Antithrombotic therapy and endovascular Stents are effective treatment for blunt carotid injuries: Results from longterm followup

BACKGROUND: Significant confusion exists about management of blunt carotid injuries (BCI). Currently, three common treatments are being used without significant longterm followup data to demonstrate efficacy. Although heparin has been shown to reduce in-hospital stroke rates, antiplatelet therapy (aspirin and clopidogrel) has emerged as an alternate therapy without proved efficacy; carotid stenting has also been implemented for pseudoaneurysms (13% BCI), but its utility has recently been challenged. This is the first study to assess longterm efficacy of various therapeutic approaches. STUDY DESIGN: Consecutive patients treated and followed at a single regional trauma center over 10 years (1996 to 2005) were reviewed. Outcomes evaluated included cerebral infarction, functional status, and angiographic evolution. RESULTS: One hundred ten patients (11/year) were diagnosed with 133 injuries (23 bilateral). Overall mortality was 26%, with 6% directly attributable to BCI. Angiographic followup was available on 67 injuries (in 50 patients) at a mean of 6 months (range 0.25 to 67 months); 75% remained the same or improved. Clinical followup was available in 55 of 81 patients (68%) who survived to discharge (mean, 34.4 months [range 1 to 109 months]). Of surviving patients receiving antithrombotic therapy, 44% were treated with antiplatelet therapy, 49% with anticoagulation, and 7% with both. No patients experienced cerebral infarction after discharge, and there was no difference in functional outcomes based on the therapy received. Twenty-two endovascular stents were placed (18 for pseudoaneurysms, 4 for extensive dissection). Mean followup on these patients was 29.7 months (range 3 to 94 months). No patients receiving stents experienced periprocedural complications, and one patient with an associated brain injury had a cerebral infarction. CONCLUSIONS: Longterm followup of BCI demonstrates that antithrombotic therapy prevents cerebral infarction; antiplatelet therapy and anticoagulation are equally effective; and carotid stents appear to be safe and effective for lesions that develop pseudoaneurysms or extensive dissections.