Neurosurgery notes/Trauma/Primary head Injury/Blunt cerebrovascular injury (BCVI)/Vertebral artery blunt injuries

Vertebral artery blunt injuries

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Blunt cerebrovascular injury (BCVI)

Numbers

  • Blunt vertebral artery injury (BVI) is very rare,
    • Found in 0.5–0.7% of patients with blunt injuries with aggressive screening.
    • Michalopoulos et al 2023
      • Incidence of VAI post blunt trauma: 0.49%
      • Incidence of bilateral VAI among all VAIs: 12.3%
      • Incidence of concurrent carotid injury among all VAIs 19.2%
  • Fq associated with fractures through the
    • Foramen transversarium
    • Facet fracture-dislocation
    • Vertebral subluxation
      • Overall incidence increases to 6% in the presence of cervical fracture or ligamentous injury

Aetiologies

  • Automobile accidents
    • Most common
  • Spinal manipulation therapy (SMT): including chiropractic or similar
    • Comprise 11 of 15 case reports reviewed by Caplan et al.
      • VA dissections were independently associated with SMT within 30 days in multivariate analysis (odds ratio = 6.62, 95% CI 1.4 to 30)
  • Sudden head turning
  • Direct blows to the back of the neck

Evaluation

  • Patients meeting the “Denver Screening Criteria” should undergo 16MD-CTA to screen for BVI
    • BCVI grading scale (aka “Denver grading scale”)
        • Grade
        Description
        I
        Luminal irregularity with < 25% stenosis
        II
        ≥ 25% luminal stenosis or intraluminal thrombus or raised intimal flap
        III
        Pseudoaneurysm
        IV
        Occlusion
        V
        Transection with free extravasation
        notion image
    • Michalopoulos et al 2023
      • VAI severity by Denver grade was as follows:
        • Grade I, 23.4%;
        • Grade II, 28.2%;
        • Grade III, 5.8%;
        • Grade IV, 42.1%;
        • Grade V, 0.5%
    • Catheter angiogram is recommended in select patients after blunt cervical trauma if 16MD-CTA is not available,
      • Especially if concurrent endovascular intervention is a consideration.
    • MRI is recommended for BVI after blunt cervical trauma in patients with incomplete SCI or vertebral subluxation injuries
  • When BVI is identified, it is critical to assess the status of the contralateral VA

Stroke from BVI

  • Can produce vertebrobasilar insufficiency (VBI) or posterior circulation stroke.
  • Unlike with carotid injuries, there is rarely a premonitory “warning” TIA.
  • Time from injury to stroke: mean 4 days (range: 8 hours -12 days).
  • Risk of stroke (Michalopoulos et al 2023) Meta-analysis
    • The overall stroke risk was 5.32%,
    • Bilateral VAI: 33.2% stroke prevalence.
        • Denver Grade
        Stroke risk
        I
        1.9%
        II
        3.0%
        III
        9.8%
        IV
        10.9%
        V
        Too rare to analyse

Treatment

  • Strokes were more frequent in patients with BVI who were not treated initially with IV heparin despite an asymptomatic BVI.
    • However, based on historical controls, it is not clear if either screening or treatment improves overall outcome.
  • Recommendations:
    • Treat all BVI with aspirin.
    • Restudy chronic occlusion in 3 months.
  • Treatment options include
    • Endovascular stenting
      • Advantage
        • Can restore near-normal flow
      • Disadvantage
        • Lacking long-term results
        • Stenting requires ≥≈ 3 months of antiplatelet therapy which is contraindicated in some situations.

Outcome

  • Overall mortality with unilateral BVI ranges from 8–18%
    • Which is lower than with ICA dissections (17–40%).
  • Bilateral VA dissection appears highly fatal.