‘Tue Jovnsat, oF Tasca Vol, , No. 2 Copyright © 1900 by The Williams & Witkins Co. Printed in’ 8. CAROTID VERTEBRAL TRAUMA DAVID 0, MONSON, M.D., JACK D. SALETTA, M.D., axn ROBERT J. FREEARK, M.D. From the Department of Surgery, Cook County Hospital, Noriiucestern University Medical School, and the Hektoen Institute for Medicat Research of Cook County Hospital, Chicago Tyjuries to the major arteries in the neck ‘are difficult to recognize and chal- lenging to repair. Since distal pulses are often impossible to palpate, and because even a small amount of bleeding may compromise the airway, routine exploratio of all penetrating neck wounds has become a common practice (5, 8, L1, 13, 16, 17, 19, 23, 26, 31). Identification of arterial injury prior to and during surgical exploration is not the sole problem. The inability of cerebral tissue to withstand even brief periods of total ischemia raises additional consideration. In spite of considerable exper- ience in the elective surgery of patients with arteriosclerotic or neoplastic disease (2, 32), the effect of temporary or permanent interruption of a carotid or verte: bral artery in trauma victims is not well established (2, 4, 6, 18, 22, 24). This report is concerned with patients who sustained penetrating injuries to the innominate, common carotid, internal carotid, or vertebral arteries in the neek. The indications for surgery and value of preoperative arteriography in neck wounds are outlined. The consequences of the interruption of eerebral circulation as imposed by the original injury or required for surgical repair, are reviewed and the need for special measures to support the cerebral circulation during repair is evaluated. MATERIAL AND METHODS During the 3-year period from July 1, 1965 to July 1, 1968, 24 patients unde went surgical exploration at Cook County Hospital for injuries to the innominate, common carotid, internal carotid, or vertebral arteries. The elinieal reeords and radiographs were reviewed, and the important features of these patients and their injuries are summarized in Table I. ‘The average age of 29 years and the predominance of males is characteristic of the population usually involved in urban trauma. In every instance, the jury was inflicted by assailants, Missile wounds were the result of civilian firearms with low muzzle velocity. Stab wounds were the consequenec of knife biades, with the exception of one patient in whom a heavy steel rod was plunged through his lateral neck. Presented at the Twenty-eighth Anuual Session of the American Association for the Surgery of Tranma, Montreal, Quebee, October 18-20, 1968, Address for reprints: Robert J. Freeark, M.D., 1825 West Harrison Street, Chicago, Mlinois 60612. os798s MONSON, SALETTA, AND FREEARK TABLE 1 General Fealures of the 24 Patients Who Sustained Injury to the Eztracranial Cerebral Vessels Ser Age Distribution Males 18 3-60 yours Females 6 | Av. 29 years Btioloay j Vessel Injured asw wi! Common earotid 15 Stabs: 7 Internal carotid: 5 1 Vertebral 3 2 | Inominate All patients were treated in the Trauma Center at Cook County Hospital under the supervision of the General Surgical Staff. The Trauma Center is a W2-bed special care facility designed to provide initial triuge for all accident vietims and intensive eare for major and multiple injuries. Management of neck wounds in this unit ineludes the careful assessment of common carotid pulsations in the neck and superficial temporal artery pulses anterior to the ear. All injuries are regularly auseultated for the presence of bruits and investigated for evidence of excessive or recurrent bleeding. Wounds involving the lower neck or ehest were studied by chest roentgenograph and by evaluation of pulses and blood pressure in both upper extremities. Missile wounds of the neck usually were investigated by standard anteropos- terior and lateral radiographs of the area to establish the missile tract or localize metallie fragments. Whenever indicated, pereutuncous common carotid or retrograde brachial angiograms were obtained. Carotid angiography was performed by the injection of § to 12 ml of 50% diatrizoate sodium (hypaque) through a 17 French needle and hand operated syringe. Serial films were exposed at 0.25 second intervals in both the AP and lateral projection. Brachial angiograms to visualize the vertebral vessels were performed, using a pressure injector with the needle inserted in the