Embolization of transected vertebral arteries in unstable trauma patients

Traumatic cerebrovascular injury: clinical characteristics and illustrative cases

OBJECTIVE

Traumatic cerebrovascular injury (TCVI) is a rare and serious complication of traumatic brain injury (TBI). Various forms of TCVIs have been reported, including occlusions, arteriovenous fistulas, pseudoaneurysms, and transections. They can present at a variety of intervals after TBI and may manifest as sudden episodes, progressive symptoms, and even delayed fatal events. The purpose of this study was to analyze cases of TCVI identified at a single institution and further explore types and characteristics of these complications of TBI in order to improve recognition and treatment of these injuries.

METHODS

The authors performed a retrospective review of cases of TCVI identified at their institution between 2013 and 2016. A total of 5178 patients presented with TBI during this time period, and 42 of these patients qualified for a diagnosis of TCVI and had adequate medical and imaging records for analysis. Data from their cases were analyzed, and 3 illustrative cases are presented in detail.

RESULTS

The most common type of TCVI was arteriovenous fistula (86.4%), followed by pseudoaneurysm (11.9%), occlusion (2.4%), and transection (2.4%). The mortality rate of patients with TCVI was 7.1%.

CONCLUSIONS

The authors describe the clinical characteristics of patients with TCVI and provide data from a series of 42 cases. It is important to recognize TCVI in order to facilitate early diagnosis and treatment.

Traumatic cerebrovascular injury: Prevalence and risk factors

BACKGROUND

Traumatic cerebrovascular injury (TCVI) is uncommon in traumatic brain injury (TBI). Although TCVI is a rare condition, this complication is serious. A missed or delayed diagnosis may lead to an unexpected life-threatening hemorrhagic event or persistent neurological deficit. The object of this study was to determine the prevalence and risk factors associated with TCVI.

METHODS

The authors retrospectively reviewed medical records and neuroimaging studies of 5178 patients with TBI. The association of various factors was investigated using time-to-event statistical analysis. A TCVI which resulted in an occlusion, arteriovenous fistula, pseudoaneurysm or cerebral artery transection was defined as an event.

RESULTS

Forty-two patients developed a TCVI after injuries with an overall prevalence of 0.8%. The risk factors for an intracranial arterial injury based on univariate analysis using the Cox proportional hazard regression were penetrating injury, severe head injury, orbitofacial injury, basilar skull fracture, subdural hematoma, and cerebral contusion. In multivariable analysis, the two variables that were independently associated with TCVI were basilar skull fracture (odds ratio [OR] 22.1, 95% confidence interval [CI] 11.5-42.2) followed by orbitofacial fracture (OR 13.6, 95% CI 6.8-27.3).

CONCLUSIONS

Although TCVI is a rare complication of TBI, early investigation in high-risk patients may be necessary for early treatment before an unexpected fatal event occurs.

The management of penetrating neck injury

Penetrating neck injuries are serious as there is a high concentration of vital structures in close proximity to each other in a compressed anatomical area. Penetrating neck injuries can be immediately life threatening due to massive bleeding from vascular structures or due to airway compromise. Injury to the digestive tract in the neck may also result in delayed and potentially life-threatening conditions. The majority (79%) of penetrating neck injuries can be managed conservatively. The clinician caring for such a patient requires a structured and comprehensive approach to managing these injuries. This article will provide a general overview of penetrating neck injuries, including resuscitation, epidemiology, surgical management and the use of appropriate imaging.

A Case of Penetrating Neck Injury with Retained Foreign Body in the Cervical Vertebral Body and Vertebral Artery Dissection

Vertebral artery injury is an uncommon but life-threatening condition. We report a young lady with penetrating neck injury, after stabbed by her husband with a ceramic knife, resulting in right C5 nerve root injury and vertebral artery dissection. The tip of the knife was retained in the cervical vertebral body. Embolisation of the proximal vertebral artery was performed before the removal of the retained knife tip. The nerve root injury was successfully repaired and the patient had only minimal proximal weakness after the operation. The management of penetrating neck trauma with vertebral artery injury is discussed.

