Prevención, manejo y seguimiento de las lesiones de la arteria vertebral. Conocimiento actual de los cirujanos de columna de la Argentina / Prevention, management and monitoring of vertebral artery injuries. Current state of knowledge of spine surgeons in Argentina

Introducción: La lesión de la arteria vertebral es un evento grave. El objetivo del estudio fue evaluar el grado de conocimiento de los cirujanos de columna en la Argentina sobre las medidas diagnósticas y terapéuticas de la lesión de la arteria vertebral. Materiales y métodos: Se realizó un estudio descriptivo observacional mediante una encuesta difundida a través de la AANC y la SAPCV. Resultados: Se recibieron 157 respuestas. El 47,4% considera relevante evaluar la anatomía de la arteria vertebral en todo tipo de patología mediante métodos angiográficos. La mitad de los encuestados diagnosticó una variante anatómica de la arteria. El 29,2% manifestó haber tenido en su práctica una lesión de la arteria. Solo el 35% tiene un protocolo de acción para el manejo de este evento adverso. El 77% adopta como primera medida el taponamiento. En el seguimiento posquirúrgico, la mayoría estudia el estado final mediante métodos angiográficos. Alrededor del 10% procuraría instaurar alguna medida de profilaxis antitrombótica. El 76,6% dispone de Servicio de Hemodinamia con cirujano endovascular. Conclusión: Esta complicación está subestimada. Menos de la mitad de los cirujanos utiliza, como rutina, herramientas de diagnóstico de posibles alteraciones anatómicas. No se han observado protocolos de manejo ni seguimiento de estas lesiones. Nivel de Evidencia: IV

Introduction: Vertebral artery injury is a serious event. The objective of this work is to evaluate the degree of knowledge of spinal surgeons in Argentina regarding the diagnostic and therapeutic measures of vertebral artery injury. Materials and methods: An observational descriptive study was carried out through a survey transmitted through AANC and SAPCV. Results: Of 157 responses, 47.4% consider it relevant to evaluate the anatomy of the vertebral artery in all types of pathology by angiographic methods. Half of those surveyed diagnosed an anatomical variant of the artery, 29.2% reported having encountered an artery injury during their practice and only 35% had an action protocol for the management of this adverse event. 77% adopted tamponade as their first measure. In the postoperative follow-up, the majority of surgeons studied the final state of the situation using angiographic methods. Around 10% would try to establish some measure of antithrombotic prophylaxis. 76.6% have an hemodynamics service with an endovascular surgeon. Conclusion: We found an underestimation of this complication. Less than half of surgeons routinely use diagnostic tools for possible anatomical changes. Management or monitoring protocols for these injuries have not been observed. Level of Evidence: IV

Characteristics and Forensic Identification of Blunt Vertebral Artery Injury / 法医学杂志

Blunt vertebral artery injury occurs frequently in forensic practice. However, injuries of the vertebral artery are easily ignored or overlooked because of its relatively deep location. Through literatures review, this paper finds that the manners of blunt vertebral artery injury are varied and one or more injury mechanisms may be involved simultaneously. Patients often undergo immediate or delayed cerebral apoplexy as well as compression and injury of surrounding structures, due to direct injury or secondary aneurysm or dissection, resulting in disability or death. Diseases such as, vertebral atherosclerosis and dysplasia can increase the disability and death risk and the difficulty of forensic identification. In forensic identification, the details of the case should be considered. For cases of suspected vertebral artery injury, in addition to routine examination of intracranial segment, attention should be paid to the examination of extracranial segment. If conditions permit, angiography can be used prior to or during the autopsy to improve the identification efficiency and accuracy of opinions.

