Penetration of the neck with a stick is a rare phenomenon and non-penetrating injury to the CCA that lies in its path is unexpected. The main concern in our patient was not BCI, but that the impaled stick would tamponade disrupted vessels with the potential for serious haemorrhage after its removal. The possibility of BCI was considered only when a breach of the carotid sheath with a tear in the adjacent IJV was observed at wound exploration.
The only report in the literature of a BCI by a penetrating force is that of stabbing by a sharp knife.4
In that instance, the injury was in the ICA well away from the stab wound and probably unrelated to the penetrating force. The authors hypothesise that their patient may have sustained the BCI because the assailant hyper-extended his neck and rotated the head for greater access to the neck when inflicting the stab wounds.4
Similar neck movements might have occurred in our patient from the moment his neck was pierced by the stick. But the injury in our patient being in the CCA rather than the ICA points to a different mechanism. We suspect that the CCA was directly struck by the penetrating stick. The elasticity and mobility of the artery would have resulted in it sliding away from a penetrating force. The relatively blunt end of the stick would have been another factor protecting the artery from being penetrated. However, the resultant overstretching and rotation of the CCA could explain the observed injury. In contrast the adjacent IJV, being non-turgid, inelastic and relatively fixed by its tributaries, would not slide away from such penetrating force and, thus, be torn.
Screening for internal injuries following penetrating trauma to the neck is by clinical means5 6
and CT is recommended only for clinically apparent injuries prior to surgical exploration.6 7
Thus, in our patient, there was no indication for diagnostic CT but surgical exploration was necessary because of impalement.
In contrast, BCI is initially asymptomatic and screening is by imaging. Imaging techniques to screen for BCI continue to evolve. Less invasive multidetector CTA with intravenous contrast is fast replacing traditional percutaneous transfemoral contrast angiography as the method of choice in screening for BCI.2
An injury grading scale based on angiographic appearance is used to prognosticate and guide treatment in BCI.3
Grade I injuries are those with lumen wall irregularity, implying intimal damage alone, which is the type of lesion our patient presented with. Our patient was anticoagulated based on the evidence that it prevents neurological deficits in the asymptomatic and improves neurological outcomes in those with neurological deficits.1 8
Nevertheless, injury progression is common and stroke risk increased at 7–10 days and, thus, follow-up imaging is recommended.9
This was the case with our patient where the injury had progressed to cause severe stenosis with intra-arterial thrombosis.
There is no reliable evidence on the best mode of treatment for such flow-limiting lesions. As the BCI was in the zone I–II junction, surgical accessibility of the proximal CCA for clamping would be challenging. Endovascular stenting seemed more appropriate in this instance. Furthermore, the distal end of injury was 3 cm proximal to the carotid bifurcation providing adequate length for landing.
Published reports of endovascular stenting for traumatic carotid injuries remain sporadic and confined to case reports and case series. Early results are encouraging, but experience with this modality and data on long-term follow-up is still very limited.10
A large prospective randomised trial is warranted to further define the role of this treatment modality in the setting of trauma.
- Combined penetrating and blunt injuries from the same penetrating object is possible.
- A penetrating injury of the neck diverts attention away from possible BCI.
- Awareness of the possibility of BCI, even in the presence of obvious penetrating neck injury, can improve care and outcome.
- Beware of injury progression despite anticoagulation.
- Endovascular stenting is feasible and arrests BCI progression.