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Bertellotti et al. Vertebral artery transection

16,582 patients, a prevalence rate of 8.4 per 10,000. laceration with no active bleeding and the interventional
When examining penetrating trauma to the neck, the radiologist was consulted. Subsequently, the wound
incidence has been reported as between 1.0-7.4%, began to bleed rapidly and profusely. Pressure
with some variation attributed to mechanism (gunshot was applied. The patient was intubated; massive
wound versus stab wound). Some believe however, transfusion protocol was activated and the patient was
[2]
that the low incidence of vertebral artery injuries rapidly transported to the operating room (OR).
previously reported is due to inefficient diagnostic tools,
before the advent of routine angiography in penetrating In the OR, the wound was explored by enlarging the
neck trauma. [3,4] Even with angiography, there are incision longitudinally, and interventional radiology
variations in vertebral artery anatomy that should (IR) was contacted. Ideally, the patient should
be taken into consideration. Preoperative imaging have gone directly to IR suite upon his admission.
revealed anomalous variations in 50% of patients Unfortunately, the patient began to bleed significantly,
with vertebral artery injuries, in a multicenter study. thus precluding this option. IR however, had already
[1]
With increasing incidence of vertebral artery injury in been consulted. In the OR, the goal was to obtain
patients with cervical spine trauma, vertebral artery hemostasis through direct control of the vessel;
[5]
injuries should be ruled out in patients presenting with however, the location of the injury at the skull base
neck and cervical spine trauma. Early diagnosis and precluded this. Temporary control in the OR was
[6]
intervention is critical to successful management of therefore obtained.
vertebral artery injuries. Multiple complications result
from these types of injuries, and the point of entry In the OR, the sternocleidomastoid was partially
and exit of the foreign object in penetrating injuries transected. Bleeding was controlled from muscular
arterial and venous branches. A deeper wound
to the neck could predict susceptibility to injury and track in the anteromedial aspect of wound was
outcome. [5,7]
partially explored and bleeding was controlled. The
In a prospective study by Jang et al., none of sternocleidomastoid was re-approximated and the
[6]
the patients experienced secondary neurologic wound was closed. Estimated blood loss (EBL) was
deterioration from vertebrobasilar ischemia, similarly 1,100 mL. Total fluid replacement was 3,900 mL:
the patient in this case report also did not develop crystalloids 2,700 mL and 4 units packed red blood
neurologic sequelae. Other studies have also shown cells (PRBCs) 1,200 mL.
that with proper management, patients experience The patient was transported to the intensive care unit
uneventful recovery without residual effects. (ICU) pending IR arrival. Immediately upon arrival,
[1]
While neurologic deficits are rare complications the patient became hypotensive with a systolic BP
of vertebral artery injury, when neurologic deficit - 55 mmHg. He bled massively. Digital control was
occurs, they could be devastating and permanent. established and he was returned to the OR.
[1]
Other severe outcomes are complications of stroke,
pseudoaneurysm, late-onset hemorrhage, brain Senior trauma surgery staff was paged signal
stem and cerebellar infarcts, and death; [1,5,8,9] early transducer and activator of transcription to the OR. The
diagnosis and management are therefore critical to patient was then re-explored. The longitudinal incision
positive outcome. was extended and the sternocleidomastoid muscle
was completely transected along with the splenius
This case report aims to describe the roles of capitis muscle. Transverse processes of C1-C2 were
surgical procedures and interventional radiology in palpated and the pre-vertebral fascia was entered. The
the successful management of emergent vertebral vertebral artery at V3 (third portion) was noted to be
artery injuries. partially transected extracranially; it was controlled with
vascular clips. Paired vertebral veins were controlled
CASE REPORT in the same fashion. Hemorrhage was thus controlled.
The accessory spinal nerve was not visualized. Bone
A 45-year-old male who sustained a single stab wound wax was applied and the wound closed. EBL was
at the apex of the posterior triangle of the neck below 3,000 mL. Total volume replacement was 6,400 mL:
the left mastoid process was transported to the level crystalloids 4,000 mL, 6 units PRBCs 1,800 mL, 2 units
1 trauma center by Emergency Medical Services fresh frozen plasma 600 mL.
personnel, who reported large blood loss at the scene.
Upon arrival, the patient’s initial vital signs were: blood During the second intervention, a more complete
pressure (BP) 106/51 mmHg, pulse 139 bpm. Physical exploration identified the injury thus allowing for
examination revealed a 9-cm longitudinal deep definitive control.
160 Vessel Plus ¦ Volume 1 ¦ September 26, 2017