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A multi-registry analysis of military and civilian penetrating cervical carotid artery injury.

INTRODUCTION
Penetrating cervical carotid artery injury (CCAI) is an uncommon but high stakes scenario associated with stroke and death. The objective of this study is to characterize and compare penetrating carotid injury in the military and civilian setting, and to provide considerations for management.


METHODS
Cohorts with penetrating CCAI from the Department of Defense Trauma Registry (2002 to 2015) and the American Association for the Surgery of Trauma Prospective Observation Vascular Injury Treatment Registry (2012 to 2018) were analyzed. A LASSO multivariate analysis using random forest-based imputation was performed to identify risk factors affecting stroke and mortality.


RESULTS
There were a total of 157 patients included in the study, of which 56 (35.7%) were military and 101 (64.3%) were civilian. The military cohort was more likely to have been managed with open surgery (87.5% vs. 44.6%, p < 0.001) and to have had any procedure to restore or maintain flow to the brain (71.4% vs. 35.6%, p < 0.001), while the civilian cohort was more likely to undergo non-operative management (45.5% vs. 12.5%, p < 0.001). Stroke rate was higher within the military cohort (41.1% vs. 13.9%, p < 0.001); however, mortality did not differ between the groups (12.5% vs. 17.8%, p = 0.52). On multivariate analysis, predictors for stroke were presence of a battle injury (log odds 2.1, p < 0.001), internal or common carotid artery ligation (log odds 1.5, p = 0.009). For mortality outcome, protective factors included a high Glasgow Coma Scale on admission (log odds -0.21 per point, p < 0.001). Increased admission Injury Severity Score was a predictor of mortality (log odds 0.05 per point, p = 0.005).


CONCLUSION
The stroke rate was higher in the military cohort, possibly reflecting complexity of injury; however, there was no difference in mortality between military and civilian patients. For significant injuries, concerted efforts should be made at carotid reconstruction to reduce the occurrence of stroke.


LEVEL OF EVIDENCE
Retrospective cohort analysis, level III.