Proximal and distal endovascular embolization of a penetrating V3 vertebral artery transection with adjunctive surgical ligation: A case report

Abstract

Background:

Penetrating vertebral artery injuries are rare, accounting for <1% of trauma admissions, and complete transection of the V3 segment is exceptionally uncommon. The resulting limited evidence base and complex V3 anatomy make management challenging. This case describes a hybrid endovascular and surgical strategy for a complete V3 transection refractory to primary surgical control.

Case Description:

A man in his 40s sustained complete transection of the right vertebral artery (V3 segment) after an accidental fall onto a machete, causing a penetrating neck injury with massive hemorrhage and cardiac arrest requiring pre-hospital resuscitation. Surgical exploration failed to achieve hemostasis, as both vessel ends had retracted behind the C2 transverse processes. Sequential endovascular embolization achieved proximal control through ipsilateral brachial access and distal control through contralateral retrograde access, with adjunctive external carotid branch embolization and surgical ligation achieving definitive hemostasis. Despite severe associated injuries, including traumatic brain injury, subarachnoid hemorrhage, and spinal cord infarction, the patient’s Glasgow Coma Scale returned to 15, and he was independent with mobility and personal care by hospital day 72. At 9-month follow-up, cerebral angiography confirmed stable, occluded vessels with no recanalization, and he had returned to independent activities of daily living with mild residual memory impairment and fatigue.

Conclusion:

A combined endovascular and surgical approach can achieve hemorrhage control in complete vertebral artery transection when surgical hemostasis alone is unsuccessful. Contralateral retrograde access facilitates distal embolization in anatomically challenging injuries, and close multidisciplinary collaboration between interventional neuroradiology and neurosurgery is critical to favorable outcomes.

INTRODUCTION

Vertebral artery injuries (VAIs) carry significant morbidity and mortality due to their proximity to the cervical spine, brainstem, and posterior circulation.[7] Most result from blunt mechanisms such as cervical hyperextension, fracture-dislocation, or blunt cerebrovascular injury, the latter now commonly screened for using advanced trauma life support-based criteria.[7,14,16] Penetrating injuries are exceptionally rare, representing <1% of trauma admissions in a multicentre review of the National Trauma Data Bank.[13] This rarity, particularly for injuries involving the V3 segment, corresponds with a limited evidence base and the absence of standardized management guidelines. Underdiagnosis may also contribute to the low reported incidence, as historical diagnostic tools lacked the sensitivity achieved with routine angiography in penetrating neck trauma.[2] Computed tomography angiography (CTA) enables rapid evaluation in hemodynamically stable patients,[15] while digital subtraction angiography (DSA) remains the gold standard, offering definitive visualization and the option of immediate endovascular treatment.

No universally accepted treatment algorithm exists for penetrating VAIs, with most approaches extrapolated from blunt injury data or limited case series.[1-5,7-10,13,14] Piper et al., proposed an individualized strategy guided by hemodynamic status, vascular anatomy, and collateral circulation, favoring DSA-guided endovascular therapy (coil embolization, balloon occlusion, or stenting) when technically feasible, and reserving open surgery for uncontrolled hemorrhage, failed or inaccessible endovascular access, or where embolization risks compromising the posterior circulation.[10] Management of V3 injuries is particularly challenging: this segment courses from the transverse foramen of C2, loops around the C1 lateral mass, and enters the cranial cavity at the foramen magnum,[4] making direct surgical exposure difficult and increasing the risk of iatrogenic injury to cranial nerves, the cervical spinal cord, and venous plexuses.[1,4] Transected ends may retract behind the transverse processes, further complicating operative management and control of hemorrhage.

Prompt recognition and early intervention are critical, as delayed management can result in uncontrolled hemorrhage, posterior circulation ischemia, pseudoaneurysm formation, and arteriovenous fistula, each associated with high mortality and permanent neurological deficits.[1,5,7-9] Even minor delays can have catastrophic consequences, emphasising the need for rapid, multidisciplinary decision-making. This report describes the successful management of a complete V3 VA transection using combined endovascular and open surgical ligation, illustrating the feasibility of a multidisciplinary approach in a high-risk anatomical region and highlighting the importance of early recognition and timely intervention to prevent catastrophic hemorrhage and neurological complications.

CASE DESCRIPTION

This case report was prepared in accordance with the CAse REport guidelines.[6] Written informed consent for publication of this report, including accompanying imaging, was obtained from the patient.

