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Thu May 7 18:41:57 BST 2009

Ken

Agree! No easy answer. Also not easy to tell the family that the relative
is no likely to recover if they then stroke!

Secondly - there is no such reality as a "minimal" vascular injury - if
there truly is an injury it should be fixed.

So:
1) Agree FORMAL CATHETER angiogram essential - make a diagnosis! All the
other things remain a screening (maybe a Duplex Doppler if your tech is
reliable)
2) IF there is an injury it sould be fixed - a true intimal flap is best
managed by resection and grafting.
If this were a "sacrificable" branch vessel - maybe observe, but this is
the CCA - the complcation (risk-benefit) is high enough for me to operate.
3) Agree the evidence for anti-coag is inadequate at the moment.

My 2c

Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma Surgeon /
Honorary Lecturer University of KwaZulu-Natal Dept Surgery
Deputy Director - IALCH Trauma Service
Durban - South Africa
> 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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