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Penetrating and Blunt Injuries of the Carotid Artery


Injuries to the carotid arteries are relatively uncommon, but not rare. Despite some variability in reported data from center to center, certain principles have evolved. Injuries to the carotid artery are traditionally considered blunt or penetrating ( Box 1 ).

BOX 1
Selected Perspectives on Carotid Artery Trauma

  • Penetrating neck injuries have a 20% incidence of major vascular injury.

  • Routine exploration of penetrating neck wounds produces a 40% to 60% negative exploration rate.

  • Physical examination signs of carotid artery injuries are often unreliable; they are absent in 30% of patients with carotid injury established at exploration.

  • Penetrating carotid artery injuries are usually from stab wounds; usually involve young men, who are often intoxicated (drugs and/or alcohol); and are more common on the left side (right-handed assailants).

  • Penetrating carotid artery injuries usually involve the common carotid artery; blunt injuries usually involve the internal carotid artery.

  • Blunt carotid artery injuries represent approximately 3% to 10% of total carotid artery injuries.

  • Blunt carotid artery injuries are bilateral in up to 20% of cases.

  • Blunt carotid artery injuries have a 20% to 40% mortality, and 25% to 80% of survivors have a neurologic deficit.

Penetrating Carotid Artery Injuries

Management algorithms for penetrating neck trauma have been well established for more than 4 decades. Treatment of penetrating vascular injuries in the neck takes into consideration the type of injury, the location (zone I, II or III) ( Figure 1 ), and potential associated injuries to the aerodigestive tracks as well as the neurologic and overall status of the patient. Zone II injuries are usually handled through conventional surgical exposures. Zone I penetrating injuries require careful consideration of intrathoracic bleeding and/or the need for intrathoracic vascular control. Zone III injuries involving the distal internal carotid artery at the base of the skull require exposures commonly used in conventional carotid artery surgery. The exact approach to a given injury, especially zone I and zone III, can be precisely tailored depending upon the results of the imaging studies. In the presence of a hard sign of vascular injury ( Box 2 ), either direct exploration or conventional angiography, if endovascular repair is being contemplated, is appropriate. Zone I and zone III injuries require serious consideration of a dedicated imaging study even when hard signs of vascular injury are lacking.

FIGURE 1, Classic zones for penetrating neck injury. These zones have been variably described in clinical reports. Zone I is easily remembered as periclavicular or low neck (from the sternal notch to 1 cm above the clavicular head); zone II is the midneck from 1 cm above the clavicular head to either the angle of the jaw or the hyoid bone; zone III is the high neck (anything above zone II). Zone II injuries are most familiar and typically require less in the way of sophisticated imaging or complex surgical approaches. Zone I injuries can require a sternotomy or thoracotomy for proximal control. Zone III injuries require high carotid exposures infrequently used in daily practice.

BOX 2
Signs of Carotid Injury

Hard Signs

  • Active bleeding

  • Large or enlarging neck hematoma

  • Pulsatile hematoma

  • Ongoing shock

  • Neurologic deficit

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