Elsevier

Cardiovascular Surgery

Volume 5, Issue 2, April 1997, Pages 196-200
Cardiovascular Surgery

Carotid arterial trauma: assessment with the Glasgow Coma Scale (GCS) as a guide to surgical management1

https://doi.org/10.1016/S0967-2109(97)82472-6Get rights and content

Abstract

Management of carotid arterial injuries associated with focal neurological deficit or altered state of consciousness (SCON) remains unresolved. Experience with these injuries in one particular hospital was reviewed and the Glasgow Coma Scale (GCS) utilized to assist with clinical stratification of these patients. A literature review was also conducted to better define indications for repair or ligation of carotid injuries. From 1978 to 1990, 34 patients with carotid arterial injuries were reviewed with reference to the GCS, focal deficit, hypotension, anatomic site and mechanism of injury. The literature from 1952 to 1993 was surveyed for carotid artery injuries (1316 patients). Outcome of treatment with or without repair was compared with pre-operative neurologic status. Thirty-four patients with injuries of the common (24) or internal (10) carotid arteries were managed with repair (68%), ligation (24%) or observation (9%). The SCON was normal in 18 patients; 16 patients (88%) underwent repair and all remained normal. All patients with GCS 9–14 regained a normal SCON after surgical repair, while 10 patients with GCS <8 had repair (5), ligation (3), and non-operative management (2); five returned to normal, four died and one remained comatose. However, outcomes correlated poorly with management. Of 1316 patients cited in the surgical literature, patients with no deficit and patients with pre-operative deficits did significantly better after repair as compared with ligation (P < 0.001). In comatose patients, management did not affect outcome. It is concluded that carotid arterial injuries should be repaired in patients with normal neurologic evaluation, focal pre-operative neurologic deficits and in patients with GCS >9. Comatose patients with GCS <8 do poorly regardless of management. The GCS provides an objective for stratification of patients with altered SCON who benefit from repair of carotid arterial injuries. © 1997 The International Society for Cardiovascular Surgery.

Section snippets

Patients and methods

For the period from 1978 to 1990, clinical records of 34 consecutive patients with penetrating injuries to the common and internal carotid arteries were reviewed. Hospital records were reviewed retrospectively for the following information: mechanism and anatomical distribution of injuries, haemodynamic stability, neurologic status, associated injuries, surgical management, Morbidity, and mortality associated with the carotid arterial injury.

Immediately following resuscitation, patients were

Results

Penetrating injuries of the common or internal carotid arteries were observed in 34 patients. Thirty patients were male (88%) and four were female; the mean age was 29 years. The distribution of injuries was 19 right and 15 left. The common carotid artery (CCA) was injured in 24 cases and the internal carotid artery (ICA) in 10. A majority of these injuries were from gunshot wounds (23), followed by stab wounds (8) and shotgun wounds (3). Compared to our previous reports[8], the proportion of

Review of the literature

The English language literature from 1952 to 1993 was surveyed for papers concerned with vascular trauma, penetrating wounds of the neck or carotid injuries. An earlier series[1]summarized the literature from 1952 to 1979. Articles from 1980 to 19939, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22were accepted for inclusion, provided information on patients' demographic data, neurologic status and hospital course were included. Those cases associated with head injury or other significant

Discussion

Management of carotid arterial injuries remains complex and continues to generate controversy. Reduction in cerebral blood flow frequently leads to major neurologic morbidity and/or death, with several recent series reporting mortality rates of 10–22%8, 9, 10, 11, 12, 23. Shock, location of arterial injury and ischaemic time have been implicated as adverse influences on neurologic outcome2, 10, 24, 25. Several prior reviews have attempted to correlate the incidence of shock with stroke.

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    1

    Presented at the Seventh Annual Meeting of the Eastern Vascular Society, held at the Sheraton Society Hill Hotel, Philadelphia, PA, USA on 30 April 1993

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