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Khormi YH, Darraj AI, Arishy A, Abuzahirah SO, Atteya M. Bilateral Blunt Traumatic Dissections of the Extracranial Internal Carotid Artery: A Case Report and Literature Review. Cureus 2024; 16:e53630. [PMID: 38449976 PMCID: PMC10917072 DOI: 10.7759/cureus.53630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
Bilateral traumatic dissections of the cervical internal carotid artery (ICA) are rare complications of polytrauma. A thorough literature review was performed, and data from selected studies were analyzed to assess the trends in clinical presentation, modes of trauma, management protocols, and clinical outcomes. The reported outcomes were categorized and graded into optimal, intermediate, and poor outcomes. We describe a rare case of bilateral dissection of ICA in a 31-year-old woman who was involved in a motor vehicle accident. She had a Glasgow Coma Scale score of 9 and right-sided hemiparesis. Radiological findings revealed left upper ICA dissection, arterial intramural thrombus, and stenosis of the upper segment of the right ICA. She improved on conservative management and had a good clinical outcome at a three-month follow-up. Emergency physicians must be knowledgeable about such cases, as more than half of these trauma victims are initially asymptomatic on initial presentation. Specific diagnostic and therapeutic modalities should be implemented based on low threshold clinical suspicion to avoid missing these potentially disabling injuries and reduce morbidity and mortality. Computed tomographic angiography is recommended in cases with atypical clinical presentations, unexplained neurological deficits, or delayed-onset clinical deterioration. While antiplatelet and anticoagulant therapies are the mainstays of conservative management, endovascular and surgical management are only used in severe cases when medical treatment has failed, the artery has been completely transected, or there is active bleeding. Generally, good outcomes were reported in about two-thirds of those patients.
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Affiliation(s)
| | | | | | - Seham O Abuzahirah
- Medicine and Life Sciences, Maastricht University, Netherlands, NLD
- Neurosurgery, King Fahad Hospital, Jeddah, SAU
| | - Mostafa Atteya
- Neurological Surgery, King Fahad General Hospital, Jazan, SAU
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Agarwal A, Yadav D, Gupta A, Vishnu VY, Rajan R, Singh MB, Bhatia R, Srivastava Mv P. Delayed bilateral internal carotid artery dissection following motor vehicle accident: time to make its screening a part of trauma protocol? QJM 2020; 113:672-673. [PMID: 32096863 DOI: 10.1093/qjmed/hcaa037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- A Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - D Yadav
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - A Gupta
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - V Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - R Rajan
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - M B Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - R Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - P Srivastava Mv
- Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
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Bilateral Traumatic Internal Carotid Artery Dissection after CrossFit Training. Ann Vasc Surg 2019; 61:466.e1-466.e5. [DOI: 10.1016/j.avsg.2019.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/20/2019] [Accepted: 04/11/2019] [Indexed: 11/20/2022]
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Jenkins JM, Norton J, Hampton T, Weeks R. Rare case of bilateral traumatic internal carotid artery dissection. BMJ Case Rep 2016; 2016:bcr-2016-217262. [PMID: 27651410 DOI: 10.1136/bcr-2016-217262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A 55-year-old man was working in a trench when the wall collapsed in on him, pinning him to the wall. On arrival in the emergency department the patient began reporting of right-sided headache. Neurological examination revealed left-sided reduced sensation with weakness. Whole-body CT scan showed right-sided flail chest and bilateral haemothorax as well as loss of flow and thinning of the distal right internal carotid artery (ICA) and loss of grey white matter differentiation in keeping with traumatic ICA dissection with a right middle cerebral artery (MCA) infarct. He was started on aspirin 300 mg once daily. 3 days postadmission the patient experienced worsening of vision and expressive dysphasia. CT angiogram showed bilateral ICA dissections extending from C2 to the skull base. The patient was managed conservatively in the stroke unit for infarction and was discharged home for follow-up in stroke clinic.
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Affiliation(s)
| | | | - Timothy Hampton
- Department of Neuroradiology, King's College Hospital, London, UK
| | - Robert Weeks
- Department of Neuroradiology, King's College Hospital, London, UK
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Crönlein M, Beirer M, Huber-Wagner S. Ganzkörper-Computertomographie. Notf Rett Med 2016. [DOI: 10.1007/s10049-015-0057-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Fatal subarachnoid hemorrhage associated with internal carotid artery dissection resulting from whiplash trauma. Forensic Sci Med Pathol 2015; 11:564-9. [PMID: 26499790 DOI: 10.1007/s12024-015-9715-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 12/13/2022]
Abstract
Spinal injury following inertial loading of the head and neck (whiplash) is a common sequel of low speed traffic crashes. A variety of non-musculoskeletal injuries have been described in association with injury to the spine following whiplash trauma, including traumatic brain injury, vestibular derangement, and cranial nerve injury, among others. Vascular injuries in the head and neck have, however, only rarely been described. We present the case of a middle-aged male who sustained an ultimately fatal injury that resulted from injury to the internal carotid artery (ICA) and intracerebral vascular structures following a hard braking maneuver, with no direct head- or neck contact with the vehicular interior. Based on this unusual mechanism of injury we reviewed hospital data from the United States nationwide inpatient database (NIS) to assess the frequency of similar injuries reportedly resulting from traffic crashes. The post-mortem examination revealed a left internal carotid artery dissection associated with subarachnoid hemorrhage (SAH). Based on the close temporal association, the absent prior history, and the plausibility of the injury mechanism, the injury was attributed to the braking maneuver. An analysis of NIS data demonstrated that the prevalence of subarachnoid hemorrhage is significantly higher when there is a traumatic etiology, and higher yet when the trauma is a traffic crash (odds ratio 3.3 and 4.3, respectively). The presented case, together with the hospital inpatient data analysis, indicate that although SAH in combination with ICA dissection is relatively rare, it is substantially more probable following a traffic crash. In a clinical or forensic setting the inference that magnitude of a trauma was low should not serve as a basis for either excluding a cervical artery dissection from a differential diagnosis, or for excluding the trauma as a cause of a diagnosed dissection. This case report illustrates a rare fatal outcome of inertial load to the head and neck induced by a sudden braking event in a commonly experienced non-collision traffic incident. The likely mechanism of injury resulted from interaction between the occupant and the 3-point seat belt. These findings indicate that ICA dissections are substantially more likely to be associated with SAH following head and neck trauma, regardless of the magnitude of the traumatic event or whether an impact was involved.
