Traumatic vertebral artery injuries occur in up to twenty percent of hospitalized patients with traumatic brain injuries and up to seventy percent of those who suffer cervical spinal fractures. It is more common in high cervical spine fractures (C1, C2, or C3) and fractures above C6 that involve a subluxation, which involves a shift of one vertebral body over the next. Motor vehicle accidents are the most common mechanism of injury but vertebral artery injuries do occur with low velocity and low force mechanisms such as swimming and chiropractic manipulation. Fortunately, a vast majority of vertebral artery injuries are asymptomatic and will remain so with effective treatment.
The vertebral artery provides circulation to the posterior portion of the brain including the visual cortex, cerebellum, and brainstem. Neurological symptoms caused by unilateral vertebral artery injuries are the result of decreased arterial blood flow to these portions of the brain that the vertebral artery supplies. Symptoms include headache, neck pain, dizziness, imbalance, nausea, vomiting, and double vision. Seventy percent of those who become symptomatic from a vertebral artery injury do so within the first 24 hours of injury, the others are delayed sometime occurring several weeks following trauma. Studies indicate that stroke rates may exceed 50% in those with vertebral artery injuries that are untreated. Unilateral and bilateral vertebral artery injuries may cause a posterior circulation stroke that may carry a mortality rate up to 18% and cause profound disability. Therefore, asymptomatic and symptomatic vertebral artery injuries must be treated.
Trauma Centers routinely screen those at risk for traumatic vertebral artery injuries with a CT-Angiogram, a test that will identify ninety nine percent of all vertebral artery injuries. Studies indicate that those at risk include hospitalized patients with traumatic brain injury; cervical spine fractures especially those between C1 and C3, and cervical fractures with a subluxation. Those with motor complete spinal cord injury (no motor function below the level of injury) are significantly more likely to have vertebral artery injuries than those who are motor incomplete. Interestingly, patients with a cervical spine fracture without a spinal cord injury were just as likely to have vertebral artery injuries as those with an incomplete motor spinal cord injury.
Early screening with a CT-Angiogram is recommended in patients at risk for a traumatic vertebral artery injury since identification of vertebral artery injury will allow physicians to grade the severity of injury and the risk it poses to the brain. A CT-Angiogram will allow the physician to determine if there is sufficient collateral blood flow from other arteries to protect the brain if there were to be an occlusion to the damaged vertebral artery. A transected vertebral artery is the most severe injury, followed by an occlusion, then by arterial dissection that represents a tear in the arterial wall. By early identification of vertebral artery injuries, physicians can plan treatment and the future diagnostic testing necessary.
Dissection and hematoma in the wall of the artery will cause narrowing (stenosis) representing the less severe vertebral artery injury. It is estimated that 90% of traumatic vertebral artery injuries will resolve with treatment. Even the more severe occlusion will reopen in two thirds of cases. Treatment of a patient with a vertebral artery injury will consist of either antiplatelet drugs such as aspirin and Plavix or anticoagulation with Coumadin. In the polytrauma patient diagnosed with a vertebral artery injury, treatment may have to be delayed because of other concomitant medical conditions such as hemorrhagic brain contusions, subdural hematomas, and active bleeding that preclude anticoagulation or antiplatelet drugs. Asymptomatic vertebral artery injuries should be treated and should be followed until they are determined to have resolved by MRA or CT-Angiogram. Generally, the only patients requiring angioplasty are those with high-grade lesions who are symptomatic.
Case managers for a catastrophically injured client must understand the significance of a reported vertebral artery hematoma, vertebral artery dissection, vertebral artery pseudoaneurysm, and vertebral artery occlusion. These diagnoses may require lifetime treatment of antiplatelet agents or anticoagulation drugs. It is not uncommon for the catastrophically injured to have multiple diagnoses that require antiplatelet drugs or anticoagulation drugs. Unfortunately, it is also not uncommon for these drugs to be discontinued by physicians unaware of the previously diagnosed vertebral artery injury. A case manager must remain vigilant of the significance of this diagnosis to prevent a posterior circulation stroke into the future.
An Academic Physician Life Care Planner must work closely with an endovascular neurosurgeon to understand the significance of a vertebral artery injury. Only then will all the necessary and appropriate medical care be provided by the plan to the patient’s life expectancy. Future care may include diagnostic studies, physician follow up care, and medications.
Stokes related to TVAI may carry a mortality rate up to 18% and therefore, asymptomatic and symptomatic TVAI must be treated aggressively.
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