Traumatic carotideal dissection after blunt cervical injury: an elusive clinical entity

Traumatic bilateral carotid dissection with concomitant cerebral infarction

A 40-year-old man presented with a major nondominant hemisphere stroke syndrome after a road traffic accident. Cranial computed tomography scan revealed an extensive right hemisphere infarction involving the entire anterior and middle cerebral artery territories. Duplex Doppler ultrasound and cerebral angiography revealed bilateral internal carotid artery dissection with evidence of underlying fibromuscular dysplasia. Anticoagulation with heparin was commenced despite the coexisting large cerebral infarction, with the objective of protecting the uninjured but at-risk left cerebral hemisphere from ischemic injury. Patients with multiple cerebral arterial dissections complicated by cerebral infarction present a significant management dilemma. Our literature review revealed a lack of clear management guidelines for such cases.

Traumatic bilateral carotid dissection

Traumatic dissection of the carotid artery is an infrequent but serious complication of blunt cranial-cervical injury. The typical patient presents with deficits attributable to cerebral ischemia in the distribution of the affected vascular supply. Key considerations in the clinical picture are a delay in symptom presentation, normal initial computed tomography scans, and potential for concomitant cerebral or visceral injury. Because the initial clinical and diagnostic picture may be normal, it is crucial for emergency physicians to aggressively search for this injury in the presence of blunt cranial trauma. We present an unusual case of bilateral high extracranial carotid dissection secondary to blunt trauma. The pathophysiology of carotid artery trauma, treatment options, and key acute care issues are discussed.