A man in his 40s, with no significant past medical history and no antiplatelet or anticoagulant use, sustained a single deep incision to the right neck (Zone III), measuring 3 cm and extending beneath the mandible, after an accidental fall onto a machete. Family and psychosocial history were non-contributory and not formally documented; he had not undergone any previous interventions related to this condition. He was Glasgow Coma Scale (GCS) 15 and ambulant when paramedics first arrived, with an estimated 1 L blood loss on scene, before progressing to cardiac arrest requiring intubation; return of spontaneous circulation was achieved pre-hospital following resuscitation with intravenous fluids, 4 units of blood, calcium gluconate, and tranexamic acid, and the wound was packed with hemostatic gauze. First contact with emergency services was at 1509 h, with paramedics arriving on scene at 1538 h, and arrival at the hospital resuscitation bay at 1618 h.

Primary survey revealed a protected, intubated airway with clear bilateral air entry. The patient was centrally warm but hemodynamically compromised, with active arterial bleeding at the right angle of the jaw controlled by direct pressure, an absent left femoral pulse, blood pressure of 145/113 mmHg, and a heart rate of 117 beats/min. He was sedated and paralyzed with a GCS of 3 and bilaterally sluggish, 3 mm pupils. Abdominal examination was unremarkable with no other injuries identified, and his temperature was 36.1°C. The massive transfusion protocol was activated, with a further 5 units of packed red blood cells administered in the emergency department.

Given ongoing hemodynamic instability, no imaging was performed, and the patient proceeded directly to theatre for surgical exploration. A longitudinal incision was made along the wound trajectory, extending proximally along the posterior border of the sternocleidomastoid and distally toward the base of the neck. Exploration revealed a complete transection of the right vertebral artery at the V3 segment, with retracted arterial ends obscured by the transverse processes at C2. The incision was extended with division of the anterior margin of the trapezius to improve exposure; however, ongoing hemorrhage persisted despite direct pressure and temporary vascular control measures.

Definitive control of the proximal vertebral artery segment was achieved through endovascular intervention. A 5 Fr short sheath was inserted intra-arterially under ultrasound guidance, and catheter angiography of the right vertebral artery demonstrated a transection with active contrast extravasation [Figure 1a, arrow A] and confirmed the vessel to be co-dominant. Hemostasis was achieved using a 5 mm microplug reinforced with two 8 mm coils, successfully controlling inflow [Figure 1b, arrow B]. The brachial access site was closed with a vascular closure device.

Figure 1:

(a) Right vertebral artery angiography demonstrating complete transection of the proximal right vertebral artery and contrast extravasation (A, arrow). (b) Right vertebral artery angiography after embolization by coils of the proximal part of the right vertebral artery (B, arrow).

Interventional neuroradiology addressed the distal vertebral artery segment through catheterization of the contralateral vertebral artery and navigation over the vertebrobasilar junction to the distal, ipsilateral vertebral artery [Figure 2a, arrow A]. Retrograde angiography again demonstrated extravasation, and the proximal V4 segment was coil-sacrificed to obtain hemostasis [Figure 2b, arrow B]. To identify other potential sources of hemorrhage, the right external carotid artery was catheterized. Angiography confirmed extravasation through a transected occipital artery and posterior auricular artery [Figure 3a, arrow A-C]. Coiling was performed to the distal and proximal occipital artery and the posterior auricular artery [Figure 3b, arrow D-F], with no extravasation on repeat angiography.

Figure 2:

(a) Left vertebral artery angiography demonstrating complete transection of the distal part of the right vertebral artery (A, arrow). (b) Left vertebral artery angiography after embolization by coils of the distal part of the right vertebral artery (B, arrow).

Figure 3:

(a) Superselected angiography of right external carotid artery demonstrating (A, arrow) right posterior auricular artery, (B, arrow) right occipital artery, (C, arrow) active contrast extravasation. (b) Repeat angiography post coil embolization of (D, arrow) right posterior auricular artery, (E, arrow) right occipital artery distal (large) and proximal (small), and (F, arrow) intradural right vertebral artery (retrogradely coiled via left vertebral artery).

On surgical exploration, residual bleeding was observed adjacent to the transected vertebral artery ends and controlled with 5-0 Prolene suture ligation reinforced by vessel clips. As post-procedural angiography demonstrated no contrast extravasation from the vertebral artery, this residual bleeding was presumed to arise from adjacent muscular branch vessels rather than the vertebral artery itself. A concomitant deep cervical venous injury was packed with hemostatic agents to achieve hemostasis. Wound closure was completed with careful re-approximation of the sternocleidomastoid and deep fascial layers, followed by skin closure with interrupted 3-0 polydioxanone sutures.