Airway and circulatory collapse due to retropharyngeal hematoma after blunt vertebral artery injury

Retropharyngeal hematoma following blunt cervical spine injury is a known cause of airway obstruction, but it is not known to cause hemorrhagic shock. We report the case of a massive retropharyngeal hematoma caused by a blunt vertebral artery transection leading simultaneously to airway obstruction and hemorrhagic shock. An 83-year-old woman was injured in a motorcycle accident. In the field, the patient exhibited paradoxical breathing with no breath sounds, and her blood pressure could not be measured. Therefore, emergency intubation and fluid resuscitation were initiated and the patient was transferred to the emergency department. Computed tomography angiography revealed a massive retropharyngeal hematoma with contrast extravasation from the right vertebral artery, which caused airway obstruction and hemorrhagic shock. The right vertebral artery was transected at the C5 level, which was associated with C4/C5 dislocation. Vertebral artery transection was successfully treated by endovascular embolization, which was followed by complication of asymptomatic posterior circulation stroke. Blunt vertebral artery transection can cause massive retropharyngeal hematoma, which can rapidly expand and lead to hemorrhagic shock in addition to airway obstruction. In cases of massive retropharyngeal hematoma with hemorrhagic shock following blunt cervical spine injury, blunt vertebral artery transection should be suspected. If blunt vertebral artery transection is detected and hemorrhagic shock is persistent, endovascular embolization should be performed immediately in addition to emergency intubation.

Delayed bilateral vertebral artery occlusion after cervical spine injury: a case report

INTRODUCTION

There are considerable risks for the secondary spinal cord injury and the initial and/or delayed vertebral artery occlusion in cases of cervical fracture dislocation.

CASE PRESENTATION

An 86-year-old man was injured in a car accident and was diagnosed with no fracture or dislocation of the cervical spine by the emergency physician. However, he was transferred to our hospital 3 days later because he had motor weakness that was evaluated to be 32 points (out of 50 points) on the upper limb American Spinal Injury Association (ASIA) motor score and was diagnosed with spontaneously reduced fracture dislocation at C5/6. Magnetic resonance images revealed that the bilateral vertebral arteries were occluded, and there were some microinfarction lesions in the brain. On the first visit to his previous doctor, he was found to have a flow void in the right vertebral artery. This indicated that it was occluded during the waiting period at his previous doctor. On the day of his arrival at our hospital, the patient underwent a C5/6 posterior spinal fusion. Three months after surgery, he recovered to 46 points on the upper extremity ASIA motor score, and blood flow in the left vertebral artery was resumed.

DISCUSSION

Early reduction and stabilization are necessary for cervical spine fracture dislocation; however, it is important not only for the prevention of the secondary injury but also for the reduction of the risk of vertebral artery occlusion.

Strategy for endovascular coil embolization of a penetrating vertebral artery injury

Background:

Penetrating vertebral artery injuries (VAIs) are even rarer than carotid artery injuries. For anatomical reasons, the surgical management of VAI is difficult, and endovascular management often yields a good outcome. We report our strategy for the endovascular treatment of a patient with a penetrating VAI at the V2 segment of the left vertebral artery.

Case Description:

In a fall on a large rake, a 76-year-old man was stabbed in the left neck by three tines. Although he manifested no neurological deficits, computed tomography (CT) suggested penetrating VAI. Digital subtraction angiography confirmed VAI and extravasation, and he underwent endovascular coil embolization. Two microcatheters, inserted proximal and distal to the injury sites, were used for successful endovascular coil embolization. Postoperative magnetic resonance imaging - and single photon emission CT studies denied cerebral infarction and a decrease in cerebral perfusion. The patient exhibited no neurological deficits and was able to leave the hospital on foot.

Conclusion:

This is the rare documentation of a patient whose penetrating VAI was treated by simultaneous coil embolization and foreign body removal. Imaging studies confirmed the patency and perfusion of the intracranial artery. Our treatment strategy produced a good outcome in this unusual patient.

Minimal invasive management of traumatic transection of the vertebral artery

Stab wounds to the neck can be potentially lethal. They are often associated with vascular injury of the carotid artery and jugular vein. Injury of the vertebral artery is rarely seen. The injury can vary from severe bleeding after transection with hemorrhage into the surrounding soft tissues of the neck to dissection and separation of the intimal lining from the subjacent media of an artery and subsequent occlusion of the vessel. We report a case of traumatic vertebral artery transection managed by minimal invasive balloon occlusion.

