Penetrating vertebral artery injuries (VAIs) are rare but devastating trauma for which the approach to treatment varies greatly. The literature on treatment modalities is limited to case reports, case series, and 1 review, with the majority of cases being treated surgically. However, with the advent of digital subtraction angiography, treatment has shifted toward less invasive endovascular modalities that allows one to assess the flow and risks of sacrificing the vertebral artery (VA). In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses, a systematic review of VAI was performed. Two case reports were also detailed. Using a multidisciplinary team, a decision algorithm was proposed for approaching penetrating VAIs. We identified 169 patients. Of the penetrating VAI, the majority were occlusions, most commonly managed conservatively. Other injuries including pseudoaneurysm, dissection, transection, and arterial-venous fistula were treated predominantly endovascularly and occasionally with the surgical exploration/ligation. Most endovascular treatments included embolization without significant stroke or complication from VA sacrifice. However, there are incidences in which VA sacrifice should be avoided and these scenarios can be better delineated with digital subtraction angiography to assess flow and anatomy. This systematic review not only details the updated treatment options but also provides a decision algorithm for the treatment of penetrating VAI. It highlights the shifting treatment options of penetrating VAI to endovascular therapy, as well as details VAI variants that may suggest stenting over embolization.