Ask the Experts - Diagnosis and Management of Blunt Carotid Injury
Ask the Experts - Diagnosis and Management of Blunt Carotid Injury
Please discuss the diagnosis and management of a carotid lesion following blunt neck injury.
Dr. D. Brunetto
Carotid artery injury is second only to major airway injury as the cause of early death following blunt injury to the neck. Carotid injury has been thought to be unusual following blunt neck injury (less than 0.1% of patients admitted following blunt injury), but recent data has suggested that these injuries are more common than prior reports would indicate. Fabian and colleagues reported that there were 96 patients reported in the medical literature up to 1980 but nearly 500 reported since then. They suggested that as more cases are being realized, there is an increased interest in evaluation and publication of this type of injury. The emergence of regionalized systems for care of the injured patient may have also resulted in concentration of these patients in hospitals that are actively researching and reviewing patient data.
The main hazard of blunt carotid injury is the rapid onset of irreversible neurologic deficit and death. This fact has stimulated trauma surgeons to search for ways to assure early detection of carotid injuries. Screening with angiography is the most dependable means of detection. Biffl and associates reported a group of patients prospectively screened with angiography, and they observed a 0.86% incidence of carotid injury. In a subsequent report, Biffl and colleagues published clinical indicators that would predict the need for screening angiography. These include aspects of the injury mechanism such as hyperextension, hyperflexion, or a direct blow to the neck. Patterns of injury are also important with LeFort II or III facial fractures, fractures of the petrous bone, and cervical spine fracture without neurologic deficit increasing the risk of carotid and vertebral artery injuries. Other indicators include Glasgow Coma Score ≤ 6 and diffuse axonal injury of the brain where there is no CT evidence of direct brain injury.
In our center, we have adopted the screening criteria reported by Biffl. On the other hand, trauma surgeons recognize the difficulty in applying angiographic screening to large numbers of patients. Prospective data are needed to evaluate less invasive and resource intensive screening methods. Studies are currently underway evaluating duplex ultrasonography and magnetic resonance angiography. Currently, conventional angiography, with all of its practical drawbacks, remains the most dependable means of diagnosis in patients at risk.
Treatment of lesions found on angiography is based on the type of lesion and its location. High lesions, such as intimal flaps and dissections where flow is maintained, are treated with anticoagulation. Lesions located below the carotid bifurcation may be amenable to direct surgical repair. Where operation is not feasible and anticoagulation is contraindicated, endovascular approaches may be warranted, although large clinical series evaluating this approach have not been published.
Please discuss the diagnosis and management of a carotid lesion following blunt neck injury.
Dr. D. Brunetto
Carotid artery injury is second only to major airway injury as the cause of early death following blunt injury to the neck. Carotid injury has been thought to be unusual following blunt neck injury (less than 0.1% of patients admitted following blunt injury), but recent data has suggested that these injuries are more common than prior reports would indicate. Fabian and colleagues reported that there were 96 patients reported in the medical literature up to 1980 but nearly 500 reported since then. They suggested that as more cases are being realized, there is an increased interest in evaluation and publication of this type of injury. The emergence of regionalized systems for care of the injured patient may have also resulted in concentration of these patients in hospitals that are actively researching and reviewing patient data.
The main hazard of blunt carotid injury is the rapid onset of irreversible neurologic deficit and death. This fact has stimulated trauma surgeons to search for ways to assure early detection of carotid injuries. Screening with angiography is the most dependable means of detection. Biffl and associates reported a group of patients prospectively screened with angiography, and they observed a 0.86% incidence of carotid injury. In a subsequent report, Biffl and colleagues published clinical indicators that would predict the need for screening angiography. These include aspects of the injury mechanism such as hyperextension, hyperflexion, or a direct blow to the neck. Patterns of injury are also important with LeFort II or III facial fractures, fractures of the petrous bone, and cervical spine fracture without neurologic deficit increasing the risk of carotid and vertebral artery injuries. Other indicators include Glasgow Coma Score ≤ 6 and diffuse axonal injury of the brain where there is no CT evidence of direct brain injury.
In our center, we have adopted the screening criteria reported by Biffl. On the other hand, trauma surgeons recognize the difficulty in applying angiographic screening to large numbers of patients. Prospective data are needed to evaluate less invasive and resource intensive screening methods. Studies are currently underway evaluating duplex ultrasonography and magnetic resonance angiography. Currently, conventional angiography, with all of its practical drawbacks, remains the most dependable means of diagnosis in patients at risk.
Treatment of lesions found on angiography is based on the type of lesion and its location. High lesions, such as intimal flaps and dissections where flow is maintained, are treated with anticoagulation. Lesions located below the carotid bifurcation may be amenable to direct surgical repair. Where operation is not feasible and anticoagulation is contraindicated, endovascular approaches may be warranted, although large clinical series evaluating this approach have not been published.
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