Scapulothoracic dissociation and blunt vertebral vascular injury: case report / > Disociación escapulo-torácica y trauma cerrado de arteria vertebral: reporte de un caso

Abstract Case Description: A 24-year-old male suffers from a motor vehicle accident with penetrating neck trauma and concomitant closed left cervicothoracic trauma. Clinical Findings: High impact trauma causing hypovolemic shock, left zone I penetrating neck trauma, ischemia due to blunt trauma to the axillary vessels, and brachial plexus injury. Transection of the vertebral artery on angiotomography. Diagnosed with scapulothoracic dissociation and vertebral artery trauma. Treatment and outcome: Axillary arteriovenous reconstruction, fasciotomies, non-surgical approach of the vertebral artery trauma, and deferred treatment of the brachial plexus trauma were performed. Survival of the patient and his limb, with major neurologic sequelae Clinical Relevance: The case presented here is an example of scapulothoracic dissociation with associated trauma to the vertebral artery, injuries that are uncommon and associated with high morbidity and mortality. Early recognition of the injuries and a multidisciplinary approach for this complex case by surgical board reviews at various levels within the course of care were key determinants in the patient's improved prognosis. This case report presents an analysis of the diagnostics, treatment, and course; considering in-hospital care and the decision-making process as determinants for the prognosis in a polytrauma patient.

Resumen Descripción del caso: Varón de 24 años que sufre accidente automovilístico con trauma penetrante de cuello y trauma cerrado cervico torácico izquierdo concomitante. Hallazgos clínicos: Shock hipovolémico, trauma en zona I cuello izquierdo, isquemia por trauma cerrado de vasos axilares y lesión por trauma cerrado del plexo braquial; producto de trauma de alto impacto. Sección de arteria vertebral por angiotomografia. Se diagnostica disociación escapulo-torácica y trauma de arteria vertebral. Tratamiento y resultado: Reconstrucción vascular arterio-venosa axilar, fasciotomías y abordaje no operatorio del trauma de arteria vertebral, con manejo diferido del trauma del plexo braquial. Sobrevida del paciente y su extremidad, con secuelas neurológicas mayores. Relevancia clínica: Es un caso de disociación escapulotorácica y lesión de arteria vertebral concomitante, siendo esta una asociación infrecuente y de alta morbi-mortalidad. El reconocimiento temprano de las lesiones y un abordaje multidisciplinario de este escenario de complejidad por medio de juntas quirúrgicas en varios niveles del proceso de atención, fueron determinantes para cambiar el pronóstico del paciente. Se presenta un análisis del diagnóstico, manejo y evolución; considerando el proceso de atención hospitalaria, toma consensuada de decisiones y el pronóstico en un paciente politraumatizado.

Ruptura traumática de la arteria vertebral por herida penetrante en el cuello / Traumatic rupture of the vertebral artery caused by penetrating neck injury

Introducción: la exanguinación es una entidad clínica dramática que requiere rapidez de pensamiento y acción para obtener buenos resultados.Presentación del caso: se reporta el caso de un paciente de 13 años que sufrió accidente automovilístico y fue atendido en el Hospital Pediátrico Eliseo Noel Camaño , de la provincia de Matanzas, Cuba. El niño llegó con múltiples traumas en miembros superiores e inferiores, y una herida penetrante en el cuello que requirió tratamiento quirúrgico inmediato para controlar hemorragia. Se necesitó un acceso multidisciplinario de intensivistas, anestesiólogos, cirujanos pediátricos, neurocirujanos y cirujanos vasculares, porque la cuantía del sangrado y la localización de la lesión hicieron sospechar una afección traumática de la arteria vertebral. El niño sobrevivió a la lesión exanguinante, y actualmente se encuentra en proceso de recuperación.Conclusiones: la lesión penetrante del cuello puede provocar ruptura traumática de la arteria vertebral, entidad infrecuente que requiere alta sospecha diagnóstica para lograr éxito en su tratamiento. Consideramos vital la visión multidisciplinaria, en la que deben prevalecer maniobras seguras, rápidas y eficientes(AU)

