ON THE REVERSIBILITY OF STROKES: CASE OF CAROTID ARTERY REPAIR WITH PROMPT RECOVERY AFTER HEMIPLEGIA AND COMA FOR TWO DAYS

Risk factors for stroke in penetrating carotid trauma-An analysis from the PROOVIT Registry

BACKGROUND

Penetrating carotid injuries are associated with an up to 20% risk of stroke. This study evaluated patients in the American Association for Surgery of Trauma PROspective Observational Vascular Injury Trial, with the aim of determining factors associated with stroke and stroke or death.

METHODS

Penetrating extracranial carotid injuries in the American Association for Surgery of Trauma PROspective Observational Vascular Injury Trial registry from 2012 to 2020 were queried. Isolated external carotid injuries were excluded. Patients with documented postinjury in-hospital stroke were compared with those without. Significant predictors (p < 0.1) for stroke and stroke or death on univariate analysis were included in multivariate analyses.

RESULTS

One hundred two patients from 17 institutions were included. Mean age was 35 ± 18 years, and 80% were male. Average Glasgow Coma Scale (GCS) score on presentation was 9 ± 5, with an Injury Severity Score [ISS] of 22 ± 13. Operative management occurred in 51% of patients who were significantly more hypotensive (systolic blood pressure: 109 vs. 131 mm Hg; p = 0.015) with a lower initial pH (7.17 vs. 7.31; p = 0.001) and presented with hard signs of vascular injury (74% vs. 26%; p < 0.001). Overall stroke rate was 17% (23% operative vs. 10% nonoperative, p = 0.076). Rate of stroke or death was 27% (64% operative and 36% nonoperative). On multivariate analysis, lower GCS (p = 0.05) and completion angiography (p = 0.04) were associated with stroke. Likewise lower GCS (p = 0.015) and ISS (p = 0.04) were associated with stroke or death.

CONCLUSION

Penetrating carotid trauma undergoing operative management had a stroke rate of 23%. Low GCS on arrival and need for completion angiography are independently associated with postinjury in-hospital stroke, whereas low GCS on arrival and ISS were associated with stroke or death. The ideal treatment strategy remains elusive, thus a dedicated multicenter study may help to achieve higher fidelity data on this rare but devastating injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological, Level III.

Management of postoperative stroke after carotid endarterectomy

Major postoperative stroke after carotid endarterectomy is often due to carotid thrombosis, and prompt thrombectomy can reverse the neurologic deficit. We advise reoperation providing the stroke occurs within several hours of carotid endarterectomy, preferably when the patient is in the recovery room, and reoperation can be done immediately. We do not delay reoperation for angiography. Reoperation has not been beneficial for strokes that occur later in the patient's course or when there has been a severe preoperative neurologic deficit. Patients with a mild postoperative stroke, especially if the stroke represents worsening of a preoperative deficit, will often improve without intervention.