Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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June 25, 2020
Traumatic Vertebral Artery Injury (Dissecting Pseudoaneurysm)
- Background:
- Traumatic vertebral artery injuries are now increasingly recognized due to more frequent imaging screening for head and neck trauma. They are usually due to blunt trauma and have been reported in about 0.5–2%.
- The most common vertebral artery involved is the V2 segment between the C3 and C6 vertebrae.
- Clinical Presentation:
- Clinical diagnosis remains a challenge due to different presentations. These injuries need to be promptly identified, as they could lead to potential ischemic events.
- Symptoms may range from being asymptomatic to headaches, neck pain, dizziness, nausea, vomiting, and those related to posterior circulation stroke.
- Key Diagnostic Features:
- Denver grading scale for arterial injuries classifies and prognosticates injuries.
- Grade I: Mild intimal injuries with less than 25% luminal narrowing; risk of stroke is about 8%
- Grade II: Hematomas, dissections, or other intimal changes with a luminal stenosis of greater than 25%; risk of stroke is about 14%
- Grade III: Pseudoaneurysms; risk of stroke is about 26%
- Grade IV: Persistent occlusions during the early postinjury period; risk of stroke is about 50%
- Grade V: Arterial transection with free extravasations; mostly lethal
- Denver grading scale for arterial injuries classifies and prognosticates injuries.
- Differential Diagnosis:
- Spontaneous dissections and dissecting pseudoaneurysms
- Various genetic and environmental factors may act as triggers.
- Treatment:
- Treatment options are observation, antithrombotic therapy, endovascular repair, or surgery and depend on the grade of injury and concurrent symptoms. Unfractionated heparin is recommended because its effects are easily reversible when compared with antiplatelet drugs.
- Endovascular treatments include parent vessel occlusion and endovascular repair with stent. Parent vessel occlusion decreases the future risk of recurrence of pseudoaneurysm and should be strongly considered.
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