Introduction: exsanguination is a dramatic clinical condition that requires quick analysis and action to achieve good results.Case report: this is a 13 years/old patient who suffered a car accident and was seen at Eliseo Noel Camano pediatric hospital in Matanzas province, Cuba. The teenager had many upper and lower limb traumas and a penetrating neck injury that required immediate surgery to control hemorrhage. It was necessary to involve intensive care experts, anesthesiologists, pediatric surgeons, neurosurgeons, and vascular surgeons because the amount of bleeding and the location of injury aroused the suspicion of traumatic damage of the vertebral artery. The teenager managed to survive from the exsanguinating injury and is currently in his recovery process.Conclusions: the penetrating neck injury may cause traumatic rupture of the vertebral artery, an uncommon condition that requires great diagnostic suspicion in order to succeed in treatment. It is vital to have a multidisciplinary vision in which safe, rapid and effective procedures should prevail(AU)

Síndrome del robo de la subclavia / Syndrome of subclavian steal

Paciente femenina de 46 años de edad, con antecedentes de hipertensión arterial y fumadora habitual. Desde hace 2 años presenta episodios aislados y breves de vértigos, inestabilidad postural, sensación de desfallecimiento sin alteraciones de la conciencia, después de realizar ejercicios del brazo izquierdo. El examen neurológico muestra asimetría de pulsos carotídeos y radiales. El doppler extracraneal reveló alteraciones ateroscleróticas en ambos ejes carotídeos, con estenosis derecha del 50 %, disminución del flujo de la arteria vertebral izquierda y obstrucción proximal de la arteria subclavia izquierda proximalmente. El síndrome del robo de la subclavia es una entidad poco frecuente, su diagnóstico es clínico y se demuestra mediante doppler o angiografía. El tratamiento debe ser decidido individualmente en cada caso.

A 46 year-old female patient with a history of hypertension and regular smoker complained of isolated and brief episodes of dizziness, postural instability, faint feeling without altered consciousness, after exercise the left arm for 2 years. Her neurological examination showed asymmetry of carotid and radial pulses. Her extracranial doppler revealed carotid atherosclerotic changes in both axes, with 50 % right stenosis, decreased flow of the proximal left vertebral artery and obstruction of the proximal left subclavian artery. Subclavian Steal Syndrome is a rare condition. Its diagnosis is clinical and it is demonstrated by Doppler or angiography. Treatment should be determined individually in each case.

Traumatic Entrapment of the Vertebrobasilar Junction Due to a Longitudinal Clival Fracture: A Case Report

Vertebrobasilar junction entrapment due to a clivus fracture is a rare clinical observation. The present case report describes a 54-yr-old man who sustained a major craniofacial injury. The patient displayed a stuporous mental state (Glasgow Coma Scale [GCS]=8) and left hemiparesis (Grade 3). The initial computed tomography (CT) scan revealed a right subdural hemorrhage in the frontotemporal region, with a midline shift and longitudinal clival fracture. A decompressive craniectomy with removal of the hematoma was performed. Two days after surgery, a follow-up CT scan showed cerebellar and brain stem infarction, and a CT angiogram revealed occlusion of the left vertebral artery and entrapment of vertebrobasilar junction by the clival fracture. A decompressive suboccipital craniectomy was performed and the patient gradually recovered. This appears to be a rare case of traumatic vertebrobasilar junction entrapment due to a longitudinal clival fracture, including a cerebellar infarction caused by a left vertebral artery occlusion. A literature review is provided.

Endovascular Stent-Graft Treatment of a Traumatic Vertebral Artery Pseudoaneurysm and Vertebrojugular Fistula

An endovascular intervention is a feasible alternative to the technically challenging conventional surgery for the treatment of traumatic vertebral arterial lesions. This report describes a rare case involving a 22-year-old patient with a traumatic vertebral arterial pseudoaneurysm and multiple arteriovenous fistulas which were successfully sealed using the endovascular stent-graft technique.

