Twenty patients with blunt mechanism injuries to the internal carotid artery were treated over a 10-year period. The purpose of this review is to assess the necessity and timing of anticoagulation as a primary therapeutic modality in patients with this injury. Sixteen patients (80%) survived, the majority with normal neurologic function. Twelve patients with either unilateral or bilateral carotid mural injury were anticoagulated. Ten survived with normal neurologic function. Five patients in the heparin anticoagulant group had a significant delay in the initiation of anticoagulation. All recovered without deficits. Two patients were treated with aspirin alone and recovered without deficits. Two patients received no treatment; one survived without deficits, and the nonsurvivor succumbed to a severe head injury. Therefore, a total of nine patients were either not treated with heparin or had a significant delay in the initiation of heparin. Eight of nine (88%) in this group recovered without deficit. A delay in the initiation of heparin therapy, no therapy, or the institution of antiplatelet therapy may all be appropriate in the initial management of mural injuries of the internal carotid artery.