Diagnosis and management of zone III carotid injuries

The management of patients with extracranial carotid injury at the base of the skull (zone III) is challenging due to inaccessibility, severity, and associated injuries. In an effort to formulate a systematic approach to the evaluation and management of zone III carotid injuries, the records of 13 consecutive patients with such injuries were reviewed: nine sustained penetrating injuries and four had blunt injuries. A total of 16 arteries were injured: internal carotid (11), external carotid (four), and vertebral (one). Neurological examinations revealed a central nervous system deficit in 1/9 with penetrating injuries and in 4/4 with blunt injuries. Angiography in patients with penetrating injuries revealed pseudoaneurysm (five), intimal flap (five), transection (two), and AV fistula (one). Angiograms of patients with blunt injuries demonstrated pseudoaneurysm (2), dissection (1), and intimal flap (1). Three patients underwent operative repair of internal carotid injuries and/or ligation of external carotid injuries. Four patients were managed with endovascular balloon occlusion. The remaining patients were observed with or without anticoagulation. Neurologically the patients remained normal or had improved on follow up with the exception of one patient with a persistent hemiparesis after a blunt injury who had been observed. The conclusions are: (1) angiography at presentation is indicated, in stable patients, to delineate the injury and guide definitive management; (2) blunt injuries should generally be managed with anticoagulation. In cases of large or expanding pseudoaneurysms or when anticoagulation fails, endovascular balloon occlusion is indicated; (3) partial thickness penetrating injuries can be observed, while full thickness lesions should be managed with balloon occlusion; (4) operative vascular reconstruction should be reserved for unstable patients, patients with active bleeding, and patients requiring surgical exploration for associated injuries.