The devastating potential of blunt vertebral arterial injuries

Objective To formulate management guidelines for blunt vertebral arterial injury (BVI ). Summary Background Data Compared with carotid arterial injuries, BVIs have been considered innocuou s. Although screening for BVI has been advocated, particularly in patients with cervical spine injuries, the appropriate therapy of lesions is controv ersial. Methods In 1996 an aggressive arteriographic screening protocol for blunt cerebrova scular injuries was initiated. A prospective database of all screened patie nts has been maintained. Analysis of injury mechanisms and patterns, BVI gr ades, treatment, and outcomes was performed. Results Thirty-eight patients (0.53% of blunt trauma admissions) were diagnosed wit h 47 BVIs during a 3.5-year period. Motor vehicle crash was the most common mechanism, and associated injuries were common. Cervical spine injuries we re present in 71% of patients, but there was no predilection for cervical v ertebral level or fracture pattern. The incidence of posterior circulation stroke was 24%, and the BVI-attributable death rate was 8%. Stroke incidenc e and neurologic outcome were independent of BVI injury grade. In patients treated with systemic heparin, fewer overall had a poor neurologic outcome, and fewer had a poor outcome after stroke. Trends associated with heparin therapy included fewer injuries progressing to a higher injury grade, fewer patients in whom stroke developed, and fewer patients deteriorating neurol ogically from diagnosis to discharge. Conclusions Blunt vertebral arterial injuries are more common than previously reported. Screening patients based on injury mechanisms and patterns will diagnose a symptomatic injuries, allowing the institution of therapy before stroke. Sy stemic anticoagulation appears to be effective therapy: it is associated wi th improved neurologic outcome in patients with and without stroke, and it appears to prevent progression to a higher injury grade, stroke, and deteri oration in neurologic status.