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Wed May 6 00:53:48 BST 2009

There is NO good answer to this clinical question.   

First, I an not really sure that there is an "injury."   I an not  even 
sure there is an intimal or medial hematoma or flap.   You did  not tell us how 
it was diagnosed, nor did you send us a picture of your  imaging.    I have 
been mislead by CT and CTA studies of the  carotid artery.    I have had 
CTA that stated there was a 50%  stenosis of the CCA secondary to blunt trauma 
and at arteriogram or surgery the  carotid was completely COMPLETELY 
normal.    I have had CTA of  the carotid artery which was read as normal, in who 
there was a major injury  with extravasation.   The very first thing I would 
do is get a PROPER  study, an arteriogram of this artery and then go from  
there.       Currently I consider CTA, CT, MRI,  MRA, and ultrasound of the 
carotid artery to NOT be anything but extraneous  information as part of a 
screening process in vascular trauma, a VOMIT if you  please.   

Second:   I have looked for 15 years for an article, any article  in any 
pathologic, radiological, trauma, vascular surgery, etc. journal that  tells 
me just what is going histologically in a blunt injured carotid  artery 
diagnosed by CT or even arteriogram.  NONE.    I  think I know that the pathology 
is in a MISSECTING HEMATOMA OF THE  THORACIC AORTA.   The disease is in the 
media and everyone taking  their board examinations can recognize the 
histologic slide of such  pathology.   No such supportive information exists for 
blunt trauma of  the carotid where some over anxious radiologist reads into 
the report,  "dissection."   Mis leading and non discript.   

Third:   I have read all of the literature on this subject from  Memphis, 
Denver and other cities where there are more people (in the literature)  with 
this diagnosis than the rest of the world combined.   There is  really no 
help in knowing just what to do from a treatment standpoint.  It  is very 
very confusing to know whether one should operate, do nothing, or put  in a 
stent, or anticoagulate, and if one anticoagulates, then what  drug should be 
used.    I could STRONGLY defend NOT giving  Coumadin, Plavix, or LMWH.    
Whether regular heparin is of any  value or not is conjecture and just what 
does should be used is a random number  generator.       

Decide what you think you can defend in court in this asymptomatic patient, 
 and consider the LONG list of complications which exists from the various  
treatments and work ups suggested.   I think from a risk benefit  
standpoint you are best off by doing NOTHING in this asymptomatic  patient.   I could 
even raise questions as to why you did the  origional imaging test in this 
asymptomatic patient to begin with.    VOMIT.        

k  

In a message dated 5/5/2009 6:35:42 P.M. Central Standard Time,  
khumarhuse at yahoo.ca writes:

Dont  know where exactly the injury is in the common carotid. 
The problem is  that you have a choice of LOW dose anticoag as opposed to 
full anticoag (pt  doesnt have any other injuries and no contraind to 
anticoag). Plus, he is  young and has half of the lumen of common carotid blocked w 
an itimal flap.  Why not operate instead of waiting for stroke to develop? 
Does full anticoag  prevent stroke in the face of major intimal dissection? 
Thanks.  KH

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Be CAREFUL Blunt CCA injury ina stable YOUNG pt