Penetrating injuries to the vertebral artery: interventions and outcomes from US Trauma Centers

Abstract

Purpose: Penetrating injuries to the vertebral artery are rare and incompletely studied. Operative, angioembolic, and nonoperative strategies are management options, although the association between management strategy and outcomes is unknown. This study endeavored to define the epidemiology, management strategy, and outcomes after penetrating injuries to the vertebral artery presenting to trauma centers nationwide.

Methods: Patients with veterbral artery injuries were identified from the National Trauma Data Bank (NTDB) (2016-2017) using ICD-10-CM codes. Only those with penetrating mechanisms of injury were included in the study. Transferred patients were excluded. Study groups were defined by management strategy (Operative management, OM; angioembolization, AE; and nonoperative management, NOM). Patient demographics, injury characteristics, and outcomes were compared between groups using univariate analysis. Multivariate analysis with logistic regression was used to examine independent risk factors for mortality and stroke.

Results: Penetrating injuries to the vertebral artery were rare (n = 476, < 1% of NTDB patient population). Median age was 28 [IQR 21-37] years and 81% (n = 385) of patients were male. Interpersonal violence was the most common injury intent (n = 374, 79%). Most patients were managed with NOM (n = 409, 86%), with AE and OM utilized less frequently (8% and 6%, respectively). Stab wounds were the most frequent mechanism of injury among patients managed with OM (62%), while gunshot wounds were most common among patients managed with NOM (84%) or AE (79%). Multivariate analysis of risk factors for stroke revealed only associated carotid artery injury (OR 4.236, 95% CI 1.284-13.970, p = 0.018) and AE (OR 6.342, 95% CI 1.417-28.399, p = 0.016) were independent predictors. Independent risk factors for mortality were advanced age (OR 1.026, 95% CI 1.001-1.052, p = 0.044); elevated ISS (OR 1.030, 95% CI 1.008-1.052, p = 0.006); and associated traumatic brain injury (OR 3.020, 95% CI 1.333-6.843, p = 0.008). Higher ED GCS was independently associated with reduced mortality (OR 0.788, 95% CI 0.731-0.849, p < 0.001).

Conclusions: Vertebral artery injuries after penetrating mechanisms are infrequent in the United States. Patients with these injuries tend to be young adult men who were injured by gunshot wounds as a result of interpersonal violence. The majority of these injuries were managed nonoperatively, with operative intervention required most commonly for patients injured by stab wounds. Risk factors for both stroke and mortality were principally due to patient factors and associated injuries. Increased risk of stroke among patients managed with angioembolization will need to be further investigated with future study to determine if this risk is imparted from the management strategy itself or from underlying injury characteristics.

Keywords: Interpersonal violence; Nonoperative management of penetrating trauma; Penetrating trauma; Stroke; Vertebral artery injury.