Post-operative imaging showed no procedural complication. Neurological examination on post-operative day 1 was limited by ongoing intubation and sedation; he opened his eyes to pain, could not be assessed verbally due to intubation, and localized to painful stimuli (GCS: Eye-opening response 3, verbal response not testable due to intubation, motor response 5). The patient’s hospital course was prolonged due to the complex traumatic presentation and the need for staged, multidisciplinary management of multiple concurrent injuries, including a subarachnoid hemorrhage with intraventricular extension and associated hydrocephalus, a subdural hemorrhage, and Terson syndrome. In addition, there was a right C1 posterior arch fracture with associated cerebrospinal fluid leak, a C1–C2 spinal cord infarct [Figure 4], and traumatic brain injury.

Figure 4:

T2 magnetic resonance imaging of the cervical spine demonstrating increased T2 hyperintensity within the central cord at the C1 vertebral level.

The patient developed deep vein thrombosis in the right lower extremity; prophylactic unfractionated heparin (5000 units subcutaneously twice daily) had been commenced on hospital day 2, before diagnosis. Definitive treatment with apixaban 5 mg twice daily was subsequently instituted, with repeat imaging planned at 3 months. He also developed clinical vertebral osteomyelitis at the cervical level of the penetrating injury, which improved following a 4–6-week course of intravenous piperacillin-tazobactam. Drain fluid cultures showed no growth, and there were no clinical signs of meningitis, although a mild fever (peak 37.8°C) and a rising white cell count (13–14.8 × 10⁹/L) were noted during this period.

Premorbidly independent with no functional deficits (modified Rankin Scale 0), the patient was alert and orientated with a GCS of 15 by hospital day 72 (discharge), and was independent with mobility and personal care, corresponding to a modified Rankin Scale score of 1 (Glasgow Outcome Scale 5, good recovery). At his first outpatient review in the brain injury clinic, approximately 3 weeks after discharge, he had returned home and was taking only apixaban and topical eye drops; he was not yet driving, due to bilateral Terson syndrome, and had not fully regained independence with all activities, though he was progressing towards his pre-injury functional level. At last follow-up (9 months post-injury), cerebral angiography demonstrated no shunting lesion, with previously embolized vessels remaining occluded and no evidence of recanalization. He had ongoing mild short-term memory difficulties and brain injury-related fatigue, managed with compensatory strategies, and had since been cleared to resume driving.

Patient perspective

The patient was not opposed to publication of this report and expressed gratitude for the care he received throughout his admission and recovery.

DISCUSSION

Penetrating VAIs are exceedingly rare, largely due to the vessel’s deep location and the protection offered by surrounding cervical structures. In the National Trauma Data Bank, only 476 cases were identified, representing <1% of all trauma admissions.[13] A systematic review of extracranial VAIs reported an incidence of 3.1% among civilian penetrating neck injuries, compared with only 0.3% in military series, reflecting differences in mechanism, protective equipment, and anatomical exposure between these populations.[1] Their infrequency, coupled with the deep and complex anatomy of the vertebral artery, contributes to delayed recognition and high morbidity if not promptly addressed. Uncontrolled hemorrhage, posterior circulation ischemia, pseudoaneurysm formation, and arteriovenous fistula are among the potential complications, all of which carry significant mortality and long-term neurological sequelae.[1,5,9]

Injuries are most commonly described in the V2 segment, which accounted for approximately one-third of cases with a documented anatomic level in a large systematic review, compared with 14% for V3 and 8% for V1.[1] The V3 segment, as in the present case, is comparatively less frequently affected but is particularly challenging due to its course from the transverse foramen of C2, looping around the C1 lateral mass, and entry into the foramen magnum.[4] Transected ends may retract behind transverse processes, complicating both surgical and endovascular management, as occurred in this case.

Mechanisms of injury vary, including stab wounds, gunshot wounds, and other penetrating trauma. Schellenberg et al., in a retrospective observational study of US trauma centers, found that stab wounds accounted for approximately 19% of penetrating VAIs, yet they represented the most frequent mechanism necessitating operative intervention (62%).[13] Across 169 reported extracranial VAIs, only six were complete transections, compared with much higher rates of occlusion (n = 61), pseudoaneurysm (n = 37), arteriovenous fistula (n = 32), and dissection (n = 8).[10] This highlights how complete transection is uncommon, consistent with other reported stab-wound case series and case reports involving the vertebral artery,[2,12,18] and underscores the limited evidence base and need for further research to guide management. Despite the low incidence, transection carries the highest risk of massive hemorrhage and hemodynamic instability, often necessitating urgent surgical control or endovascular occlusion.

