Trauma penetrante de arteria vertebral. Del control de daños a lo endovascular

Introducción: El trauma penetrante de la arteria vertebral es extremadamente infrecuente. Objetivo: Aportar evidencia clínica mediante la revisión de una serie de casos. Materiales y Método: Se analizan cuatro casos de trauma penetrante con compromiso de la arteria vertebral entre los años 2020 y 2021, manejados en la unidad de trauma y urgencias del Complejo Asistencial Dr. Sótero del Río. Resultados: Se presentan cuatro casos clínicos relatando su proceso diagnóstico y manejo. Discusión: La evidencia de compromiso traumático de arteria vertebral es escasa. Reconocer su compleja anatomía y variada clínica resultan trascendentales para su adecuado manejo. Ante sospecha de este tipo de lesión, la angiografía por tomografía computada es el estudio de elección cuando se presentan hemodinámicamente estables. El abanico de opciones terapéuticas incluyen: observación, terapia antitrombótica o con antiagregantes, terapia endovascular o cirugía abierta. Conclusión: El trauma penetrante de arteria vertebral es una condición infrecuente, sin embargo, su diagnóstico y manejo deben ser conocidos por el cirujano.

Introduction: Traumatic involvement of the vertebral artery is extremely rare and difficult to diagnose. Objective: To provide clinical evidence by reviewing a case series. Materials and Method: We analyze four cases of penetrating trauma with involvement of the vertebral artery between 2020 and 2021, managed in the trauma and emergency unit of the Dr. Sótero del Río Care Complex. Results: Four clinical cases are presented describing diagnosis and management process. Discussion: There is little evidence of traumatic involvement of the vertebral artery. Recognizing its complex anatomy and varied clinic are transcendental for its proper management. When this type of lesion is suspected, computed tomography angiography is the choice study when hemodynamically stable. The range of therapeutic options include observation, antithrombotic or antiplatelet therapy, endovascular therapy or open surgery. Conclusion: Penetrating trauma of the vertebral artery is an uncommon condition, however, its diagnosis and management should be known to the surgeon.

Airway management in a displaced comminuted fracture of the mandible and atlas with a vertebral artery injury: A case report

Complex cervical spine fractures are a serious complications of maxillofacial trauma and associated with high mortality and neurological morbidity. Strict vigilance in preventing further insult to the cervical spine is a crucial step in managing patients who are at risk for neurologic compromise. We report a rare case of a right transverse process of atlas fracture with right-sided vertebral artery injury that was associated with a comminuted fracture of the body and angle of the mandible, which restricted mouth opening. Airway management was performed by an awake fiber-optic nasotracheal intubation, where neck movement was avoided with a cervical collar. Vertebral artery injuries may have disastrous consequences, such as basilar territory infarction and death, and should be suspected in patients with head and neck trauma. After mandibular plating, the patient was on cervical collar immobilization for 12 weeks and anti-coagulant therapy.

Radiographic assessment of vertebral artery injury in anterior cervical surgery in healthy adults / 中华外科杂志

Objectives@#To study the relationship between the anatomical parameters of transverse foramen and intervertebral discs in the cross-section of the cervical spine in healthy adults, and to evaluate the risk of vertebral artery injury in the anterior cervical spine surgery.@*Methods@#There were 24 healthy adults(12 male, 12 female) underwent neck CT angiography with clear vertebral artery and the adjacent structure imaging from June to December 2014 in Huashan Hospital, Fudan University. The anatomical parameters of vertebral artery V2 segment with lower cervical vertebrae and intervertebral discs were measured by cross-sectional images of C3-6. The corresponding parameters of different sex and both sides of the same segment were analyzed by independent samples t-test and paired t test, respectively. The least significant difference(LSD) t test was used to compare the corresponding data between different segments.@*Results@#The vertebral artery was not walking in the middle of the transverse foramen in healthy individual, but partial medial, partial front walking. Transverse diameter of transverse foramen in male and female were 6.62-6.89 mm and 6.21-6.45 mm, and sagittal diameter was 5.41-6.48 mm and 5.40-6.10 mm, respectively.The transverse foramen were slightly oval. The distance between vertebral artery and midline in male and female were 14.23-16.12 mm and 13.60-15.04 mm, respectively, which was much larger than the width of cervical vertebral corpectomy. Compared with C3-4, intervertebral disc, the transverse distance between the vertebral artery and the uncovertebral joint of C4-5, C5-6 was smaller, and the distance from the vertebral artery to the posterior margin of the uncovertebral joint was relatively small, the difference was statistically significant (t=2.449, P=0.022). The distance from vertebral artery to the posterior margin of uncinate process was 1/5-2/5 of the distance between the anterior and posterior edge of the corresponding segmental vertebra.@*Conclusion@#Based on this anatomical study, the risk of vertebral artery injury in conventional anterior cervical decompression is small, and the risk of vertebral artery injury in different segments is slightly different.

