BACKGROUND: Penetrating carotid artery injuries (CAIs) are rare with high morbidity and mortality. We aimed to perform a systematic review of the published literature to evaluate the work-up and management of penetrating CAI. METHODS: Studies of acute management of adult trauma patients with penetrating common or internal CAIs on MEDLINE or EMBASE from 1946 through July 2024 were included following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement methodology. Exclusion criteria was case series with <
5 patients, review articles, animal studies, cadaver studies, non-English language, and age<
18. Risk of bias was assessed with Oxford Level of Evidence and findings evaluated via Grading of Recommendations, Assessment, Development, and Evaluations. RESULTS: Our systematic review identified 4,737 studies, of which 35 were included. Preoperative evaluation transitioned to screening computed tomography angiography of the neck in the absence of hard signs. Management now includes endovascular and nonoperative in select cases: nonoperative for some small intraluminal injuries and stenting or embolization for surgically inaccessible lesions. Repair or revascularization was preferred in all but neurologically devastated comatose patients, in which, ligation was deemed acceptable. Temporary intravascular shunting with a takeback for definitive revascularization was associated with a 100% stroke or death. Postoperative antiplatelet or anticoagulation therapy and follow-up was nonstandardized with a shift toward antiplatelet therapy for all injuries described more recently. CONCLUSIONS: Penetrating CAI remains challenging with a shift toward less invasive initial workup with computed tomography angiography and management including endovascular and nonoperative in select cases. Temporary intravascular shunting with delayed revascularization and ligation were both associated with poor outcomes. Postoperative antiplatelet therapy has become increasingly common and postoperative surveillance is not standardized.