brachial artery just above the elbow. ‘The 24 patients are most conveniently studied by dividing them into two groups bused upon the vessel injuries. Table IT deseribes the essential findings in 17 patients who sustained injuries to the immominate or common exrotid arteries (Group I). None of the patients entered the hospital with a ncurologic deficit that could be ascribed to cerebral ischemia, All were promptly explored without pre- operative angiographie study. ‘A second group of seven patients is reviewed in Table III, These patients sustained injuries to the internal earotid or vertebral arteries. Six of the seven were studied angiographically prior to exploration. In both groups the time interval between injury and repair was calculated irom police records and from information provided by the patient or relatives. ‘The “occlusion time” refers to the period during which all flow was interrupted in the injured artery in order to effect repair, and was obtained from the anes- thetic record or operative note.CAROTID VERTEBRAL ‘TRAUMA TABLE UL Findings in the 17 Patients with Wounds Involving the Innominute and Conunon Carotid Arteries 989 eset | Injury Age | Time Phy Bs Proceture ‘Rime; Rel oe ee : Lee sw 32 | thee ledinas tell Repair amin | 1 & Ww zoe |asw | as | shi {Bini Reseet Winn | Lew zee fasw | a [ithe | None Rowet | sz min | ew ee | st in| ne | Homann; brit eye min L&W BC & [GSW 35 tire | Hlemmtomas bruit Repairs CC iS nin | Did vA lig vert | 6.6C 6 Hematoma Rezuir somin | Lew rec a Hemnatoron Repair 2inin | Lett ' Mosner [10 | 40 | semaine Lovet tmin | ew 40 | 61 | Herutom Revwet 2 min | 1 ew 1 | hr | Decrease pube eres. amin, Lew ao | 4 kre | Hematoma Resoct. s0min | Lew 6 | kr | Shoek Rey 15min | 1 &W i | 13, OC 3 1 2hr | Alsent putse Reset, Mmin | Lew 14 oC 46 | 3am | Hematuina;shock —— Reseet 25min |. ew 15, Ino 30} Shim | Hemostonx Resects pratiesin jd min | 1 W ww. cc [a | mF sto Revect 25min [1 &W 22 | eoiues | Nones dovelopod cone | Throrabeewomy;éntimal | tye Ts talateral hemiparesis | repair nd operation) | i boxtoperstively Se — = TABLE IIL Findings in Seven Patients with Injuries Involving Internal Carotid _and Vertebrat Arteries i : Age | Time Phy. Es jean Provedure Result |" a 21 S0lirs Rt howmipasosing — | Vos Ligution Sporeh ok; de nba, j creasing hemi | | pores are casw | 3p rte | Hom You | Ligation 7b nerve yarns BCG /SW | 28 dwks Hem 1 Yen | Uinution of 16; repair ares VIt, XID IM | ! or Ee rial nerves | G8W 19 agi Hnlarging Nematoma | Yes! Ligation Lett fries SW 128) Zhi | uit hematoma con | Yor | Kigation; repair AV Died P.O. day 7 {tolatena etn fists i | press wn | usin ! 6. 31, 2¥ghm | Seek; caine areat | No | Ligation Died : js thee” | Hemaiome vee | Gewin ‘Wr RESULES Group I Jn Group I (Table IL) the vascular injuries were limited to the common carotid or immomii te arteries. Physieal findings suggesting vascular injury were present in all but one patient. ‘The most frequent finding, that of a large local wound hematoma, was observed990 MONSON, SALBITA, AND FREEARK in half of the injuries. Hemorrhagic shock, pulse deficits, ative bleeding, and hemothorax were also noted, but in decreasing frequeney. No angiograms were performed preoperatively in this group of patients However, one patient had a carotid angiogram performed in the postoperative period, when progressive neurological signs developed following a reported “negative exploration.” ‘This angiogram revealed 2 complete occlusion of the takeoff of the internal carotid artery (Wig. 1) ‘The average time before surgieal exploration for this group of patients was 5 hours post injury. AM of the arterial injuries were repaired without the use of internal or external shunts, and the average vascular occlusion time during repair was 31 minutes. One of these injuries, a stab wound of the common earotid artery, was repaired. by lateral arteriorrhaphy. Another patient mentioned earlicr had a “negative” exploration initially, and was found at r ploration to have a contusion of the carotid bifurcation with intimal disruption and a thrombosis extending into the internal carotid artery. Following thrombectomy and intimal repair he had full recovery from his progressive hemiparesis. ‘Lhe remaining 15 arteries were repaired with reseetion and end-to-end anas- tomosis. On two oceasions, the magnitude of vascular injury necessitated inter- position of 2 Dacron® prosthesis One patient