Surgical treatment for fracture-dislocation of upper cervical spine complicated with vertebral artery injury / 中华创伤骨科杂志

Objective To explore the perioperative management and surgical outcomes of fracture-dislocation of the upper cervical spine complicated with vertebral artery injury.Methods We retrospectively analyzed the clinical data of 19 patients diagnosed with fracture-dislocation of the upper cervical spine complicated with vertebral artery injury who had been treated at our department from January 2008 through December 2012.They were 14 males and 5 females,aged from 22 to 53 years (mean,35.2 years).All the patients had fractures of the atlas and/or axis,and disordered atlanto-axial relationship as well.According to Frankel grading system,8 cases were Grade D and 11 Grade E.The cervical posterior fixation with pedicle screws was adopted for all and hemostasis was conducted for those with bleeding from the broken vertebral artery.Their Frankel grade,Japanese Orthopedic Association (JOA) score and visual analogue scale (VAS) score were compared between preoperation and final follow-up.Results Intraoperative hemorrhage occurred in 2 patients from the injured vertebral artery.Hemostasis was achieved through direct tamponade with bone wax and gelatin sponge in one and through endovascular intervention after bleeding control by direct tamponade in another.Neither of them presented with symptoms of posterior circulation ischemia after operation.The mean operation time was 153.5 min,and the mean blood loss was 542.1 mL.All the patients were followed up for an average time of 28 months.Bony union was obtained in all after an average time of 13.5 weeks.Follow-ups revealed no ischemic stroke in this series.Symptoms of transient ischemic attack,like transient dizziness and blurred vision,appeared in 2 patients.At the final follow-up,all the patients were assessed as Frankel Grade E.Their mean JOA and VAS scores were significantly improved from 8.1 ± 1.2 and 7.0 ± 1.7 preoperatively to 12.7 ± 1.6 and 1.3 ± 1.2,respectively (P ＜ 0.05).Conclusions Angiography examination is routinely indicated for the patients with fracture-dislocation of the upper cervical spine perioperatively.Preoperative evaluation of the vertebral artery and its adjacent structures and effective intraoperative hemostasis can avoid uncontrollable bleeding during operation,reduce postoperative complications,and improve surgical outcomes.

Vertebral Artery Injury in C2-3 Epidural Schwannoma Resection: A Case Report and Literature Review / 대한신경손상학회지

The incidence of vertebral artery (VA) injury (VAI) in posterior approach tumor resection surgery is extremely rare, but it can lead to serious complication. In this case, a 57-year-old man underwent surgery for resection of the tumor involving left epidural space and neural foramen at C2-3 level. Iatrogenic VAI occurred suddenly during tumor resection procedure using pituitary forceps. Immediate local hemostasis and maintaining of perfusion for reducing the risk of posterior circulation ischemia were performed. Intraoperative angiogram of both VA and emergent trapping embolization were done as well. It may reduce the risk of immediate postop complication, and further delayed occurrence. The patient had no complication after VAI by appropriate intraoperative management. Preoperative angiographic work up and preparation of endovascular team cooperation are positively necessary as well as a warning for the VAI during cervical spine surgery.

