
- Department of Interventional Therapy, 207475Qinghai University, Affiliated Hospital of Qinghai University, Xining, China
| | - Haiming Yang
- Department of Interventional Therapy, 207475Qinghai University, Affiliated Hospital of Qinghai University, Xining, China
| | - Cunkai Ma
- Department of Interventional Therapy, 207475Qinghai University, Affiliated Hospital of Qinghai University, Xining, China
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Pataki Á, Nguyen DT, Nagy Z, Nardai S, Nemes B. Stent-Graft Treatment of a Giant Asymptomatic Extracranial Vertebral Artery Aneurysm: Case Report and Literature Review. Ann Vasc Surg 2021; 79:442.e1-442.e6. [PMID: 34656725 DOI: 10.1016/j.avsg.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/01/2021] [Accepted: 08/05/2021] [Indexed: 11/20/2022]
Abstract
With the widespread appliance of endovascular techniques, a plethora of options is available in the treatment of extracranial vertebral artery aneurysms. If the vertebral artery can be sacrificed, embolization with coiling, liquid injection, or parent artery exclusion can be done. We hereby present a case of a 74-year-old male patient presenting with an asymptomatic atherosclerotic giant extracranial vertebral artery aneurysm in the V1 segment of the vertebral artery, successfully treated with balloon expandable stent-graft deployment. No neurologic symptoms occurred, and the stent-graft was patent with no signs of endoleak at 24 months follow-up with computed tomography angiography.
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Affiliation(s)
- Ákos Pataki
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
| | - Dat T Nguyen
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsuzsa Nagy
- Department of Vascular Surgery, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Sándor Nardai
- Department of Cardiology Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Balázs Nemes
- Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Ramos Perkis JP, Goyenechea Miralles F, Rodriguez Galvan H, Benítez Pérez J, Ottolino P. Challenges in acute care surgery: penetrating vertebral artery injury in 'extremis' patient. Trauma Surg Acute Care Open 2021; 6:e000684. [PMID: 33912686 PMCID: PMC8030487 DOI: 10.1136/tsaco-2021-000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Juan Pablo Ramos Perkis
- Unidad de Trauma y Urgencias, Complejo Asistencial Doctor Sotero del Rio, Puente Alto, Chile
| | | | | | | | - Pablo Ottolino
- Unidad de Trauma y Urgencias, Complejo Asistencial Doctor Sotero del Rio, Puente Alto, Chile
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12
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Penetrating Vertebral Artery Injuries: A Literature Review and Proposed Treatment Algorithm. World Neurosurg 2021; 148:e518-e526. [PMID: 33460818 DOI: 10.1016/j.wneu.2021.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Penetrating vertebral artery injuries (VAIs) are rare but devastating trauma for which the approach to treatment varies greatly. The literature on treatment modalities is limited to case reports, case series, and 1 review, with the majority of cases being treated surgically. However, with the advent of digital subtraction angiography, treatment has shifted toward less invasive endovascular modalities that allows one to assess the flow and risks of sacrificing the vertebral artery (VA). METHODS In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses, a systematic review of VAI was performed. Two case reports were also detailed. Using a multidisciplinary team, a decision algorithm was proposed for approaching penetrating VAIs. RESULTS We identified 169 patients. Of the penetrating VAI, the majority were occlusions, most commonly managed conservatively. Other injuries including pseudoaneurysm, dissection, transection, and arterial-venous fistula were treated predominantly endovascularly and occasionally with the surgical exploration/ligation. Most endovascular treatments included embolization without significant stroke or complication from VA sacrifice. However, there are incidences in which VA sacrifice should be avoided and these scenarios can be better delineated with digital subtraction angiography to assess flow and anatomy. CONCLUSIONS This systematic review not only details the updated treatment options but also provides a decision algorithm for the treatment of penetrating VAI. It highlights the shifting treatment options of penetrating VAI to endovascular therapy, as well as details VAI variants that may suggest stenting over embolization.
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13
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Penetrating injuries to the vertebral artery: interventions and outcomes from US Trauma Centers. Eur J Trauma Emerg Surg 2020; 48:481-488. [PMID: 32567022 PMCID: PMC7306101 DOI: 10.1007/s00068-020-01416-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/12/2020] [Indexed: 11/24/2022]
Abstract
Purpose Penetrating injuries to the vertebral artery are rare and incompletely studied. Operative, angioembolic, and nonoperative strategies are management options, although the association between management strategy and outcomes is unknown. This study endeavored to define the epidemiology, management strategy, and outcomes after penetrating injuries to the vertebral artery presenting to trauma centers nationwide. Methods Patients with veterbral artery injuries were identified from the National Trauma Data Bank (NTDB) (2016–2017) using ICD-10-CM codes. Only those with penetrating mechanisms of injury were included in the study. Transferred patients were excluded. Study groups were defined by management strategy (Operative management, OM; angioembolization, AE; and nonoperative management, NOM). Patient demographics, injury characteristics, and outcomes were compared between groups using univariate analysis. Multivariate analysis with logistic regression was used to examine independent risk factors for mortality and stroke. Results Penetrating injuries to the vertebral artery were rare (n = 476, < 1% of NTDB patient population). Median age was 28 [IQR 21–37] years and 81% (n = 385) of patients were male. Interpersonal violence was the most common injury intent (n = 374, 79%). Most patients were managed with NOM (n = 409, 86%), with AE and OM utilized less frequently (8% and 6%, respectively). Stab wounds were the most frequent mechanism of injury among patients managed with OM (62%), while gunshot wounds were most common among patients managed with NOM (84%) or AE (79%). Multivariate analysis of risk factors for stroke revealed only associated carotid artery injury (OR 4.236, 95% CI 1.284–13.970, p = 0.018) and AE (OR 6.342, 95% CI 1.417–28.399, p = 0.016) were independent predictors. Independent risk factors for mortality were advanced age (OR 1.026, 95% CI 1.001–1.052, p = 0.044); elevated ISS (OR 1.030, 95% CI 1.008–1.052, p = 0.006); and associated traumatic brain injury (OR 3.020, 95% CI 1.333–6.843, p = 0.008). Higher ED GCS was independently associated with reduced mortality (OR 0.788, 95% CI 0.731–0.849, p < 0.001). Conclusions Vertebral artery injuries after penetrating mechanisms are infrequent in the United States. Patients with these injuries tend to be young adult men who were injured by gunshot wounds as a result of interpersonal violence. The majority of these injuries were managed nonoperatively, with operative intervention required most commonly for patients injured by stab wounds. Risk factors for both stroke and mortality were principally due to patient factors and associated injuries. Increased risk of stroke among patients managed with angioembolization will need to be further investigated with future study to determine if this risk is imparted from the management strategy itself or from underlying injury characteristics.
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