Scott William W, Sharp Steven, Figueroa Stephen A, Madden Christopher J, Rickert Kim L
Departments of Neurosurgery and.
J Neurosurg. 2014 Aug;121(2):450-6. doi: 10.3171/2014.4.JNS132235. Epub 2014 Jun 6.
Screening of blunt vertebral artery (VA) injuries has increased since research has shown that they occur at a higher incidence than originally reported. Grade 1 and 2 injuries are the most common form of blunt VA injury. Proper screening, management, and follow-up of these injuries remain controversial. In this report, imaging, progression, treatment, and outcomes of Grade 1 and 2 blunt VA injuries were analyzed to better define their natural history and to establish a rational management plan based upon their risk of progression and cerebral infarct.
A retrospective review of all blunt traumatic carotid artery and VA injuries from December 2003 to April 2013 was performed. For the purposes of this report, focus was given to Grade 1 and 2 VA injuries. Grade 1 injuries were defined as a vessel lumen stenosis of less than 25%, and Grade 2 injuries were defined as vessel lumen stenosis between 25% and 50%. Demographic information, radiological imaging, number of images performed per individual, length of radiological follow-up, radiological outcome at the end of follow-up, treatment provided, and documentation of stroke or transient ischemic attack were recorded.
One hundred eighty-seven Grade 1 and 2 VA injuries in 143 patients were identified. Of these 143 patients, 120 with 152 Grade 1 or 2 blunt VA injuries were available for follow-up. The mean duration of follow-up was 40 days. Repeat imaging showed that 148 (97.4%) Grade 1 or 2 blunt VA injuries were stable, improved, or resolved on final follow-up imaging. Seventy-nine patients (66%) were treated with aspirin, whereas 35 patients (29%) received no treatment. The remaining patients were treated with other antiplatelet agents or anticoagulant medication. Neuroimaging demonstrated 2 cases (1.7%) with posterior circulation infarcts that were believed to be related to their blunt VA injuries, both of which occurred during the initial hospitalization and within the first 4 days after injury.
Although follow-up imaging showed progressive worsening without radiological improvement in only a small number of patients with low-grade blunt VA injuries, these findings did not correlate with adverse clinical outcome. The posttraumatic cerebral infarction rate of 1.7% may be overestimated, and the use of acetylsalicylic acid or other antiplatelet or anticoagulant medication did not correlate with radiological changes or rate of cerebral infarction. While these data suggest the possibility that these low-grade VA injuries may not require treatment or follow-up, future prospective studies are needed to make conclusive changes related to management.
自从研究表明钝性椎动脉（VA）损伤的发生率高于最初报道以来，其筛查工作有所增加。1级和2级损伤是钝性VA损伤最常见的形式。对这些损伤进行恰当的筛查、管理和随访仍存在争议。在本报告中，分析了1级和2级钝性VA损伤的影像学表现、病情进展、治疗及结果，以更好地明确其自然病程，并根据其进展风险和脑梗死风险制定合理的管理方案。
对2003年12月至2013年4月期间所有钝性创伤性颈动脉和VA损伤进行回顾性研究。为撰写本报告，重点关注1级和2级VA损伤。1级损伤定义为血管腔狭窄小于25%，2级损伤定义为血管腔狭窄在25%至50%之间。记录人口统计学信息、放射影像学检查结果、每人的检查图像数量、放射学随访时间、随访结束时的放射学结果、所提供的治疗以及中风或短暂性脑缺血发作的记录。
共识别出143例患者的187处1级和2级VA损伤。在这143例患者中，120例患者的152处1级或2级钝性VA损伤可供随访。平均随访时间为40天。重复影像学检查显示，148处（97.4%）1级或2级钝性VA损伤在最终随访影像学检查时稳定、改善或恢复。79例患者（66%）接受了阿司匹林治疗，而35例患者（29%）未接受治疗。其余患者接受了其他抗血小板药物或抗凝药物治疗。神经影像学检查显示2例（1.7%）发生后循环梗死，据信与钝性VA损伤有关，均发生在初次住院期间及受伤后的头4天内。
尽管随访影像学检查显示只有少数低级别钝性VA损伤患者病情逐渐恶化且无放射学改善，但这些发现与不良临床结局无关。1.7%的创伤后脑梗死发生率可能被高估，使用乙酰水杨酸或其他抗血小板或抗凝药物与放射学改变或脑梗死发生率无关。虽然这些数据表明这些低级别VA损伤可能不需要治疗或随访，但未来需要进行前瞻性研究以对管理做出决定性改变。