Atlantoaxial Stabilization Using C1 and C2 Laminar Screw Fixation

We describe the use of a C1 laminar screw in combination with a C2 laminar screw as a salvage technique to treat two patients, one with persistent first intersegmental artery and the other with vertebral artery occlusion after cervical spine fracture. The combined use of C1 and C2 laminar screws allows for good fixation of the atlantoaxial joint with a lower risk of vertebral artery injury; therefore, it can be an alternative surgical procedure for patients with congenital or traumatic anomalous vertebral artery.

Delayed Brain Infarction due to Bilateral Vertebral Artery Occlusion Which Occurred 5 Days after Cervical Trauma

Vertebral artery (VA) injuries usually accompany cervical trauma. Although these injuries are commonly asymptomatic, some result in vertebrobasilar infarction. The symptoms of VA occlusion have been reported to usually manifest within 24 hours after trauma. The symptoms of bilateral VA occlusions seem to be more severe and seem to occur with shorter latencies than those of unilateral occlusions. A 48-year-old man had a C3-4 fracture-dislocation with spinal cord compression that resulted from a traffic accident. After surgery, his initial quadriparesis gradually improved. However, he complained of sudden headache and dizziness on the 5th postoperative day. His motor weakness was abruptly aggravated. Radiologic evaluation revealed an infarction in the occipital lobe and cerebellum. Cerebral angiography revealed complete bilateral VA occlusion. We administered anticoagulation therapy. After 6 months, his weakness had only partially improved. This case demonstrates that delayed infarction due to bilateral VA occlusion can occur at latencies as long as 5 days. Thus, we recommend that patients with cervical traumas that may be accompanied by bilateral VA occlusion should be closely observed for longer than 5 days.

Radiologic Characteristics of Vertebral Artery Injury in the Cervical Spine Fracture

STUDY DESIGN: A retrospective study. OBJECTIVES: This study was performed by probing vertebral artery injuries and their radiologic characteristics in cervical spine fractures, and analyzing MRI findings of vascular injuries. SUMMARY OF LITERATURE REVIEW: Vertebral artery injuries are found relatively often in cervical spine fractures. MATERIALS AND METHODS: We evaluated 57 cases of cervical spine fractures that occurred beginning in June 2011 and ending in February 2003. The characteristics of each fracture were evaluated using conventional radiographs, CT, and MRI. The presence of a vertebral artery injury was based on the absence of signal void in multilevel transverse foramens. RESULTS: Twelve out of the 57 cases (21.1%) were found to have unilateral vertebral artery injuries. Clinically, impairment in cerebral circulation was not found. We found no statistical correlation between the signal change in the spinal cord and in the vertebral artery injury (P=0.424). We noted fractures of transverse processes in 7 cases, 6 of which showed vertebral artery injuries. Thus, the transverse process facture was associated with t vertebral artery injury (P=0.000). There seemed to be no relationship between the vertebral artery injury and each of following: fracture level (P=0.416), fracture type (P=0.723) and severity of soft tissue injury (P=0.195). CONCLUSIONS: Unilateral vertebral artery injuries were frequently found in the cervical spine fractures. And of all radiographic factors associated with vertebral artery injury, only the presence of transverse process fracture was statistically significant. Absence of signal void at multi-section MR images is considered to be a useful guide to commence additional vascular evaluation.

Emergent Endovascular Embolization for Iatrogenic Vertebral Artery Injury during Cervical Discectomy and Fusion

Injury to the vertebral artery during anterior cervical discectomy is rare but potentially fatal. We report a case of cerebellar infarction after endovascular embolization for iatrogenic vertebral artery injury at C5-C6 during an anterior cervical discectomy and fusion. A 61-year-old man had an intraoperative injury of the right vertebral artery that occurred during anterior cervical discectomy and fusion at C5-C6. Hemorrhage was not controlled successfully by packing with surgical hemostatic agents. While the patient was still intubated, an emergency angiogram was performed. The patient underwent endovascular occlusion of the right V2 segment with coils. After the procedure, his course was uneventful and he did not show any neurologic deficits. Brain computed tomographic scans taken 3 days after the operation revealed a right cerebellar infarction. Anti-coagulation medication was administered, and at 3-month follow-up examination, he had no neurologic sequelae in spite of the cerebellar infarction.

