Contemporary management of combat-related vertebral artery injuries.

MedStar author(s):
Citation: The Journal of Trauma and Acute Care Surgery. 74(3):818-24, 2013 Mar.PMID: 23425741Institution: MedStar Washington Hospital CenterDepartment: RadiologyForm of publication: Journal ArticleMedline article type(s): Comparative Study | Journal Article | Research Support, Non-U.S. Gov'tSubject headings: *Diagnostic Imaging/mt [Methods] | *Endovascular Procedures/td [Trends] | *Military Personnel | *Neck Injuries/su [Surgery] | *Vascular System Injuries/su [Surgery] | *Vertebral Artery/in [Injuries] | Adult | Afghan Campaign 2001- | Follow-Up Studies | Humans | Incidence | Male | Neck Injuries/ep [Epidemiology] | Neck Injuries/ra [Radiography] | Retrospective Studies | Treatment Outcome | United States/ep [Epidemiology] | Vascular System Injuries/ep [Epidemiology] | Vascular System Injuries/ra [Radiography] | Vertebral Artery/ra [Radiography] | Vertebral Artery/su [Surgery] | Young AdultYear: 2013Local holdings: Available online from MWHC library: 1995 - present, Available in print through MWHC library: 1999 - 2006Name of journal: The journal of trauma and acute care surgeryAbstract: 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.CONCLUSION: 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.LEVEL OF EVIDENCE: Therapeutic study, level V.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.All authors: Armonda RA, Bell RS, Fox CJ, Gillespie DL, Greer LT, Kuehn RB, White PWFiscal year: FY2013Digital Object Identifier: Date added to catalog: 2013-09-17
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Journal Article MedStar Authors Catalog Article 23425741 Available 23425741

Available online from MWHC library: 1995 - present, Available in print through MWHC library: 1999 - 2006

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.

CONCLUSION: 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.

LEVEL OF EVIDENCE: Therapeutic study, level V.

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.

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