Management of carotid artery injuries: What you need to know

Carotid artery injury (CAI), encompassing both penetrating (PCAI) and blunt carotid artery injury (BCAI), occurs infrequently but carries substantial risk of stroke and death. This review summarizes contemporary evidence and best practices in the management of adult PCAI and BCAI. Management of CAI has evolved significantly, driven by the transition from digital subtraction angiography (DSA) to computed tomography angiography (CTA), selective operative exploration of penetrating neck injury, expanded blunt cerebrovascular injury (BCVI) screening, and earlier initiation of antithrombotic therapy (ATT) for BCVI. Initial assessment should follow standard trauma principles, with emphasis on airway control, hemorrhage management, and recognition of hard signs of injury. Hemodynamically stable patients should be evaluated with CTA, which supports both diagnosis and operative planning. For PCAI, management is guided by hemodynamic status, injury location, and lesion characteristics. Open surgical repair is common for accessible injuries, particularly in zone II, with revascularization preferred over ligation given its association with lower stroke and mortality risk. Endovascular or hybrid approaches are alternatives for hemodynamically stable patients with zone I or zone III injuries, pseudoaneurysms, arteriovenous fistulae, or lesions not amenable to open exposure. Non-operative management is increasing PCAIs, although optimal ATT regimens and surveillance strategies in this population remain poorly defined. BCAI is predominantly managed non-operatively. Injury classification using the Denver Grading Scale guides treatment decisions, with ATT recommended as early as feasible. Available evidence supports ATT as a critical intervention to reduce both stroke and mortality, although the ideal agent, dose, duration, and follow-up imaging schedule remain debated. Future priorities include development of a standardized PCAI grading system and follow-up protocols, clarification of ATT strategies for BCVI through prospective multicenter comparative trials, and improved risk stratification tools for stroke prediction. Continued refinement of evidence-based management is essential to optimize neurological outcomes after CAI.