Blunt carotid arterial injuries: Implications of a new grading scale

Background: Blunt carotid arterial injuries (BCI) have the potential for de vastating outcomes. A paucity of literature and the absence of a formal BCI grading scale have been major impediments to the formulation of sound prac tice guidelines, We reviewed our experience with 109 BCI and developed a gr ading scale with prognostic and therapeutic implications, Methods: Patients admitted to a Level I trauma center were evaluated with c erebral arteriography if they exhibited signs or symptoms of BCI or met cri teria for screening. Patients with BCI were treated with heparin unless the y had contraindications, and follow-up arteriography was performed at 7 to 10 days, Endovascular stents were deployed selectively, A prospective datab ase was used to track the patients. Results: A total of 76 patients were diagnosed with 109 BCI, Two-thirds of mild intimal injuries (grade I) healed, regardless of therapy. Dissections or hematomas with luminal stenosis (grade II) progressed, despite heparin t herapy in 70% of cases. Only 8% of pseudoaneurysms (grade III) healed with heparin, but 89% resolved after endovascular stent placement. Occlusions (g rade IV) did not recanalize in the early postinjury period, Grade V injurie s (transections) were lethal and refractory to intervention. Stroke risk in creased with injury grade. Severe head injuries (Glasgow Coma Scale score l ess than or equal to 6) were found in 46% of patients and confounded evalua tion of neurologic outcomes. Conclusion: This BCI grading scale has prognostic and therapeutic implicati ons. Nonoperative treatment options for grade I BCI should be evaluated in prospective, randomized trials, Accessible grade II, III, IV, and V lesions should be surgically repaired. Inaccessible grade II, III, and IV injuries should be treated with systemic anticoagulation, Endovascular techniques m ay be the only recourse in high grade V injuries and warrant controlled eva luation in the treatment of grade III BCI.