sustained a severe brain stem injury, and was quadriplegic on admission to the hospital. The bullet which penetrated his brain stem had also severed the right common earotid and vertebral arteries. The common earotid ViG. 1. Lateral and anteroposterior views of a carotid angiogram performed postopera tively in patient with hemiparesis following “negative exploration” for « gunshot wowd of neck. Note complete ocelusion of internal earotid artery due to intimal disruptionCAROTID VERTEBRAL ‘TRAUMA 991 F 1.2. Arbitrary division of the cervical region into tee ing wounds of the neek is based upon the area involved. ones. Manuygement of penetra artery was repaired and the vertebral artery ligated without any appreciable change in his ncurologie deficit. This patient had a progressive downhill couse and he died on the fifth postoperative day. He represents the only death in this group of patients. A child of 3 years, who sustained a gunshot wound of his carotid artery, wi noted to have sn ipsilateral brachial plexus palsy postoperatively. The finding were the result of at ated with hurried transfer to the hospital, and were unrelated to the vascular injury or cerebral ischemia. ‘The remaining 14 patients have no residual neurological deficit, and were discharged following un- eventful recoveries. Tn this group of patients, no morbidity or mortality resulted from either the vaseular injury or its operative repair ion injury asso Group IT Group If (Lable HZ) includes five internal carotid injuries and two vertebral injuries. A third vertebral artery injury occurred concomitantly with a common carotid injury, and was included in Group I. All of the internal carotid i (Wig. 2). Two of these patients were admitted with physical findings of a con- tralateral hemiparesis. Of the remaining five patients, four had large wound hematomas and the fifth was in profound shock with active bleeding from a small posterior stab wound of the neck. One patient had an ipsilateral hemipar: secondary to a high cervical cord injury juries occurred above the angle of the mandible992 MONSON, SALE PA, AND FRBEARK All of the patients with internal carotid injuries had carotid angiograms, In three patients the angiogram revealed an occlusion of the extracranial portion of the internal carotid artery, and in two patients a false ancurysm of the internal carotid artery was appreciated. left brachial angiogram was performed in one of the patients with a v artery injury, and revealed complete ocelusion of the left vertebral artery at the lovel of the first cervical vertebra (Vig. 3). ‘Two of the patients in this group had pressing indications for early exploration, namely, active hemorrhage and an enlarging hematoma. They were explore’ and 41% hours after injury respectively. One patient was followed at another hospital for 314 weeks before transfer to our institution, and was then explored 3 days later, The remaining four patients were explored an average of 38 how post injury. All of the arterial injuries were treated with ligation, One of the two patients with contralateral hemiplegia had an embolus to the ebral Fic. 3. Percutaneous brachial arteriogram in patient with gunshot wound of the neck: ‘ote complete veclusion of the left vertebral artery.CAROTID VERTEBRAL TRAUMA, 993 middle cerebral artery which was precisely demonstrated on angiography. The other patient had some improvement of his hemiparesis and a complete clearing of his associated aphasia in the late postoperative period. One of the patients with a vertebral artery injury died 6 hours postoperatively as a result of the sequelae of irreversible shock. ‘The patient with the middle cerebral embolus also died on the fourth postoperative day. ‘The remaining five patients are living and well. DISCUSSION ‘Most penetrating wounds of the eervical region require prompt surgical ex- ploration. Findings on physical examination correlate closely with the presence of vascular injury. A history of blood loss, hypotension, an established or expanding hematoma, a palpable thrill, or the finding of audible bruit, or absent or diminished pulses distal to the site of injury suggest vascular injury. A neurologic deficit resulting from the interruption of one of the four major extracranial ves- sels is uncommon, but a finding of great importance. Careful evaluation during the initial and follow-up cxamination is required because of the added hazard of progressive