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Crönlein M, Sandmann GH, Beirer M, Wunderlich S, Biberthaler P, Huber-Wagner S. Traumatic bilateral carotid artery dissection following severe blunt trauma: a case report on the difficulties in diagnosis and therapy of an often overlooked life-threatening injury. Eur J Med Res 2015. [PMID: 26199074 PMCID: PMC4511249 DOI: 10.1186/s40001-015-0153-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Traumatic carotid artery dissections are very rare, often overlooked and life-threatening injuries. Diagnosis and treatment are difficult especially in multiple injured patients. CASE PRESENTATION We report on a 28-year-old female major trauma patient (injury severity score, ISS 50) who was involved in a motor vehicle accident. She was primarily transferred to a level II trauma center. After initial assessment and operative management, an anisocoria was diagnosed on the intensive care unit. Subsequent CT angiography and extracranial duplex sonography revealed a bilateral internal carotid artery dissection. The patient was transferred to our level I trauma center where conservative treatment with high-dose heparin therapy was started at day two after trauma. Outcome after 6 months was very good. CONCLUSION Besides presenting the case and outcome of this patient, the article discusses the diagnostic and therapeutic management of this extremely rare and often overlooked dangerous injury. To avoid overlooking carotid artery dissections, CT angiography of the neck region should be generously included into the initial multislice CT whole-body scan, when the injury results from an according trauma. For the best outcome, sites of hemorrhage should be abolished quickly and the anticoagulative therapy should be initiated as soon as possible. Interdisciplinary treatment of trauma surgeons and neurologists is crucial.
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Affiliation(s)
- Moritz Crönlein
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Gunther H Sandmann
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Marc Beirer
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Stefan Huber-Wagner
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
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Jansen G, Popp J, Dietrich U, Mertzlufft F, Bach F. [Traumatic dissection of the carotid artery: challenges for diagnostics and therapy illustrated by a case example]. Anaesthesist 2013; 62:817-23. [PMID: 24057761 DOI: 10.1007/s00101-013-2243-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/28/2013] [Accepted: 08/28/2013] [Indexed: 11/24/2022]
Abstract
Traumatic dissection of the carotid artery is an easily overlooked consequence of trauma with notable morbidity and mortality which can be observed in up to 4% of cases involving multiple trauma. Certain mechanisms and patterns of injury as well as specific symptoms should serve as indicators of a dissection and should therefore result in further diagnostic measures. An early diagnosis is of major relevance. This report describes the case of a 45-year-old victim of a traffic accident who showed symptoms of a dissection which had initially not been diagnosed.
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Affiliation(s)
- G Jansen
- Klinik für Anästhesie, Intensiv-, Notfall-, Transfusionsmedizin und Schmerztherapie, Evangelisches Krankenhaus, Burgsteig 13, 33617, Bielefeld, Deutschland,
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Marschner-Preuth N, Warnecke T, Niederstadt TU, Dittrich R, Schäbitz WR. Juvenile stroke: cervical artery dissection in a patient after a polytrauma. Case Rep Neurol 2013; 5:21-5. [PMID: 23466599 PMCID: PMC3573792 DOI: 10.1159/000347001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Dissections of the cervical arteries cause about 20% of total juvenile strokes. Approximately 4% of the carotid artery dissections are due to a (poly)trauma such as car accidents. Despite improved diagnostic facilities, traumatic dissections are often underdiagnosed or diagnosed too late due to a lack of awareness of potential initial signs and symptoms. We report here a case of a delayed embolic stroke after a car accident caused by a dissection of the carotid artery and subsequent pseudoaneurysm. To reduce the long-term morbidity or mortality of multiple trauma patients, an early detection of cervical carotid and vertebral dissections is strictly necessary.
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Affiliation(s)
- Nicole Marschner-Preuth
- Department of Neurology, University Hospital of Münster, Münster, Bielefeld, Germany ; Department of Department of Neurology, Bethel Evangelisches Krankenhaus of Bielefeld, Bielefeld, Germany
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