BACKGROUND
Aggressive screening for blunt cerebrovascular injury (BCVI) has uncovered an astonishing incidence of vertebral artery injuries (VAIs) and associated stroke rate. Stroke incidence is reduced with early recognition and prompt anticoagulation. Because of the proximity of the cervical spine and vertebral arteries, we queried whether all patients with cervical spine fractures required arteriography to rule out VAI.
METHODS
Four-vessel cerebrovascular angiography remains the standard screening test for patients at risk for BCVI. Patients undergoing angiographic screening for blunt cerebrovascular injuries have been prospectively followed at our regional trauma center since January 1990; however, in January 1996, we began aggressive screening based on injury patterns.
RESULTS
Ninety-two patients with vertebral artery injuries were identified during the study period from January 1996 to June 2002. Two patients with vertebral injuries had minor cervical fractures, a C6 body fracture and a C7 spinous process/laminar fracture; both underwent diagnostic angiography for injury mechanism. Of the 21 patients without cervical spine fracture, angiographic screening for BCVI was performed for neurologic symptoms (11 patients), basilar skull fracture (6 patients), or severe facial fractures (4 patients). Cervical spine fracture was the sole indication for VAI in 69 patients. The fracture patterns were subluxations in 38 patients (55%) or extension of the fracture through the foramen transversarium in 18 patients (26%). The remaining injuries (18%) were located in the upper cervical spine: isolated C1 arch in eight patients and C2/3 body fractures in five patients.
CONCLUSION
Blunt vertebral artery injury is associated with complex cervical spine fractures involving subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Routine screening should incorporate these findings to maximize yield while limiting the use of invasive procedures.
[1]
E. Moore,et al.
Noninvasive diagnosis of blunt cerebrovascular injuries: a preliminary report.
,
2002,
The Journal of trauma.
[2]
T. Fabian,et al.
Prospective Screening for Blunt Cerebrovascular Injuries: Analysis of Diagnostic Modalities and Outcomes
,
2002,
Annals of surgery.
[3]
T. Fabian,et al.
Blunt cerebrovascular injuries: diagnosis and treatment.
,
2001,
The Journal of trauma.
[4]
E. Moore,et al.
The devastating potential of blunt vertebral arterial injuries.
,
2000,
Annals of surgery.
[5]
E. Moore,et al.
Optimizing screening for blunt cerebrovascular injuries.
,
1999,
American journal of surgery.
[6]
E. Moore,et al.
Blunt carotid arterial injuries: implications of a new grading scale.
,
1999,
The Journal of trauma.
[7]
E. Moore,et al.
The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome.
,
1998,
Annals of surgery.
[8]
T. Fabian,et al.
Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy.
,
1996
.
[9]
E. Benzel,et al.
The incidence of vertebral artery injury after midcervical spine fracture or subluxation.
,
1994,
Neurosurgery.
[10]
J. Woodring,et al.
Transverse process fractures of the cervical vertebrae: are they insignificant?
,
1993,
The Journal of trauma.
[11]
J. Louw,et al.
Occlusion of the vertebral artery in cervical spine dislocations.
,
1990,
The Journal of bone and joint surgery. British volume.