Abstract
Aims: The main aim of this study is to analyze the effectiveness and causal relationships of treatment of patients with blunt injury of the cervical segment of internal carotid artery (ICA) in a prospective observational study. Methods: A retrospective analysis with prospective data collection was used to evaluate a cohort of patients diagnosed with extracranial ICA injuries between the years 2010 and 2020. In all patients, we followed up the initial clinical symptomatology, findings on initial CT angiography (CTA), chosen therapy, follow-up brain imaging, and assessment of neurological status with carotid imaging after 3 months. Sixteen patients with blunt ICA injury diagnosed in triage-positive patients examined by whole-body CT scan for suspected polytrauma were included. Patients with severe bleeding lesions were left without antithrombotic therapy until the hemorrhagic injuries were repaired, after which they were treated with a combination of antiplatelet therapy with acetylsalicylic acid (ASA) + low molecular weight heparin (LMWH) at a prophylactic dose. Patients with brain injury (contusions or intracranial haemorrhage) were treated with LMWHonly at prophylactic dose from the second or third day after trauma. Patients who developed neurological symptomatology related to ICA injury were managed on a strictly individual basis with consideration of all potential risks associated with aggressive antithrombotic therapy. All patients with ICA lumen stenosis underwent follow-up CTA in 2-3 days to rule out severe progression of the lesion. In addition, patients were followed up after 3 months with ultrasound or CTA. In the evaluation of the cohort, we focused on the incidence of neurological complications in relation to the severity of the stenotic ICA lesion.
Results: Of the 4145 patients examined on CT after high-energy trauma, 16 (0.4%) patients with blunt ICA injury were recorded. In 4 cases, the ICA findings were bilateral, thus the total number of carotid injuries was 20. Four times (20%) the artery was closed, 7 times (35%) with stenosis greater than 80%, and 9 times (45%) with stenosis less than 80%. All patients were treated conservatively. Three patients (19%) were treated with LMWH at a prophylactic dose from the second day after trauma due to the findings of traumatic SAH and cerebral contusions. In 7 (44%) patients, treatment with ASA + LMWH in prophylactic dose was set after the treatment of hemorrhagic injuries. In 6 (38%) mobilized patients without associated major trauma, only antiplatelet therapy was deployed. We did not observe any stroke symptoms in 5 patients with ICA stenosis up to 80%. In 6 patients with ICA stenosis above 80%, we observed once neurological symptomatology, and in 4 patients with ICA occlusion, we observed permanent neurological disability in 2 cases. Thus, we recorded a total of 3 (19%) neurological complications related to blunt ICA injury, of which one (6 %) was severely disabling. Conclusion: Patients with blunt injury of ICA after high-energy trauma with stenosis findings up to 80% can be successfully treated conservatively. In patients with ICA oclusion, neurological disability can be expected in 50 % of cases. The treatment of symptomatic patients with associated injuries should be strictly individualized with consideration of all potential risks of pharmacological or endovascular treatment.