Blunt cerebrovascular injuries

Durante a década passada, o reconhecimento e tratamento do traumatismo cerebrovascular contuso, sofreu importante evolução. Este tipo de ferimento era considerado como ocorrência rara, mas atualmente o quadro é diagnosticado em cerca de 1% dos pacientes. O reconhecimento da existência de um período clínico silencioso permite uma seleção angiográfica baseada no mecanismo de trauma e na sistematização dos ferimentos dos pacientes. A avaliação sistemática e a suspeita diagnóstica precoce destes pacientes tem resultado em rápido confirmação durante a fase assintomática, permitindo a instauração de tratamento cuja meta é impedir o desenvolvimento de seqüelas neurológicas. Embora o tratamento ideal, antitrombótico, ainda precise ser determinado, o uso de agentes antiplaquetários ou anticoagulantes reduz a incidência de lesões cerebrovasculares relacionada a fenômenos tromboembolíticos. O traumatismo cerebrovascular contuso é raro, porém devastador. A seleção angiográfica apropriada em pacientes de alto risco deve ser realizada e o tratamento deve ser imediatamente iniciado para impedir eventos neurológicos isquêmicos.

Aneurisma da artéria vertebral extracraniana em puérpera portadora de neurofibromatose clássica / Extracranial vertebral artery aneurysm during the puerperium in women with neurofibromatosis type 1

Paciente de 26 anos, no 10° dia de puerpério, apresentou dor súbita em região cervical esquerda irradiada para região supraclavicular do mesmo lado, seguida de aparecimento de massa pulsátil. Relatava hipertensão sistólica média de 160 mmHg, e diastólica média de 130 mmHg na gravidez e neurofibromatose. Ao exame físico, apresentava massa pulsátil em região supraclavicular esquerda, sem frêmitos e/ou sopros. Um alargamento do mediastino foi detectado através de raio-x de tórax. Uma tomografia computadorizada (região cervical e torácica) evidenciou tumoração em território de artéria subclávia esquerda na sua porção proximal, sem limites definidos pelo extravasamento de contraste, além de hemotórax gigante à esquerda. A paciente evoluiu com choque hipovolêmico, sendo submetida à cirurgia de urgência, com toracotomia seguida de cervicotomia, onde se evidenciou lesão aneurismática rota da artéria vertebral esquerda logo após sua emergência. Após controle do sangramento, procedeu-se à sua ligadura. A paciente evoluiu satisfatoriamente, estando em acompanhamento ambulatorial.

A 26-year-old patient, on the 10th day of the puerperium, presented sudden pain in the left cervical region irradiated to the supraclavicular region on the same side, followed by the presence of a pulsatile mass. She reported a mean systolic hypertension of 160 mmHg, and mean diastolic hypertension of 130 mmHg in pregnancy and neurofibromatosis. At physical examination, she presented a pulsatile mass in the left supraclavicular region, without thrill and/or murmur. A widening of the mediastinum was detected by a thoracic X-ray. A computed tomography (cervical and thoracic region) showed a pulsatile mass in the territory of the left subclavian artery in its proximal portion, without having limits defined by contrast extravasation, besides a giant hemothorax on the left. The patient evolved with hypovolemic shock and was submitted to an urgent surgery, undergoing thoracotomy followed by cervicotomy, in which a ruptured aneurysmal lesion of the left vertebral artery was shown right after its emergency. After controlling the bleeding, a ligation was performed. The patient progressed satisfactorily, having an outpatient follow-up.

Heridas penetrantes del cuello. Experiencia de 28 casos / Penetring injuries of the neck. Experiencie in 28 cases

La presente comunicación tiene por objeto presentar una serie de 28 pacientes con heridas penetrantes del cuello, atendidos por los autores en un lapso de 1970 a 1996. Estos lesionados acudieron a los Hospitales ®La Villa¼ del D.F., Hospital Central Militar, y dos instituciones privadas, en todos ellos se conoce el mecanismo tipo de la lesión, tratamiento, evolución y estado final del enfermo. Se establecen conductas para decidir sobre la cirugía inmediata o selectiva, el criterio para establecer anastomosis o ligadura en las lesiones arteriales, el manejo de las lesiones aerodigestivas, las vías de acceso al cuello y una técnica original de manejo de las lesiones de la caja laríngea, se hace una revision amplia de la literatura pertinente

Seudo-aneurisma de la arteria vertebral en el cuello. Comunicación de un caso / Pseudoaneurysm of vertebral artery in the neck. Communication of a case

