Carotid injury: postrevascularization hemorrhagic infarction

Penetrating neck injury: a review

Penetrating injury to the neck has inspired considerable controversy with regard to its management, owing to the large number of important, susceptible structures contained in this area. Mandatory exploration of all wounds has generally given way to selective operative management. Clinical assessment has, once again, become the prime diagnostic tool. This review describes the evolution of management and the value of various diagnostic modalities. It concludes with a summary of appropriate operative techniques.

Management of Traumatic Vascular Injuries to the Neck: A 7-Year Experience at a Level I Trauma Center

Injury to the carotid artery results in significant mortality and morbidity. The general consensus is to repair all injuries to the common and internal carotid arteries. Ligation is usually reserved for neurologic or hemodynamic instability. We report our experience at a Level I trauma center with vascular injuries to the neck. Retrospective chart review of all patients with vascular injuries in the neck resulting from either blunt or penetrating trauma treated at a Level I trauma center between January 2000 and February 2007. Demographics and outcomes were collected from a chart review. Twenty-five patients with vascular injuries to the neck were identified. There were 13 carotid artery injuries (CAI), five internal jugular vein (IJV) injuries, and 13 external jugular vein (EJV) injuries. Of the carotid artery injuries, six (50%) underwent operative repair (4 primary repairs and 2 bypasses), five (38%) were managed nonoperatively, and one was treated using endovascular techniques. No patient had a postoperative decrease in Glasgow Coma Scale score. There were five isolated IJV injuries (3 primary repair and 2 ligations). Four of the venous injuries (all internal jugular veins) were repaired and the remaining 13 were ligated. Vascular injuries to the neck have significant mortality and morbidity. Treatment of these injuries must be individualized. All CAI in noncomatose patients should be repaired if hemodynamically stable. All IJV injuries should be repaired but may be ligated if hemodynamically unstable. All EJV injuries can be ligated without reservation regardless of neurological status.

Penetrating thoracoabdominal injuries: ongoing dilemma-which cavity and when?

The aims of this study were to (1) define characteristics for the thoracoabdominal injury patient population; (2) describe sequences of surgical interventions with combined procedures (i.e., thoracotomy and laparotomy); and (3) describe pitfalls leading to inappropriate sequencing of surgical interventions for thoracoabdominal injuries. It was a retrospective 4-year study (January 1995 to December 1998) conducted at an urban level I trauma center. The study population comprised 254 patients who had sustained thoracoabdominal injuries requiring surgical intervention: 187 (73%) gunshot wounds (GSWs), 64 (25%) stab wounds (SWs), and 3 (2%) shotgun wounds (STWs). The mean revised (RTS) was 6.04; the mean Injury Severity Score (ISS) was 27; the mean estimated blood loss (EBL) was 3000 ml. The overall survival was 175 of 254 (69%). Of the 254, 51 (20%) underwent emergency department (ED) thoracotomy. Altogether, 73 (29%) underwent combined thoracotomy and laparotomy: 59 (81%) GSW, 13 (18%) SW, 1 (1%) STW (mean RTS 5.2, mean ISS 34, mean EBL 6800 ml). Overall survival was 30 of these 73 (41%). A total of 21 of the 73 (29%) underwent ED thoracotomy. In group I (laparotomy then thoracotomy: Lap + Thor, n = 34) the initial procedure was interrupted in 18 (53%). In group II (thoracotomy then laparotomy: Thor + Lap, n = 39) the initial procedure was interrupted in 14 (36%). Pitfalls leading to inappropriate surgical sequencing were persistent hypotension (13/73, 18%) and misleading chest tube output (8/73, 10%). It was concluded that penetrating thoracoabdominal injuries incur high mortality (31%), and the mortality doubles for patients who require combined procedures (59%). Inappropriate surgical sequencing occurred in 32 of 73 (44%) patients undergoing combined procedures. Persistent hypotension, indicating that the wrong cavity was accessed, and misleading chest tube output are the leading pitfalls in thoracoabdominal injury management.

Penetrating vascular trauma in Johannesburg, South Africa

An awareness that time crucially affects outcome underpins the principles of management of vascular injury. Patients with hard signs of vascular injury should undergo urgent exploration. Soft signs mandate investigation, and arteriography is still the standard of care. Noninvasive vascular imaging may prove its worth in the future. All patients with penetrating arterial injury should receive broad-spectrum antibiotic prophylaxis. Early repair of carotid artery injury provides the best likelihood of a neurologically intact survivor. There is a definite and emerging role of endovascular therapy both for difficult access injuries and for the later complications of vascular injury, such as false aneurysm and arteriovenous fistulas. The experimental and clinical evidence for the use of intraluminal shunts in peripheral vascular injury is compelling, and experience in their use is accumulating. Vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment; resuscitation and prompt revascularization are likely to lead to satisfactory outcomes. The major trauma load in South Africa represents an unparalleled experience in management of vascular injury, which seems likely to continue for the foreseeable future.

Diagnosis, treatment, and outcome of blunt carotid arterial injuries

BACKGROUND

Blunt carotid injuries are rare, and present late with devastating strokes. A sizeable single-institution descriptive report could help characterize the injury and its diagnosis and treatment.

METHOD

We performed a retrospective review of blunt carotid artery injuries from May 1988 to December 1997 at a level I trauma center. Chart review consisted of demographics, mechanism of injury, associated injuries, diagnostic modalities, initial neurologic status, treatment, and outcome. Discharge outcome was classified as "good" (normal-mild deficit), "fair" (needing daily assistance), "poor" (institutionalized), or "dead."

RESULTS

During the study period 16 patients sustained a carotid artery injury. Mean age was 35 years and 63% were female. Vehicular trauma was the most common mechanism of injury (81%), followed by assaults (13%). Dissection was the most common injury (75%), with one quarter having an associated pseudoaneurysm. Initial neurologic presentation was normal in 31% and Glasgow Coma Score was < 13 in 31% (including 13% in coma). Eventual hemispheric symptoms developed in 81%. Associated injuries were present in 94%, commonly head (44%) and chest (50%). Duplex ultrasound accurately identified the injury in all patients (5 of 5) when used. Anticoagulation (88%) had no complications. Observation and therapeutic embolization each resulted in 1 fatal stroke. A third patient, with worsening deficits on heparin, died after carotid ligation, for an overall mortality of 19%. There were no deaths in the 13 patients treated by anticoagulation alone. Six patients (38%) had a "good" neurologic outcome, five (31%) "fair," and two (13%) "poor." Initial neurologic presentation, associated injuries, and mechanism of injury did not appear to correlate with these outcome categories.

CONCLUSIONS

These uncommon injuries should be suspected in the presence of head and/or chest injuries, basilar skull fracture, or coma (particularly if the computed tomography scan is unremarkable). Presentation may be varied, but most patients eventually develop hemispheric symptoms. Duplex ultrasound detects many of these injuries, but this does not demonstrate its utility as a screening tool. Anticoagulant therapy appears to be associated with a better outcome than expectant or occlusive therapy.