Department of Neurosurgery, University of South Florida, Tampa, Florida, USA.
Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.
World Neurosurg. 2021 Apr;148:e518-e526. doi: 10.1016/j.wneu.2021.01.021. Epub 2021 Jan 15.
Penetrating vertebral artery injuries (VAIs) are rare but devastating trauma for which the approach to treatment varies greatly. The literature on treatment modalities is limited to case reports, case series, and 1 review, with the majority of cases being treated surgically. However, with the advent of digital subtraction angiography, treatment has shifted toward less invasive endovascular modalities that allows one to assess the flow and risks of sacrificing the vertebral artery (VA).
In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses, a systematic review of VAI was performed. Two case reports were also detailed. Using a multidisciplinary team, a decision algorithm was proposed for approaching penetrating VAIs.
We identified 169 patients. Of the penetrating VAI, the majority were occlusions, most commonly managed conservatively. Other injuries including pseudoaneurysm, dissection, transection, and arterial-venous fistula were treated predominantly endovascularly and occasionally with the surgical exploration/ligation. Most endovascular treatments included embolization without significant stroke or complication from VA sacrifice. However, there are incidences in which VA sacrifice should be avoided and these scenarios can be better delineated with digital subtraction angiography to assess flow and anatomy.
This systematic review not only details the updated treatment options but also provides a decision algorithm for the treatment of penetrating VAI. It highlights the shifting treatment options of penetrating VAI to endovascular therapy, as well as details VAI variants that may suggest stenting over embolization.
穿透性椎动脉损伤（VAIs）较为罕见，但却是一种破坏性极大的创伤，其治疗方法差异很大。关于治疗方式的文献仅限于病例报告、病例系列和 1 项综述，大多数病例采用手术治疗。然而，随着数字减影血管造影的出现，治疗方式已经转向创伤更小的血管内治疗，这种治疗方法可以评估椎动脉（VA）的血流和牺牲椎动脉的风险。
根据系统评价和荟萃分析的首选报告项目，对 VAIs 进行了系统评价。还详细介绍了 2 个病例报告。通过多学科团队，提出了一种处理穿透性 VAIs 的决策算法。
我们共确定了 169 名患者。穿透性 VAIs 中，大多数为闭塞，最常见的治疗方法是保守治疗。其他损伤包括假性动脉瘤、夹层、横断和动静脉瘘，主要采用血管内治疗，偶尔也采用手术探查/结扎。大多数血管内治疗包括栓塞，没有明显的中风或 VA 牺牲的并发症。然而，存在一些情况下应避免牺牲 VA，这些情况可以通过数字减影血管造影更好地评估血流和解剖结构。
本系统评价不仅详细介绍了最新的治疗选择，还为穿透性 VAIs 的治疗提供了决策算法。它强调了穿透性 VAIs 治疗方法向血管内治疗的转变，并详细介绍了可能提示支架置入优于栓塞的 VA 变异。
