Kuehne J P, Weaver F A, Papanicolaou G, Yellin A E
Department of Surgery, University of Southern California School of Medicine, Los Angeles, USA.
Arch Surg. 1996 Sep;131(9):942-7; discussion 947-8. doi: 10.1001/archsurg.1996.01430210040008.
To assess management of penetrating internal carotid artery (ICA) injuries.
Retrospective review of institutional protocol.
Level 1 trauma center in a major urban area.
Sixty-one patients with penetrating ICA injuries.
In the period 1975 to 1987 (group 1; n = 36), management was based on individual surgeons' preferences. Between 1988 and 1995 (group 2; n = 25), an algorithm was employed: (1) hemodynamically stable patients with suspected ICA injuries underwent a diagnostic angiography; (2) surgically accessible injuries were reconstructed regardless of neurologic status with 2 exceptions: (a) neurologically intact patients with ICA occlusion were treated by anticoagulation and mild pharmacological hypertension and (b) minimal nonocclusive injuries were managed nonoperatively and followed up by serial angiography or duplex ultrasonography; and (3) heparinization, shunting, and completion angiography were employed.
Neurologic status at admission and discharge were compared by the Fisher exact test.
In group 1, 24 patients (67%) presented neurologically intact, and 12 (33%) with a deficit. Sixteen injuries were managed nonoperatively, 14 were repaired, and 6 were ligated. At discharge 6 (17%) were improved, 24 (66%) were unchanged, 6 (17%) were worse. Four patients (11%) died of cerebrovascular causes. In group 2, 19 patients (76%) presented neurologically intact, and 6 (24%) with a deficit. Eleven injuries were managed nonoperatively, 12 were repaired, and 2 were ligated. A death occurred in a patient who arrested, was admitted to the hospital in a coma, and died before ICA repair.
Neurologic outcome after ICA injury is enhanced by an algorithm predicated on the liberal use of angiography, a predefined surgical approach, and selective observation.
评估穿透性颈内动脉（ICA）损伤的处理方法。
对机构方案进行回顾性分析。
某大城市的一级创伤中心。
61例穿透性ICA损伤患者。
在1975年至1987年期间（第1组；n = 36），处理方法基于个别外科医生的偏好。1988年至1995年期间（第2组；n = 25），采用了一种算法：（1）血流动力学稳定且怀疑有ICA损伤的患者接受诊断性血管造影；（2）无论神经功能状态如何，手术可及的损伤均进行重建，但有两个例外：（a）ICA闭塞且神经功能完好的患者采用抗凝和轻度药物性高血压治疗，（b）微小非闭塞性损伤采用非手术治疗，并通过系列血管造影或双功超声进行随访；（3）采用肝素化、分流和完成血管造影。
采用Fisher精确检验比较入院时和出院时的神经功能状态。
第1组中，24例患者（67%）神经功能完好，12例（33%）有神经功能缺损。16例损伤采用非手术治疗，14例进行修复，6例进行结扎。出院时，6例（17%）病情改善，24例（66%）无变化，6例（17%）病情恶化。4例患者（11%）死于脑血管疾病。第2组中，19例患者（76%）神经功能完好，6例（24%）有神经功能缺损。11例损伤采用非手术治疗，12例进行修复，2例进行结扎。1例患者死亡，该患者心跳骤停，入院时昏迷，在ICA修复前死亡。
基于广泛使用血管造影、预定义的手术方法和选择性观察的算法可改善ICA损伤后的神经功能结局。