Por lo poco frecuente de la situación presentamos un caso de seudoaneurisma postraumático de la arteria vertebral en el cuello, en una mujer joven. Previo a esta intervención, presentó herida lateral del cuello por arma blanca, cinco meses antes. Se intervino con diagnóstico de seudoaneurisma de la arteria carótida común derecha, comprobándose en la intervención el diagnóstico. Debido a la localización del seudoaneurisma entre dos apófisis transversas y que el extremo distal del mismo estaba por ingresar al hueso, no existían posibilidades de ligarlo, realizándose la resección y endoaneurismorrafia. Se realizó un seguimiento de 5 años y medio, clínico y una arteriografía por tomografía computada doble helicoidal sin mostrar recidiva

Pseudoaneurisma de artéria vertebral: relato de caso clínico / False aneurysm of the vertebral artery: report of a case

Os autores apresentam um caso de pseudoaneurisma da artéria vertebral, pós-trauma, em paciente de 12 anos. O trauma da artéria vertebral é incomum e ocorre em menos de 10 por cento dos traumas vasculares da cabeça e do pescoço, segundo a literatura. O propósito deste relato de caso é chamar a atençao para o diagnóstico arteriográfico, onde devemos estudar também a circulaçao intracraniana, da qual dependerá a escolha do melhor tratamento cirúrgico.

Disección de arteria vertebral: presentación de un caso y revisión de la literatura / Vertebral artery disection: 1 case report and literature review

Vertebral artery dissection seems to be a frequent cause of stroke in young adults. We report a 34 years old female that suffered a cardiac arrest while practicing aerobics, with complete recovery and four months later developed an acute Wallenberg`s syndrome. Magnetic resonance imaging showed an infarction in the right cerebellar hemisphere. Angiography revealed an occlusion of the third segment (V3) of the right vertebral artery which was hypoplastic. The patient was anticoagulated with a favorable clinical outcome. A follow up angiography, performed six months later, showed an incomplete recanalization of the vessel. Vertebral artery dissection should be suspected in every patient with ischemic symptoms or signs related to the vertebrobacilar territory, specially in young or middle aged patients with a history of trauma. magnetic resonance imaging and ultrasound-doppler examinations are the diagnostic test of choice

Traumatic subarachnoid haemorrhage: elastic tissue distribution across the wall of some major cerebral arteries in relation to arterial wall disruption

The observed shredding of the vertebro-basilar arterial wall in cases dying of traumatic subarachnoid haemorrhage, together with the uneven centrifugal travel of tears across the wall indicate that, arterial wall never blows out like a simple tube of homogeneous structure, and that there might be some mechanical weak points of apparent normal histological structure. In this work, examination of three groups of intact, in-vivo ruptured and in-vitro ruptured vertebral arteries showed that across the wall of the vertebral artery, the elastic fibres are non-uniformly distributed at the tunica media and adventitia. This finding, would result in uneven strain across the wall when become stressed by the water hammer pressure wave to produce such a type of arterial wall disruption at sites of scanty or lacking elastic fibres

Angioplastía transluminal percutánea de los troncos supraórticos / Percutaneus transluminal angioplasty of the supraortic branches

La angioplastía transluminal percutánea (ATP) de los troncos supraórticos son en la actualidad un método seguro, eficaz y económico para el tratamiento de las lesiones estenóticas de los vasos con destino cervicoencefálico, además de que los indices de morbimortalidad son similares o menores a los publicados para endarterectomía. Este trabajo presenta una revisión bibliografíca de la técnica, indicaciones, resultados y complicaciones de la ATP. La puede llegar a ser método de elección par el tratamiento de las estenósis no ulceradas de los troncos supraórticos.

Trauma de la arteria vertebral: embolizacion selectiva: presentacion de 1 caso / Vertebral artery trauma: selective embolization: presentation of 1 case

Presentamos un caso de fistula arteriovenosa de la arteria vertebral izquierda de origen traumatico, tratada exitosamente con embolizacion proximal y distal; a los 3 anos de seguimiento no hay evidencia de recidiva. La embolizacion selectiva de la arteria vertebral es el tratamiento de eleccion en el control parcial o total de una comunicacion arteriovenosa de la arteria vertebral