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Updated: Dec 7 2022

Vertebral Artery Injury

  • Epidemiology
    • Incidence of vertebral artery injury (VAI)
      • 0.5% of all trauma patients
        • 70% of VAI in blunt trauma has associated cervical fracture
        • 33%-39% of all cervical spine fractures
      • 0.3% anterior cervical spine surgery
      • 4.1-8.2% posterior cervical spine surgery (C1-2 transarticular screws)
  • Etiology
    • Pathophysiology
      • blunt traumatic injury
        • pathoanatomy
          • highest injury risk at point of entry into C6 transverse foramen
          • second highest risk at C1-2 articulation
      • iatrogenic injury during elective surgery
        • safe zone
          • C1: avoid dissection cephalad to the C1 posterior arch > 1.5 cm lateral to midline
          • C1 lateral mass screw should be placed in a 10 degrees medial and 22 degrees cephalad trajectory
  • Anatomy
    • 4 arterial segments
      • V1
        • extraosseous
        • origin at subclavian artery, anterior to C7 transverse process, to the entry point of C6 transverse foramen
      • V2
        • within the transverse foramina of C6-C1
        • most traumatic injuries occur here
        • high risk during drilling, tapping, insertion of lateral mass or pedicle screws
      • V3
        • superior aspect of the arch of atlas to foramen magnum
        • VA is vulnerable during lateral exposure and laminectomy of C1
        • high risk of C1-2 transarticular screws are directed caudally and laterally
      • V4
        • intradural extension from foramen magnum to unite with contralateral vertebral artery
        • forms the basilar artery
      • most injuries from cervical trauma in V2 (foraminal segment)
    • Anomalous anatomy
      • reported prevalence of 2.7% in anterior cervical surgery
        • transverse foramen may be medial to or within 1.5mm of the uncovertebral joint
      • reported prevalence of 2.3-20% in the atlantoaxial region
        • high-riding C2 foramen
        • C2 pedicle erosion
        • C2 lateral mass thinning
  • Classification
      • Biffl VAI Injury Grading
      • Grade I
      • Arteriographic appearance of vessel dissection/intraumural hematoma; <25% luminal stenosis
      • Grade II
      • Intraluminal thrombosis or raised intimal flap; dissection/intramural hematoma with >25% luminal stenosis
      • Grade III
      • Pseudoaneurysm
      • Grade IV
      • Vessel occlusion
      • Grade V
      • Vessel transection
  • Presentation
    • History
      • consists of recent:
        • cervical spine trauma
          • C1 or C2 fractures
          • subaxial facet fractures and dislocations
        • elective surgery of the cervical spine or craniocervical junction
    • Symptoms
      • variable in presentation and time of onset
      • vertebrobasilar insufficiency manifests with
        • dizziness
        • vertigo
        • nausea
        • diplopia
        • blindness
        • ataxia
        • bilateral weakness
        • oropharyngeal dysfunction
  • Imaging
    • Radiographs
      • xrays of certain fracture patterns raise suspicion for VAI
    • CT angiography (CTA)
      • identification of local occlusion or extravasation 
      • sensitivity reported at 100%
      • indications for the trauma patient (any single criteria is an indication)
        • unexplained central or lateralizing neurologic deficit
        • evidence of acute cerebral infarct on CT scan of head
        • GCS <9
        • evidence of diffuse axonal injury
        • facial fracture or Le Fort type-II or III fracture
        • cervical spine fracture or subluxation
          • C1, 2, 3 fracture
          • Fracture extension into the transverse foramen
          • VAI demonstrated in 20%
        • cervical spinal cord injury
        • hanging injuries
        • major thoracic injury or first-rib fracture
    • Magnetic resonance angiography (MRA)
      • identification of local occlusions/stenosis
      • sensitivity 93.9%
      • indications
        • cervical spine fractures with neurologic deficits attributable to damaged vertebral or basilar artery perfusion
      • sensitivity and specificity
  • Treatment
    • Post-operative anticoagulation
      • goal is to prevent thromboembolic sequelae of injury
        • intravenous heparin
        • acetylsalicylic acid (aspirin)
          • indications
            • first line of treatment
          • modalities
            • heparin, aspirin, clopidogrel, IV thrombolysis, glycoprotein IIb/IIIa antagonists (abciximab, eptifibatide, tirofiban)
      • contraindications:
        • major intracranial infarction
        • intraspinal hematoma/arteriovenous fistula
    • Operative reduction and stabilization as neccessitated by fracture pattern
    • Surgical techniques to control hemorrhage (see Techniques)
    • Immediate intra-operative angiography
      • can assist intra-operative decision making
    • Post-operative management following iatrogenic injury
      • observation
        • further intervention dictated by clinical course
      • immediate post-operative angiography
        • detects vascular complications
        • confirms adequate collateral cerebral circulation
        • allows embolization of fistulae or pseudoaneurysm
  • Techniques
    • Hemostatic tamponade
      • utilization of topical hemostatic agents, bone wax
      • if injured during C1-2 transarticular screw placement, can tamponade by screw insertion
      • risks include:
        • delayed hemorrhage
        • fistula formation
    • Microvascular repair
      • allows restoration of normal blood flow
      • minimizes risk of ischemic complications
      • technically demanding
    • Direction ligation
      • consider intraoperative angiography first to evaluate collateral circulation
      • risks certain morbities
        • cerebellar infarction
          • loss of flow via the posterior inferior cerebellar atery (PICA)
        • isolated cranial nerve paresis
        • hemiplegia
    • IR-guided embolization
  • Complications
    • Complications may occur days to years following injury
      • arteriovenous fistula
      • late-onset hemorrhage
      • pseudoaneurysm
        • may be delayed presentation
      • thrombosis with embolic incidents
      • cerebral ischemia/Stroke
        • persistent vertigo
      • death
  • Prognosis
    • Impact of VAI difficult to predict
    • Many patients initially asymptomatic
      • some progress to cerebral ischemia or stroke with permanent neurologic deficit
    • Variable symptomatology
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