End-to-End Anastomosis of an Unanticipated Vertebral Artery Injury during C2 Pedicle Screwing

Vertebral artery (VA) injury is a rare and serious complication of cervical spine surgery; this is due to difficulty in controlling hemorrhage, which can result in severe hypotension and cardiac arrest, and uncertain neurologic consequences. The authors report an extremely rare case of a 56-year-old woman who underwent direct surgical repair by end-to-end anatomosis of an unanticipated VA injury during C2 pedicle screwing. Postoperatively, the patient showed no neurological deterioration and computed tomography angiography of the VA demonstrated normal blood flow. Although direct occlusion of an injured VA by surgical ligation or endovascular embolization has been used for management of an unanticipated VA injury during surgery, these methods may be associated with significant morbidity and mortality. However, despite its technical demand, microvascular primary repair can restore normal blood flow and minimizes the risk of immediate or delayed ischemic complications. Here we report an iatrogenic VA injury during C2 pedicle screwing, which was successfully treated by end-to-end anastomosis.

Research progress of iatrogenic vertebral artery injury / 中国矫形外科杂志

Iatrogenic vertebral artery injury is a rare complication in cervical spine surgeries,the consequences of which may be catastrophic.With the extensive development of cervical spine surgeries and application of diverse new internal fixations of cervical spine,there is a potential increase of risk of iatrogenic vertebral artery injury,which should be paid attention to.This article reviews the rate,cause and management etc.of iarogenic vertebral artery injury.

Intraoperative radiographic technique in defining the safe lateral limits of anterior cervical corpectomy / 中国矫形外科杂志

[Objective]To assess the accuracy and value of radiographic technique using computed tomography(CT) measurements in cadaveric specimens during anterior cervical corpectomy in order to define the safe lateral limit of dissection.[Method]The gutter of C4～6 corpectomy on 5 cadaveric samples was filled with radioopaque dye.An antero-posterior X-ray was used to measure the narrowest distance from dye column to the line of uncovertebral joints.A CT scan confirmed the distance from the borderline of the gutter to vertebral arteries.[Result]The distance between the X-ray dye column and the line of uncovertebral joints averaged 4.7 mm in the left and 4.2 mm in the right.While the distance from the borderline of the gutter to vertebral arteries with CT scan averaged 6.1 mm in the left and 5.9 mm in the right.The measured distance by radiographic technique underestimated the true distance.[Conclusion]Intraoperative radiographic technique can estimate the lateral distance between the gutter of corpectomy and vertebral arteries by measuring the distance from the dye column to the line of uncovertebral joints.This technique provides surgeons an additional margin of safety during anterior cervical corpectomy.

Vertebral Artery Injury during Anterior Cervical Spine Surgery: Report of Two Cases

Vertebral artery injury is a rare complication of anterior cervical approach. We report two patients who suffered injury to vertebral artery during anterior cervical spine surgery. The mechanism of injury, their operative management, and the subsequent outcome were assessed and relevant literatures reviewed. The awareness of the possibility of vertebral artery injury is most important to prevent and it's occurrence is best avoided by a thorough understanding of the anatomical relationships of the artery, the spinal canal, and the vertebral body and careful use of surgical instruments.

Selective Spinal Cord Infarction on Gray Matter in a Child with Injured Unilateral Vertebral Artery: A case report

Several studies report varing incidence of spinal cord injury without radiologic abnormality (SCIWORA) from 21% to 66% in children. Fifty-five percentage of SCIWORA involves the cervical cord. The mechanisms of neural damage of SCIWORA include flexion, hyperextension, longitudinal distraction and ischemia. But spinal cord infarction related to vertebral arterial injury is rare. The authors report a case of selective spinal cord infarction on gray matter with unilateral vertebral artery injury after a minor trauma, in a 4-year-old boy. Neurological signs and symptoms developed 12 hours after the trauma. Initial postcontrast magnetic resonance imaging (MRI) showed an enhancement in the left vertebral artery. Follow up postcontrast MRI showed a selective signal change on the central gray matter and unilateral vertebral artery. We present this case with the review of literatures.