Traumatic Vertebral Artery Injury: Diagnosis, Natural History, and Key Considerations for Management

Vertebral artery injury (VAI) is a known complication of blunt cervical spine trauma with a potential risk of stroke. Factors including cervical bony injury, spinal cord injury, and overall trauma severity have been linked to an increased risk of VAI. Despite its prevalence, there is little consensus on various aspects of this pathology, including its initial screening, diagnostic approaches, and therapeutic strategies. A recent systematic review and meta-analysis from our group highlighted the dynamic nature of vertebral artery occlusion, revealing the underrecognized recanalization rates and potential stroke risks associated with delayed recanalization. While anticoagulant and/or antiplatelet therapy (ACAP) remains the cornerstone of VAI management, treatment is often complicated by co-existing injuries, such as intracranial hemorrhage or cervical trauma, which may preclude or delay ACAP usage or necessitate surgical intervention. This comprehensive narrative review synthesizes the latest evidence on VAI and associated ischemic sequelae, with the goal of elucidating its pathophysiology and natural history, summarizing current data on screening and diagnosis, and exploring key considerations for medical and endovascular management.