Carotid Artery Injury: Up-to-Date Management

Carotid artery injuries are not common in trauma patients although they are associated with a high morbidity and mortality. The practician needs to have a high level of suspicion in trauma patients with injuries of the neck and skull, and always taking into consideration the mechanism of injury. Prompt diagnosis and treatment are imperative for optimal results. This review aims to focus on main diagnostic and therapeutic strategies and produce useful conclusions on proper management. age should raise suspicion of a blunt carotid injury. Almost one third of such patients could present with a cerebrovascular infarct that could not be justified otherwise. Over 80% of these patients will present a cerebrovascular event within the first 7 days from the injury, according to literature. In cases of blunt carotid trauma and dissection, only 10% of cases present symptoms immediately although most clinical signs occur within 24 hours of the cervical injury [1,4]. Furthermore, the classification of cervical vascular injuries into zones has added a very important and useful algorithm into everyday clinical practice (Figure 1). Zone I extends from the level of the clavicles up to the level of the cricoids cartilage, zone II from the cricoids cartilage up to the angle of the jaw, and finally zone III begins over the level of the jaw angle. Injuries of the Zone II could be evaluated with physical examination where a major vascular injury can be verified or excluded without difficulty. However, immediate clinical evaluation of injuries located in Zones I and III is difficult, and therefore further diagnostic imaging is required. It is estimated that physical examination yields a 93% sensitivity and 97% negative prognostic value for the prediction of angiographic results independently from the zone of trauma [2,5]. Regarding prognosis, there are also several clinical risk scores in order to predict the possibility of carotid artery injury in patients with blunt cervical trauma (Table 2). The Denver group has produced the most widely used classification for blunt cervical trauma in the literature [1]. Although this index seems to be the most efficient and complete to date, several other indices such as the Memphis or Kerwin Hard signs Soft signs Shock Refractory hypotension Pulsatile bleeding Enlarging hematoma Bruit Loss of pulse with stable or evolving neurologic deficit History of bleeding (at the scene of the injury) Stable hematoma Nerve injury Proximity of the injury track Unequal upper extremity blood pressure measurements. Table 1: Signs indicating carotid artery injury.