CONTEMPORARY OUTCOMES OF VERTEBRAL ARTERY INJURY: A TEN YEAR SINGLE CENTER EXPERIENCE
Daniel M Alterman, Todd A Nickloes, Stanley J. Kurek, Oscar H Grandas, Scott L Stevens, Mitchell H Goldman, Michael B Freeman
University of Tennessee Graduate School of Medicine, Knoxville, TN
BACKGROUND: Vertebral artery injury (VAI) associated with cervical trauma is being increasingly recognized with more aggressive screening. Disparate results from previous literature have led to uncertainty of the significance, natural history and optimal therapy for VAI.
METHODS: We performed a retrospective, single-center review from a level I trauma center for the previous 10 years of all VAI. Injuries were identified from search of administrative trauma database, a resident-run working database, and all radiology dictations for the same period. VAI were classified according to segmental involvement, Denver grading scale, and laterality. Analysis of associated injuries, demographics, neurologic outcome, mortality, length of stay, treatment plan, and follow-up imaging was also performed.
RESULTS: Fifty-one patients with VAI were identified from 2001-2011 from a total 36,942 trauma admissions (0.13% incidence). Associated injuries were significant with an average NISS 29.6. Penetrating trauma occurred in 14%. Cervical spine fracture was present in 88% with VAI. Diagnosis was obtained with CT angiography in 95%. Screening was prompted by injury pattern or high-risk mechanism in all cases. Injuries classified according to the Denver grading scale were; grades 1=24%, 2=35%, 3=4%, 4=35%, and 5=2%. Distribution across segments included; V1=18%, V2=67%, V3=31%, and V4=6%. Only one posterior circulation stroke was attributable to VAI. Overall mortality was 8% being associated with other injuries. Treatment rendered was antiplatelet therapy (50%), observation (29%), warfarin (17%) or stent (4%). Follow-up was obtained with 13% (n=6) of survivors. CT angiogram or MRA demonstrated injury stability in 4 patients and resolution in 2 patients. Accuracy of the administrative trauma database was 53% compared with 96% for the resident-run working database.
CONCLUSIONS: Neurologic sequelae attributable to VAI was rare. Grade of VAI or vertebral artery segment did not correlate with morbidity. Posterior circulation stroke was low. Patient morbidity and mortality was attributable to severe associated injuries. Of those seen at follow-up, injury resolution or stability was documented by CT angiogram. A conservative approach with either observation or anti-thrombotic therapy is suggested. Our search strategy urges awareness of the limitations of administrative databases for retrospective vascular study.
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