DIAGNOSIS AND MANAGEMENT OF ZONE-III CAROTID INJURIES

The management of patients with extracranial carotid injury at the bas e of the skull (zone III) is challenging due to inaccessibility, sever ity, and associated injuries. In an effort to formulate a systematic a pproach to the evaluation and management of zone III carotin injuries, the records of 13 consecutive patients with such injuries were review ed: nine sustained penetrating injuries and four had blunt injuries. A total of 16 arteries were injured: internal carotid (11), external ca rotid (four), and vertebral (one). Neurological examinations revealed a central nervous system deficit in 1/9 with penetrating injuries and in 4/4 with blunt injuries. Angiography in patients with penetrating i njuries revealed pseudoaneurysm (five), intimal flap (five), transecti on (two), and AV fistula (one). Angiograms of patients with blunt inju ries demonstrated pseudoaneurysm (2), dissection (1), and intimal flap (I). Three patients underwent operative repair of internal carotid in juries and/or ligation of external carotid injuries. Four patients wer e managed with endovascular balloon occlusion. The remaining patients were observed with or without anticoagulation. Neurologically the pati ents remained normal or had improved on follow up with the exception o f one patient with a persistent hemiparesis after a blunt injury who h ad been observed. The conclusions are: (I) angiography at presentation is indicated, in stable patients, to delineate the injury and guide d efinitive management; (2) blunt injuries should generally be managed w ith anticoagulation. bl cases of large or expanding pseudoaneurysms or when anticoagulation fails, endovascular balloon occlusion is indicat ed; (3) partial thickness penetrating injuries can be observed, while full thickness lesions should be managed with balloon occlusion; (4) o perative vascular reconstruction should be reserved for unstable patie nts, patients with active bleeding, and patients requiring surgical ex ploration for associated injuries. (C) 1997 Elsevier Science Ltd. All rights reserved.