Advanced imaging modalities, including CTA and DSA, provide superior sensitivity and specificity in hemodynamically stable patients and guide procedural planning.[7,15-17] In this patient, the need for immediate hemorrhage control precluded imaging before intervention. The decision for early surgical exploration aligns with prior recommendations: Greer et al. described early operative intervention for unstable penetrating VAIs in military series, while Reid and Weigelt reported that stable patients without acute hemorrhage may be safely evaluated with imaging before intervention.[8,11] In cases of acute, life-threatening hemorrhage, however, imaging may delay definitive control, and immediate surgical exploration is required when clinical signs of major vascular injury are present.[8] Surgery was selected as the first-line approach in this case based on speed of access in an exsanguinating, peri-arrest patient, rather than a specific institutional protocol; direct surgical control ultimately failed due to retraction of the vessel ends behind the C2 transverse process, necessitating escalation to endovascular therapy.

Management of V3 transections remains challenging due to difficult surgical exposure, proximity to cranial nerves and the spinal cord, and risk of iatrogenic injury.[12] Endovascular management of penetrating VAIs has evolved significantly, offering an alternative to direct surgical exposure in selected patients.[1,10] Coil embolization is widely used to achieve definitive vessel occlusion in hemodynamically stable patients with transections or pseudoaneurysms, while stent-assisted reconstruction may be considered when vessel preservation is critical, particularly in intracranial disease, poor collateralization, or where the spinal cord circulation is jeopardised.[10] Piper et al., suggested that injuries near the origin of the posterior inferior cerebellar artery, which typically arises from the V4 rather than the V3 segment, may favor surgical clipping to reduce stroke risk, while also noting that endovascular embolization is the most utilized approach in contemporary practice and is associated with low complication rates when technically feasible.[10] Accordingly, sequential proximal and distal coil embolization through anterograde ipsilateral and contralateral retrograde vertebral artery access achieved complete hemostasis in the present case, with adjunctive surgical ligation providing definitive control. This staged, hybrid approach underscores the utility of combining endovascular and open techniques in complex cervical vascular trauma and remains consistent with evolving management strategies.

The right vertebral artery was confirmed to be co-dominant. Sacrifice of a co-dominant vessel carries an intermediate risk of posterior circulation ischemia relative to sacrifice of a clearly dominant or non-dominant vessel, as the contralateral vertebral artery continues to supply substantial, though not sole, inflow to the basilar artery. Despite this, and the severity of associated injuries, including traumatic brain injury and spinal cord infarction, the patient achieved remarkable functional recovery. This outcome likely reflects several factors: Rapid hemorrhage control preventing further ischemic injury, preservation of contralateral vertebral artery flow, and adequate collateral circulation through posterior communicating arteries. The C1–C2 spinal cord infarction was most likely attributable to the initial vascular injury or peri-operative hypotension, rather than an embolic complication of the endovascular intervention. Screening angiography did not demonstrate any spinal arterial supply arising from the right V3 or V4 segments; although a contribution from coil embolization cannot be entirely excluded, the infarction was considered more likely to reflect the primary traumatic insult.

Long-term neurological follow-up is essential, as delayed complications, including posterior circulation ischaemia, may develop months to years after injury. At last follow-up (9 months post-injury), cerebral angiography demonstrated stable findings with no evidence of recurrent vascular abnormality or recanalization, and the patient had returned to independent activities of daily living, albeit with ongoing mild short-term memory impairment and fatigue managed using compensatory strategies.

CONCLUSION

This case contributes to the literature by demonstrating the feasibility of combined endovascular and surgical management for a complete V3 transection, a scenario infrequently described in prior reports. Unlike many previous studies, which primarily address blunt cerebrovascular injuries or partial transections, this case illustrates a staged approach leveraging both contralateral retrograde access and surgical ligation for definitive control in a trauma setting. The detailed documentation of procedural technique highlights the importance of early recognition, innovative approaches, and coordinated multidisciplinary management in achieving successful outcomes.

Given the rarity of penetrating vertebral artery injury, individual case reporting remains critical to building the evidence base for optimal management strategies. Future research should focus on developing standardised algorithms for penetrating vertebral artery injury management, investigating long-term neurological outcomes following different treatment approaches, and establishing training and pathway protocols for the hybrid techniques demonstrated here. Multicentre collaboration will be essential to advance understanding and guide management of these rare but potentially catastrophic injuries.

Ethical approval:

Institutional review board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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