thrombosis of the cerebral blood supply distal to the injury or repair (3). Injury to a major vessel without significant physical findings does occur (4). ‘The management of penetrating wounds of the eervieal region is aided by its arbitrary division into three areas (lig. 2). Wounds below the sternal noteh may potentially involve a variety of vessels, both arterial and venous (15). Clinical evaluation is the primary determinant for exploration in this area. Peripheral pulse deficit, differences in extremity blood pressure, bruits, intra- thoracic bleeding, or peripheral neurologic abnormalities are indications for surgical exploration. The estimated pathway of the missile, in addition to loca zation by physical examination, allows the ehoiee of a proper surgical approach from among the many available. Emergency arteriographic evaluation is not casily accomplished. Retrograde examination of the aortic arch via the brachial or femoral artery may be of par. ticular value in identifying the less acute problem of a false aneurysm or ar- teriovenous fistula. The availability of arteriographie examination in the acute problem would be an aid in preoperative evaluation and in the choice of operative approach. Wounds in the mid-cervical region, between the sternal noteh and the angle of the mandible, are encountered most frequently. They are managed by routine exploration through an anterior neck incision. Radiographic evaluation is rarely obtained preoperatively, since percutaneous injection is necessarily made more difficult by the presence of the wound. The information obtained by a normal arteriogram does not eliminate the possibility of esophageal, tracheal, or venous injury. Nor will a positive angiogram in this region measurably influence the surgieal approach used or the technique of vaseular repai Consideration should be given to intraoperative carotid angiography for oc- casional patients in this group. This is best illustrated by Case No. 17, Group 1 At the initial exploration no gross evidence of vascular injury was seen, and weak994 MONSON, SALETTA, AND FREEARK pulses were present. An intraluminal problem was considered, but no arteriotomy was performed and no angiography employed. The patient subsequently de- veloped signs of neurologic deficit, and re-exploration was undertaken after angiography had demonstrated carotid occlusion. Thrombectomy and intimal repair were accomplished, with complete recovery by the patient. ‘The management of wounds above the angle of the mandible and below the base of the skull is aided by angiographic evaluation. An injury of significance in this region will be vascular, primarily arterial. Secondly, the surgical exposure of this vessel is less easily accomplished, and its mobility for repair is restricted due to its passage through the carotid foramen. Carotid angiography will demon- strate the presence or absence of an arterial lesion, thereby justifying a relatively difficult exploration. Also, by localizing the lesion, angiography will demonstrate the likelihood of re-establishing continuity of the vessel or the need for ligation. An injury to the external carotid system alone, or in combination with the internal carotid, can be demonstrated. Wounds in this region of the neck should be managed surgically after evaluation by carotid angiography. An ad- ditional benefit of angiographic study might be the demonstration of cerebral cross-circulation and collateral flow. In the presence of bilateral cerebral supply from the site of the injury, a grave prognosis will be established without resto- ration of carotid flow. An additional instance where extracranial vascular study is of value is in the multiply injured patient with a developing neurologie deficit. The prognosis as- sociated with injuries to the common carotid artery was dependent upon ac- companying injury, rather than the vascular injury. ‘There was no morbidity or mortality as a direct result of the vascular injury. Rather, the direct missile in- jury to the brain stem accounted for the death of one patient, and associated injury to the brachial plexus was responsible for a right arm paresis in another. Of utmost significance was the fact that no neurologic deficit resulted from common carotid occlusion for purposes of repair. Beall et al. reported two deaths in 22 patients, both being secondary to CNS ischemia (1). Although a variety of tech- niques have been