Neurologic outcome after penetrating extracranial arterial trauma
Date
2003
Authors
Du Toit D.F.
Van Schalkwyk G.D.
Wadee S.A.
Warren B.L.
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Abstract
Purpose: We undertook this study to determine factors that adversely affect outcome in patients with penetrating injury to the extracranial cerebral vasculature. Patients and Methods: Medical records were reviewed for all patients who had undergone surgical intervention to treat penetrating injury to the extracranial cerebral arteries between January 1989 and December 1999. Forensic autopsy findings were also reviewed for all patients who died as a result of their injury. Results: One hundred fifty-one patients with injury to the brachiocephalic artery (n = 21), common carotid artery (n = 98), or internal carotid artery (n = 32) were identified. Overall mortality was 21.2%, and stroke rate in surviving patients was 15.1%. Twenty-five of 32 deaths (78.1%) were stroke-related. Brachiocephalic artery injury was associated with the highest mortality (38.1%), and survivor stroke rate was highest in patients with internal carotid injuries (22.7%). Hemodynamic instability at presentation led to both higher mortality (30.7%) and stroke rate (19.2%). Preoperative angiography did not influence mortality or stroke rate in hemodynamically stable patients. Procedural mortality associated with arterial ligation was 45% (9 of 20 patients), and no surviving patient experienced a change in pre-ligation neurologic state. Nine patients remained neurologically intact after ligation, and 2 patients with preoperative localized neurologic deficit were unchanged postoperatively. In 131 patients, mortality after arterial repair was 17.6%, and in 5 surviving patients (5.4%) an ischemic neurologic deficit developed. Twelve of 15 surviving patients (80%) with preoperative neurologic deficit who underwent arterial repair had improved neurologic status. Cerebral infarcts were confirmed at autopsy in 23 patients; 18 infarcts were ischemic (10, repair; 8, ligation), and 5 infarcts were hemorrhagic (all, repair). No factor was identified that was predictive of ischemic versus hemorrhagic infarction in patients undergoing repair. Conclusions: The presence of hypovolemic shock, internal carotid artery injury, complete vessel transection, and arterial ligation are associated with unfavorable outcome. Penetrating injury to the brachiocephalic, common carotid, or internal carotid artery should be repaired rather than ligated when technically possible. Subsequent ischemic or hemorrhagic cerebral infarction is unpredictable, but overall outcome is superior to that with ligation of the injured artery. Copyright © 2003 by The Society for Vascular Surgery and The American Association for Vascular Surgery.
Description
Keywords
angiography, artery injury, artery ligation, artery reconstruction, brachiocephalic trunk, brain infarction, brain ischemia, common carotid artery, hemodynamics, human, hypovolemic shock, internal carotid artery, mortality, nervous system injury, neurological complication, preoperative treatment, priority journal, review, stroke, adolescent, adult, article, carotid artery injury, female, injury, male, middle aged, neurologic disease, penetrating trauma, retrospective study, Adolescent, Adult, Brachiocephalic Trunk, Carotid Artery Injuries, Cerebral Infarction, Female, Humans, Male, Middle Aged, Nervous System Diseases, Retrospective Studies, Wounds, Penetrating
Citation
Journal of Vascular Surgery
38
2
38
2