title: Contemporary management of combat-related vertebral artery injuries.
abstract: BACKGROUND
  Vertebral artery injuries (VAIs) following cervical trauma are uncommon. Advances in imaging technology and emerging endovascular therapies have allowed for the improved diagnosis and treatment of VAIs. We aimed to examine the contemporary management of combat-related penetrating VAIs during current US military operations.
  
  
  METHODS
  A retrospective review was performed on US casualties with combat-related VAIs evacuated to a single military institution in the US from September 2001 to 2010 for definitive management. Casualty demographics, mechanism of injury, location and type of VAI, neurologic sequela, associated injuries, method of diagnosis, and therapeutic management were collected.
  
  
  RESULTS
  Eleven casualties with a mean age of 26 years (mean [SD] ISS, 18 [7.0]) were found to have VAIs from gunshot wounds (6, 55%) or blast fragments (5, 45%). Cervical spine fractures (8, 72%), facial fractures (5, 45%), and spinal cord injury (3, 27%) were not uncommon. One casualty experienced a posterior cerebellar and parietal infarcts. All injuries were evaluated with digital subtraction angiography, 64-slice multidetector row computed tomography, or both. Casualties were noted to have vertebral artery occlusion (4, 36%), pseudoaneurysms (5, 45%), dissection (1, 9%), or arteriovenous fistula (1, 9%), with most injuries occurring in the V2 segment (6, 55%). Pseudoaneurysms were treated with coiling or stent-assisted coiling. Of 11 casualties, 6 were managed nonoperatively, half of whom with anticoagulation or antiplatelet therapy.
  
  
  CONCLUSIONS
  VAIs are infrequent in modern combat operations, occurring in only 3% of casualties experiencing arterial injuries and are often incidentally discovered during the delayed secondary evaluation of penetrating face and neck injuries at higher echelons of care. One should have a high index of suspicious for a VAI in a casualty with concurrent cervical spine fractures. Endovascular therapies using coils and covered stents have expanded the management options and simplified the treatment of combat-related VAIs.
  
  
  METHODS
  Therapeutic study, level V.
authors: General Surgery Service, Department of Surgery, Walter Reed National Military Medical Center, Uniformed University of the Health Sciences, Bethesda, Maryland 20889-5600, USA.
authors: Lauren T
authors: LT
authors: Greer
authors: Reed B
authors: RB
authors: Kuehn
authors: David L
authors: DL
authors: Gillespie
authors: Paul W
authors: PW
authors: White
authors: Randy S
authors: RS
authors: Bell
authors: Rocco A
authors: RA
authors: Armonda
authors: Charles J
authors: CJ
authors: Fox
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D003952:Diagnostic Imaging / Q000379:methods*; D057510:Endovascular Procedures / Q000639:trends*; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008889:Military Personnel; D019838:Neck Injuries / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D011859:Radiography; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D057772:Vascular System Injuries / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D014711:Vertebral Artery / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D055815:Young Adult