described and their routine usage recommended, no internal or external shunts were employed here. No hypothemia techniques were utilized, and systemic anti-coagulation was not used. The absence of preoperative signs of cerebral ischemia in wounds of the common earotid artery indicates an adequate collateral blood flow, and probably makes undue haste during repair as well as recourse to ancillary measures unnecessary. Zone TIT injuries in the upper cervical region, involving the internal carotid artery, were approached more deliberately. Angiographic evaluation demon- strated the probability of repair or ligation of the vessel. Ligation was employed n all cases with no neurologic deficit ineurred. One patient showed an established hemiparesis and aphasia. Angiography prior to internal carotid ligation demon- strated embolization to the middle cerebral artery, presumably from the false aneurysm of the internal carotid artery, As has been mentioned, this localiza- tion of responsible lesions is an important benefit to be gained from angiography. Vertebral artery trauma is an uncommon injury, and is frequently misdiag-CAROTID VERTEBRAL TRAUMA. 995 nosed. In the patient who has sustained a neck wound with evidence of major vascular injury, the carotid system is usually incriminated. Localization of an arterial injury to the vertebral vessels is difficult unless angiography is employed. However, if the patient has a bruit in the neck, the failure of this bruit to dis- appear following digital compression of the carotid artery should make one suspicious of a vertebral injury. Unilateral vertebral artery ligation has been followed by fatal midbrain or cerebellar necrosis (10, 27, 31). Numerous other articles scem to suggest that ligation of one vertebral artery i undertaking (7, 8, 24, 28). Studies of ecrebral blood flow in man indicate that approximately 90% of the total blood flow to the human brain is through the internal carotid vessels, and that the other 10% is supplied by the vertebrals (25). When one of these vessels is occluded, an increased blood flow is usually appreciated in the other three ves- sels (12). Thomas and his associates in 1956 reviewed the vertebral-basilar system of 96 consecutive autopsy eases and also performed an exhaustive review of the litera- ture (30). Figure 4 summarizes the results of their work and reveals that, on oc- casion, either vertebral artery may be hypoplastie or may terminate in the pos- terior inferior cerebellar artery with inadequate communication to the basilar artery. The effect of ligation of a vertebral artery whose contralateral partner is hypoplastic would undoubtedly be variable. However, on the basis of an absent, or inadequate communication of the contralateral vertebral, they estimate that an innocuous VERTEBRAL — BASILAR SYSTEM BASILAR A. CY 1.8% VERTEBRAL A }) post INF. CEREBELLAR A. 9.7% Fic. 4. Diagramatic representation of common anomalies of the eervieal portion, right and left vertebral arteries.996 MONSON, SALETTA, AND PREBARK 3.1% of pationts with a left vertebral ligation and 1.8% of patients with a right vertebral ligation will develop an acute midbrain necrosis. In the face of massive hemorrhage resulting from a partially severed vertcbral artery, immediate ligation becomes a surgical necessity with a reasonable pros- pect of “doing no harm.” Ti the vertebral injury is not actively bleeding, a preoperative retrograde brachial arteriogram should be performed to visualize the contralateral vertebral artery. Ifa hypoplastic or anomalous vertebral artery is seen on angiography, we believe that an attempt should be made to repair the injured vertebral artery. SUMMARY AND CONCLUSIONS: 1. The clinical and radiographic findings and the hospital course of 24 pa- tients with penetrating wounds of the extracranial cerebral arteries were re- viewed. An approach to the problem of penetrating wounds of the cervical region is outlined, based upon the area involved and the major structures contained therein. 3. Injuries involving the innominate or common carotid arteries generally show signs of vaseular injury without evidence of cerebral ischemia. Prompt ex- ploration is advisable to control bleeding and to exclude associated injuries, 4. Injuries involving the internal carotid and vertebral arteries may reveal ns of vascular injury or cerebral ischemia. Preoperative angiographic study aids in both the recognition and the operative management of these injuries, 5, Treatment of wounds to the cerebral arteries should conform to established principles of vascular surgery, and recourse to special operative measures to pro- tect against cerebral ischemia appears unwarranted. REFERENCES 1. Beall, A.C., A. L. Shirkey, and M. E. DeBakey. 