Vertebral artery injuries in penetrating neck and cervical spine trauma

Abstract

Although relatively rare, vertebral artery (VA) injuries are a source of significant morbidity and mortality after penetrating neck trauma and are frequently associated with cervical spine injuries. In addition to the risk of massive hemorrhage, partial VA injuries carry a significant risk of posterior circulation stroke. In contrast, total occlusion of a VA is generally well tolerated, with only 2-3 % risk of ischemic stroke due to poor collateral circulation. Therefore, VA sacrifice should always be considered if surgical or endovascular repair is not feasible. Patients presenting with active hemorrhage should undergo emergent surgical exploration and/or angiography to identify and repair the injured vessel. In contrast, stable patients should undergo a thorough physical examination followed by CTA. Endovascular treatment is generally preferred over surgery, given its low risk of complications, high technical success rate, and the possibility of stenting for vessel preservation. However, given the need for prolonged dual antiplatelet therapy, the decision to stent an acutely injured VA should be cautiously made. Nonhemorrhagic VA dissections are often managed with antithrombotic therapy, although the potential benefits of treatment should be carefully weighed against the hemorrhagic risks. Outcomes after penetrating neck trauma are typically determined by associated injuries, rather than the VA injury itself. Neurological deficits, in particular, are almost always due to direct spinal cord or nerve root damage, not posterior circulation stroke. Given recent advances in prehospital and critical care, as well as surgical and endovascular techniques, mortality rates following VA injury have significantly dropped, averaging 5-7 % in contemporary practice.