Management of extra-cranial vertebral artery injuries

Objectives. To review the management of vertebral artery injuries, and the impact of pre-operative angiography. Materials and methods. A retrospective review was conducted of all patients with vertebral artery (VA) injuries admitted to Groote Schuur Hospital, Cape Town between January 1987 and December 2002. Patients presenting with uncontrolled active bleeding or haemodynamic instability with a poor response to resuscitation were taken immediately to surgery. Stable patients, including those who stabilised after simple resuscitation, with evidence of a vascular injury (a bruit or a large haematoma) or trans-cervical gunshot wounds, underwent routine aortic arch and selective angiography. Results. One hundred and one patients with vertebral artery injuries were included in the study. Ninety-two patients sustained penetrating injuries (41 gunshot, 51 stab), three were iatrogenic and six due to blunt trauma. Angiography was performed as the primary investigation in 88 patients, while seven patients had angiography following surgery. Thirty-nine vertebral artery occlusions, 11 arteriovenous fistulae, two intimal injuries and 36 false aneurysms were identified. Thirty-three radiological interventions were performed. There were 22 associated vascular injuries in 16 patients, 27 nerve injuries in 25 patients, 11 osseous injuries in nine patients and eight aerodigestive injuries., Seven patients died. Conclusions. Angiography and intervention is of great benefit in the diagnosis and management of traumatic vertebral artery injuries. Angiography often avoids unnecessary exploration and permits endovascular treatment.