1963. Penetrating wounds of the earotid arteries. J. Trauma 8: 276-287. Brackett, C. E. 1953. The complications of earotid artery ligation in the neek. J. Nouro- surg. 10: 91-106, 3, Caldwell, TL W., and F.C, Hadden. 1948. Carotid artery thrombosis: report of eight cases due to trauma, Aun. Ing. Med. 28: 1132-1142 4. Cohen, 8. M. 1944. Traumatie arterial spasm. Brit. Med. Bull. 2: 14-145. 5, DeBakey, M. E., and P. A. Simeone. 1946, Battle injuries of the arteries in World War I. Ann, Surg. 123: 584-579. 6. Ecker, A. D. 1945. Spasm of skin, D. C., and M. HL. Hat Aim, Surg, 124: 931-951, 8, Elkin, D. C., and M. E, DeBakey. 1955, Surgery in World War II: vaseular surg p. 256-263. Office of Surgeon General, Dept. of Army, Government Printing Office, Wash- ternal carotid artery. J. Neurosurg. 2: 479-484 1046, Arteriovenous aneurysm of the vertebral vessels. ington. 9. Freed, T. A., and L. H, Bosher, Jr, 1968. Arteriorgaphie demonstration of lacerations of great vessels secondary (o blunt chest trauma, Radiology 90: 88-89. 10. French, A. L., and G. L, ULaines. 1950. Unilateral vertebral artery ligation. J. Neurosurg.AROTID VERTEBRAL TRAUMA, 997 1, Fogelman, M. J., and R. 1D, Steward, 1956, Penetrating wounds of the neck. Amor. J Surg. 91: 581-698 12, Hardesty, W. IL, W. B. Whituere, J. F. Toole, P. Randall, and If, P. Royster. 1963. Studies on vertebral artery blood flow in man, Surg. Gynec. Obstet. 116: 662-664 18. Inghes, C. W. 1958. Arterial repair during the Korean War, Ann, Surg. £47: 555-561. 14. Mlusni, H. A., TLS. Bell, and J. Storer. 1966. Mechanical veclusion of the vertebral artery. JAMA, 196: 475-478. 15. Imamoglu, K., R. C. Read, and IL. C. Tuebl. 1967. Cervicomediastinal vasewlar inju: Surgery 6/: 74-279. 16. Jalinke, I. J., dr, and 8. P, Secley. 1953. Acute vascular injuries in the Korean war. Ann, Stig. 138: 158-177, Joues, Rv F,, J. C. Terrell, and K. 1. Salyer. an atilysis of 274 eases, J. Trauma 7: 228-237, 18, Lichtenstein, M. E, 1917. Acute injuries involving the large blood vessels in the neck. Surg. Gynee. Obstet. 85: 165-175. fakins, G. H. 1919, Gunshot injuries of the blood vessels. John Wright, Bristol. Matas, R, 1893, Traumatisms and traumatic aueurysms of the vertebral artery and their surgical treatinent, with report of a cured ease. Aun. Surg. 18: 47-521. 21, Moore, UL. G., L. M. Nyhus, E. A. Kanai, and 11.N, Harkins. 1952. Preliminary experi- mental observation of the nature, extent, and repair of gunshot injuries of the aorta. West J.8.G.0. 61: 607-618. 22. Morris, G. C., Jr., A.C. Beall, W. R. Roof, and M. B, DeBakey. 1960, Surgical experi- ence with 220 acute arterial injuries in civilian practice. Amer. J. Surg. 99: 775-781 23. Murray, D. 8. 1956. Post-traumatic thrombosis of the internal earotid and vertebral arteries after non-penetrating injuries of the neck. Brit. J. Surg. 44: 556-561 24, Patman, R.D., B. Poulos, and G. . Shires. 1964. The management of eivilian arter injuries. Surg. Gynee. Obstet. 118: 725-738, 25. Roberts, B., W. IL Hardesty, I.E. Holling, M. Reivieh, and J. P. Toole. 1964. Studies on extractanial cerebral blood flow. Surgery 38: 826-833. 26. Shirkey, A. L., A.C. Beall, Je, and M. H. DeBakey. 1963. Surgical management of penetrating wounds of the neck. Arch. Surg. 86: 955-963, 27. Shumaker, IT, B., Jr. 1946, Arteriovenous fistulas of the cervieal portion of the vertebral vessels. Surg. Gynee, Obstet. 83: 625-630. 28. Shumaker, I. B., Jr., R. L. Campbell, and R. F. Heimburger. 1960. Operative treatment of vertebral arteriovetions fistulas. J. Trauma 6: 3-19. uki, J., A. Takaku, 8. Hori, J. Ohara, and R. Kwak. 1967. Spasm of the cervical portion of the carotid artery and its surgical treatment, J. Neurosurg. 27; 4-101, 30. Thomas, G. L., KN. Anderson, RF. Hain, and K. A. Merendino, 1956, The significance of anomalous vertebral-basilar artery communications in operations on the hoart and great vessels. Surgery 462 747-757 BL. Tsuji, 1. K., J. V. Redington, and I. J. Kay. 1968. Vertebral arteriovenous fistula. J. ‘Thorne. Cardiovasc. Surg. 55: T4H6-753. 1967. Penetrating wounds of the neck 1 82. Watson, W. L, and 8. M. Silverstone. 