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Thu May 7 19:31:19 BST 2009

Tim:  

Dr. Hardcastle and I agree.     The first big problem  with the case as 
presented is the assumption that anything seen on ultrasound,  CT, CTA, or MRA 
is gospel and true.    UNTRUE.     ARTERIOGRAM using a catheter or needle 
and dye.     Be sure  of what you see.    I still see at meetings, in 
journals, and in  the many hospitals of Houston, and when I am a visiting professor, 
significant  numbers of false positives, false negatives, and operations in 
patients with  normal anatomy because of ultrasounds, CTs, CTAs, MRIs, and  
MRAs.     Be Careful.    Do not just follow  the unquestioning crowd.     
Evaluate and treat you patient  as you hope to be treated when your roles are 
reversed.     

k

In a message dated 5/7/2009 12:42:55 P.M. Central Standard Time,  
dr.tchardcastle at absamail.co.za writes:

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

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Be CAREFUL Blunt CCA injury ina stable YOUNG pt