PENETRATING TRAUMA OF THE INTERNAL CAROTID-ARTERY

Objective: To assess management of penetrating internal carotid artery (ICA) injuries. Design: Retrospective review of institutional protoco l. Setting: Level 1 trauma center in a major urban area. Patients: Six ty-one patients with penetrating ICA injuries. Interventions: In the p eriod 1975 to 1987 (group 1; n=36), management was based on individual surgeons' preferences. Between 1988 and 1995 (group 2; n=25), an algo rithm was employed: (1) hemodynamically stable patients with suspected ICA injuries underwent a diagnostic angiography; (2) surgically acces sible injuries were reconstructed regardless of neurologic status with 2 exceptions: (a) neurologically intact patients with ICA occlusion w ere treated by anticoagulation and mild pharmacological hypertension a nd (b) minimal nonocclusive injuries were managed nonoperatively and f ollowed up by serial angiography or duplex ultrasonography; and (3) he parinization, shunting, and completion angiography were employed. Main Outcome Measures: Neurologic status at admission and discharge were c ompared by the Fisher exact test. Results: In group 1, 24 patients (67 %) presented neurologically intact, and 12 (33%) with a deficit. Sixte en injuries were managed nonoperatively, 14 were repaired, and 6 were ligated. At discharge 6 (17%) were improved, 24 (66%) were unchanged, 6 (17%) were worse. Four patients (11%) died of cerebrovascular causes . In group 2, 19 patients (76%) presented neurologically intact, and 6 (24%) with a deficit. Eleven injuries were managed nonoperatively, 12 were repaired, and 2 were ligated. A death occurred in a patient who arrested, was admitted to the hospital in a coma, and died before ICA repair. Conclusions: Neurologic outcome after ICA injury is enhanced b y an algorithm predicated on the liberal use of angiography, a predefi ned surgical approach, and selective observation.