1939. Ligature of the common carotid artery in cancer of the head and neck. Ann. Surg. 109: 1-27. DISCUSSION Dr. Juuiax R. Youwtans (Davis, California): I enjoyed this paper very much. As a neurosurgeon, however, I have a slightly different view of this problem, and T would like to mention a group of patients with other but related problems. ‘They are patients who have a blow to the neck, and they too have a carotid injury. However, we don’t focus on the neek right away because of other injuries that are more apparent. The symptoms related to the neck injury are often de-998 MONSON, SALBTTA, AND PREBARK layed, sometimes up to 36 hours or more. The symptoms usually start as a numb- ness and a very mild weakness in the extremities. Then as the hours go by, there is a progression, usually quite gradual, and finally it is apparent that we have a serious neurological problem. ‘Then angiograms are made and a diagnosis of oc- clusion of the carotid artery is made. Why it takes so long for the symptoms to develop, I don’t know. It would seem. to me that they would oceur immediately after the carotid artery is injured. Per- haps the delay in the symptoms is due to the fact that usually the pathology in these eases is an intraluminal hematoma in the artery. This hematoma could develop slowly. Prior to the days of angiography, these people had burr holes done in a search, for am intracranial hematoma. Nothing would be found and, if the diagnosis was made at all, it was at autopsy. Very few were promptly diagnosed and treated prior to angiography. We usually start off suspecting a head injury and get the diagnosis when we are doing the arteriogram to rule out an intracerebral hema- toma. Sometimes we are shrewd enough to notice evidence of trauma to the neck and suspect the diagnosis initially. Undoubtedly, in most instanecs when the circle of Willis is normal, the patient can tolerate the occlusion of a carotid artery and remain asymptomatic. When the patients develop neurological symptoms, they are demonstrating that they have an inadequate cirele of Willis. Tt is extremely important to move rapidly, once any suggestion of a neurological deficit begins. This is so because they can de- velop an ischemic infaretion of the brain in a matter of a few minutes or hours. Since the infarction may produce an irreversible deficit, it is fair to say that these paticnts are even more of an emergency in regard to thei need for immediate treatment then if they had an intracerebral hematoma. Dr. Roperr J. Fxexark (closing): I would like to show a few more slides. Dr. Youmans very properly brought up the problem of blunt trauma to the neck and its occasional vaseular sequelae. I don’t think there is any question but that neck angiography is often indicated and extremely valuable in patients with neurologic findings or diminished temporal artery pulses following blunt trauma to the neck. We would, however, like to emphasize particularly its role in penetrating wounds, both preoperatively and in the operating room. In one of our eases, when a gunshot wound in the region of the carotid was explored by a competent surgeon, he felt that there was some external evidence of injury to the carotid artery; but there was no bleeding, and a pulse was palpable through the contused ares. He closed the neck, and the previously asymptomatic patient later developed signs of cerebral ischemia much as Dr. Youmans de- ribed. On re-exploration he had indeed an intimal fracture and traumatic thrombosis, an insidiously developing lesion. I think if there is any question about the integrity of the artery in the field or beyond it, it is extremely important to have operative angiography available. ItCAROTID VERTEBRAL ‘TRAUMA 999 is much casior than investigating arteries by opening them, particularly where you have arteries as critical to the circulation as the carotid may be. ‘There is one other point in this paper that I hope will be of some benefit to you. If neek exploration reveals a penetrating wound of a major artery, don’t panic. There is, in our experience, no need for undue haste. Clamp the carotid artery and take your time to do an anatomieal repair. We did not use shunts or any of the so-called ancillary measures to protect the circulation to the brain, and none of these patients appeared to suffer from the period of occlusion that accompanied the operative procedure.