Sudden asphyxia caused by retropharyngeal hematoma after blunt thyrocervical artery injury

BACKGROUND

Retropharyngeal hematomas are often associated with blunt cervical spine injury. Generally, they improve with conservative treatment; however, rarely, airway obstruction occurs due to delayed swelling of retropharyngeal hematoma.

OBJECTIVES

To report a case of sudden asphyxia due to retropharyngeal hematoma caused by blunt thyrocervical artery injury.

CASE REPORT

A 30-year-old woman was admitted to the Emergency Department of Tokai University Hospital 4h after injury in a motor vehicle collision. On arrival, she had severe dyspnea and neck swelling; thereafter, a 26-mm-thick retropharyngeal swelling was visualized on lateral cervical plain X-ray study, extending from C1 anterior vertebrae to mediastinum. Emergency intubation was performed for the asphyxia. Because extravasation of contrast agent was observed in the hematoma on emergency contrast-enhanced computed tomography (CT) scan, emergency angiography was performed, from which we diagnosed a hemorrhage from the right thyrocervical artery.

CONCLUSION

If a patient with a non-displaced cervical spine injury suffers airway obstruction due to retropharyngeal hematoma, vigorous hemorrhage from a thyrocervical artery injury should be considered as the cause, and emergency contrast-enhanced CT scan of the neck should be performed after emergent tracheal intubation.

Traumatic Cervical Vertebral Artery Transection Associated with a Dural Tear Leading to Subarachnoid Extravasation

Vertebral artery injuries can be seen following trauma. Most traumatic vertebral artery injuries are limited to an intimal dissection. Rarely, transection of the vertebral artery can be seen with extravasation of hemorrhage into the surrounding soft tissues of the neck. Dural tears are rare in the setting of trauma. They are usually the result of penetrating trauma or severe blunt trauma. We present a case with both a vertebral artery transection and a dural tear. The combination of these lethal injuries resulted in extravasation of hemorrhage into the soft tissues of the neck, through the dural tear, and into the subarachnoid space of the cervical spine. The subarachnoid hemorrhage extended superiorly into the brain. The diagnosis was made by computed tomography (CT) and computed tomography angiography (CTA). The treatment of traumatic vertebral artery transections and dural tears are discussed.

Vertebral artery injuries associated with cervical spine injuries: a review of the literature

STUDY DESIGN

Literature review.

OBJECTIVE

To determine the incidence of vertebral artery injuries (VAIs) in association with cervical spine trauma and investigate the optimum diagnostic and treatment protocols.

SUMMARY OF BACKGROUND DATA

VAIs may result from cervical spine trauma and have the potential to cause cerebral, brainstem, and even spinal cord ischemia. Screening and treatment for traumatic VAI are very controversial, with conflicting recommendations within the trauma and spine literature.

METHODS

A literature review was performed to identify publications pertaining to VAIs associated with cervical spine trauma. These publications were evaluated to determine the incidence, radiographic evaluation, and treatment options of VAIs.

RESULTS

Approximately 0.5% of all trauma patients will have a VAI, and 70% of all traumatic VAIs will have an associated cervical spine fracture. Cervical spine translation injuries and transverse foramen fractures are most commonly cited as having a significant association with VAIs. The incidence of neurologic deficits secondary to VAI ranges from 0% to 24% in published series that incorporate a screening protocol for asymptomatic patients. Catheter angiography has been the gold standard for the diagnosis of VAIs; however, new 16-slice computed tomography angiography seems to have sensitivity and specificity close to that of catheter angiography. Treatment options include observation, antiplatelet agents, anticoagulation, and endovascular treatments. Although some authors have advocated antithrombotic therapy for most asymptomatic VAIs, there is a lack of class I evidence to support any strong guidelines for treatment.

CONCLUSIONS

VAIs can occur in association with cervical spine trauma and have the potential for neurological ischemic events. Screening for and treatment of asymptomatic VAIs may be considered, but it is unclear based on the current literature whether these strategies improve outcomes.

Imaging of blunt cerebrovascular injuries

Blunt cerebrovascular injuries are uncommon but potentially devastating injuries that can lead to stroke and death. While uncommon, appreciation of the seriousness of these injuries, a high index of suspicion in high risk patients, and aggressive screening of multitrauma patients leads to early diagnosis of asymptomatic lesions that may be amenable to treatment prior to the onset of ischemia. The radiologist can play a vital role in the early diagnosis, follow-up, and, in some cases, treatment of these challenging injuries.