title: Clinical and radiological outcomes following traumatic Grade 3 and 4 vertebral artery injuries: a 10-year retrospective analysis from a Level I trauma center. The Parkland Carotid and Vertebral Artery Injury Survey.
abstract: OBJECTIVE
  Grade 3 and 4 blunt vertebral artery (VA) injuries may carry a different natural course from that of lower-grade blunt VA injuries. Proper screening, management, and follow-up of these injuries remain controversial. Grade 3 and 4 blunt VA injuries were analyzed to define their natural history and establish a rational management plan based on lesion progression and cerebral infarction.
  
  
  METHODS
  A retrospective review of a prospectively maintained database of all blunt traumatic carotid and vertebral artery injuries from August 2003 to April 2013 was performed, and Grade 3 and 4 blunt VA injuries were identified. Grade 3 injuries were defined as stenosis of the vessel greater than 50% or the development of a pseudoaneurysm, and Grade 4 injuries were defined as complete vessel occlusion. Demographic information, radiographic imaging findings, number of imaging sessions performed per individual, length of radiographic follow-up, radiographic outcome at end of follow-up, treatment(s) provided, and documentation of ischemic stroke or transient ischemic attack were recorded.
  
  
  RESULTS
  A total of 79 high-grade (Grade 3 and 4) blunt VA injuries in 67 patients were identified. Fifty-nine patients with 66 high-grade blunt VA injuries were available for follow-up. There were 17 patients with 23 Grade 3 injuries and 42 patients with 43 Grade 4 injuries. The mean follow-up duration was 58 days for Grade 3 and 67 days for Grade 4 blunt VA injuries. Repeat imaging of Grade 3 blunt VA injuries showed that 39% of injuries were radiographically stable, 43% resolved, and 13% improved, while 1 injury radiographically worsened. Repeat imaging of the Grade 4 blunt VA injuries showed that 65% of injuries were radiographically stable (persistent occlusion), 30% improved (recanalization of the vessel), and in 2 cases (5%) the injury resolved. All Grade 3 injuries that were treated were managed with aspirin or clopidogrel alone, as were the majority of Grade 4 injuries. There were 3 cerebral infarctions thought to be related to Grade 4 blunt VA injuries, which were likely present on admission. All 3 of these patients died at a mean of 13.7 days after hospital admission. No cerebral infarctions directly related to Grade 3 blunt VA injuries were identified.
  
  
  CONCLUSIONS
  The majority of high-grade blunt VA injuries remain stable or are improved at final follow-up. Despite a 4% rate of radiographic worsening in the Grade 3 blunt VA injury group and a 35% recanalization rate in the Grade 4 blunt VA injury group, there were no adverse clinical outcomes associated with these radiographic changes. No cerebral infarctions were noted in the Grade 3 group. A 7% stroke rate was identified in the Grade 4 blunt VA injury group; however, this was confined to the immediate postinjury period and was associated with 100% mortality. While these data suggest that these high-grade vertebral artery injuries may require less intensive radiographic follow-up, future prospective studies are needed to make conclusive changes related to treatment and management.
authors.affiliation: Departments of Neurosurgery.
authors.forename: William W
authors.initials: WW
authors.lastname: Scott
authors.forename: Steven
authors.initials: S
authors.lastname: Sharp
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Figueroa
authors.forename: Alexander L
authors.initials: AL
authors.lastname: Eastman
authors.forename: Charles V
authors.initials: CV
authors.lastname: Hatchette
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Madden
authors.forename: Kim L
authors.initials: KL
authors.lastname: Rickert
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D020212:Carotid Artery Injuries / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy*; D002544:Cerebral Infarction / Q000209:etiology; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D013997:Time Factors; D014193:Trauma Centers; D016896:Treatment Outcome; D014711:Vertebral Artery / Q000293:injuries; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy*; D055815:Young Adult
keywords: CA = carotid artery; CTA = CT angiography; DSA = digital subtraction angiography; GCS = Glasgow Coma Scale; MVC = motor vehicle collision; PCVAIS = Parkland Carotid and Vertebral Artery Injury Survey; VA = vertebral artery; blunt cervical vascular injury; cerebral infarction; trauma; vascular disorders; vertebral artery injury