Penetrating carotid artery injury: CT angiography findings, imaging predictors of hemodynamic instability, and concordance with digital subtraction angiography.

PURPOSE: To characterize the computed tomography angiography (CTA) findings of penetrating carotid artery injury in a high-volume trauma center, to identify imaging manifestations associated with neurological and hemodynamic instability at admission, and to assess the diagnostic concordance between CTA and digital subtraction angiography (DSA). METHODS: An observational, cross-sectional study with an analytical component and retrospective data collection was conducted in patients over 18 years of age with penetrating carotid trauma admitted to a tertiary referral center in Cali, Colombia, between January 2012 and December 2022. Imaging findings on CTA were characterized, factors associated with a Glasgow Coma Scale (GCS) ≤ 8 and with systolic blood pressure (SBP) < 90 mmHg at admission were analyzed by logistic regression and bivariate analysis, and the diagnostic concordance between CTA and DSA was assessed using Cohen's kappa. RESULTS: A total of 89 patients were included, with a median age of 33 years (IQR 23-42), of whom 84 (94.4%) were male. CTA was performed in 87 patients and DSA in 51 (49 with complete comparative data). Single lesions predominated (70.1%), zone II was the most frequently affected neck region (51.7%), non-laceration was the most common lesion type (67.8%), and the left side was most involved (55.2%). Dissection involving more than 25% of the lumen was the most prevalent manifestation (26.4%), and the cervical segment of the internal carotid artery was the most affected anatomical area (47.1%). Among the 70 patients with a recorded GCS, 26 (37.1%) had a GCS ≤ 8. Intubation at admission (adjusted OR 14.07, 95% CI 2.33-84.97) and older age (adjusted OR 1.06 per year, 95% CI 1.00-1.11) were independently associated with GCS ≤ 8. Vessel rupture was the strongest imaging predictor of hemodynamic instability (OR 9.02, 95% CI 2.49-32.71). Overall in-hospital mortality was 23.6% (21/89); no imaging-based variable was independently associated with mortality. Diagnostic concordance between CTA and DSA was almost perfect for neck zone (κ = 0.924), laterality (κ = 0.956), and anatomical area (κ = 0.845), but only moderate for lesion manifestation (κ = 0.540). CONCLUSION: Penetrating carotid trauma predominantly affects young males, with the cervical segment of the internal carotid artery in zone II being the most involved. Intubation at admission and older age were independently associated with severe neurological impairment, while vessel rupture was the strongest imaging predictor of hemodynamic instability. In-hospital mortality (23.6%) was not associated with any specific imaging manifestation. CTA showed almost perfect concordance with DSA for anatomical localization but only moderate agreement for lesion manifestation, supporting its role as a first-line diagnostic tool while highlighting the added value of DSA in selected cases.