Volume 24, Issue 8 , Pages 1133.e9-1133.e11, November 2010
Bilateral Post-Traumatic Carotid Dissection as a Result of a Strangulation Injury
Article Outline
Carotid trauma is always very serious. Post-traumatic carotid dissection is rather rare and can be diagnosed late. Authors present a case report of post-traumatic bilateral carotid dissection and its spontaneous recovery. Symptoms, diagnosis, and treatment are discussed.
Introduction
Post-traumatic dissection in the carotid artery bed is most commonly due to blunt head and neck trauma. This event occurs rather rarely and is very frequently associated with a trauma that is not consistent with life. Its course, however, may also be totally asymptomatic so that diagnosis might possibly be established with delay after subsequent complications have developed. The authors present a case of bilateral internal carotid dissection that was due to a neck strangulation injury.
Case Reports
A 49-year-old woman, J.S., in rather serious general condition was brought to the emergency room, Plzeň Teaching Hospital, by the Emergency Medical Service (EMS). The EMS physician was informed by a family member of the patient after he found her unconscious in a bathtub with a strangulation groove on her neck. The patient presents disturbed consciousness (Glasgow coma scale = 3), blood pressure 115/70 mm Hg, pulse rate 68/min, reacts to pain stimuli, and breathes spontaneously (breathing rate 8/min). She is markedly hypothermic (body temperature of 26°C). There is a visible strangulation groove on her neck, and carotid pulses are palpable. Pupils are mydriatic, without reaction to light. The patient was first stabilized with basic interventions (orotracheal intubation, artificial lung ventilation), then transferred for an investigation with computed tomography (CT). She underwent brain and neck CT angiography. The only, but rather serious, finding is dissection of the wall of both internal carotid arteries (ACIs) (Fig. 1, Fig. 2 and 3). The brain showed no circumscribed lesions or edema. In view of the patient's serious condition, it was decided to proceed conservatively for the time being. She is being treated at the Department of Anaesthesiology and Reanimation, and attached to controlled pulmonary ventilation with gradual rewarming. Sixteen hours after admission, the patient is in stable condition, sedated, and manifests tonic-clonic cramps on reduction of pharmacological sedation. At that time, according to the consultation of the vascular surgeon and radiologist, the patient was indicated for radio-interventional solution with ACI dissection. Our plan is to insert stents into both ACIs.
Fig. 1
Volume rendering tissue (VRT) reconstruction of the left carotid artery bed with observable starting point of dissection.
Fig. 2
Maximal intensity projection (MIP) reconstruction of ACC and internal carotid arteries with dissection.
Fig. 3
Transversal section at the ACC level closely under the bifurcation with observable bilateral dissection.
Approaching through the left common femoral artery, a guiding device was gradually introduced into both arteria carotis communis (ACC), but subsequent injection revealed that both ACIs were totally without signs of dissection, stenosis, or retention of contrast medium (Fig. 4). Hemodynamics did not show any delayed filling in the intracranial area that is characterized by typical anatomical relationships of the circulation. The plan to conduct stenting was, therefore, abandoned.
Fig. 4
Digital subtraction angiography of internal carotid arteries –no signs of dissection present.
Over the next 13 days, the patient was gradually disconnected from artificial pulmonary ventilation, awakened to full consciousness, and is now without any tonic-clonic seizures and neurological symptoms. It was also possible over this period of time to complete the patient's history, which revealed that she underwent repeated inpatient stays at the Department of Psychiatry for addiction to hypnotics and benzodiazepines. There also were suicide attempts in the past. The Czech Police closed the case as an attempted suicide, the patient made an attempt to hang herself in the bathtub with a clothesline and lost consciousness, which was followed by drowning. The motivation was family disagreements.
The patient was then gradually transferred to internist and psychiatric care. She started antidepressant therapy with citalopram. On Day 22 from admission, the patient was discharged to home care and referred to outpatient psychiatry for further care.
Discussion
Carotid artery dissection due to blunt head or neck trauma is among the rather rare injuries, and various authors report an occurrence rate in patients with blunt neck trauma to be approximately 0.3–1%.1, 2 Very often, the dissection itself causes no symptoms shortly after injury, with only about 10% of the patients presenting instantaneous symptoms,3 whereas 35% develop symptoms after more than 24 hours from the injury.4 The symptoms may be rather heterogeneous, from simple headache, neck pain in the carotid region (carotidynia) to mild circumscribed ischemic lesions that remain practically asymtomatic, to extensive cerebrovascular events with fully developed contralateral hemiplegia. There was also a presence of incomplete Horner syndrome due to ipsilateral carotid dissection.5 In view of the aforementioned text, it is often possible to overlook this rare injury or to establish diagnosis with delay. The cause is most commonly blunt head or neck trauma as part of a car accident, and there have been reports of cases of injuries caused by seat belts.6 Published cases also include dissection subsequent to mandibular fracture or combined chest-head injuries with “stretching” of the aortic arch.7 Injuries due to hanging or strangling are rarer.
As early diagnosis is very important for the prognosis, each patient with a neck injury, be it due to blunt stroke, strangulation, or strangling, should undergo imaging investigation focused on the arterial system. Ultrasound investigation, including imaging with dopplerometry might be done as the first rapid investigation. In our hospital, CT angiography is preferred on the basis of its rapid availability and rather high values of sensitivity and specificity. Very often, it is also necessary to obtain the results of CT scans of the trunk to detect other accompanying injuries. Here, the alternative is magnetic resonance imaging, which is not appropriate, however, in urgent cases due to the time it demands. Digital subtraction angiography, with the advantage that one can proceed with immediate therapeutic intervention, is reserved for symptomatic cases or for patients with positive results obtained with noninvasive methods where the consideration also includes endovascular procedure. Post-traumatic carotid artery dissection is clearly treated with an interventional radiology procedure as the first measure of choice, that is, with the implantation of a stent to the true lumen and abolishment of the second, false lumen. Attempts at urgent surgical desobliteration remain reserved for developing strokes and confirmed acute ACI occlusion.
In the particular case of our patient, she experienced injuries to both ACI because of strangulation, but the dissection found at the time of admission has not been demonstrated again with digital subtraction angiography 16 hours later. The most likely scenario is that there was spontaneous reparation of the injured ACI intima, that is the intimal flap pressed back to the carotid artery wall spontaneously. This is a rather rare bilateral spontaneous reparation in this type of carotid artery injury and a situation that made it possible for us to proceed with conservative therapy.
References
- . Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996;223:513–525
- Traumatic carotid artery dissection. Isr Med Assoc J. 2009;11:507–508
- . Asymptomatic carotid artery dissection caused by blunt trauma. Neurol Med Chir. 2008;48:22–25
- . Traumatic internal carotid artery dissection. J Clin Neurosci. 2006;13:123–128
- Flaherty PM, Flynn JM. Horner syndrome due to carotid dissection. J Emerg Med (in press).
- Endovascular stent placement of cervical internal carotid artery dissection related to a seat-belt injury: a case report. Minim Invasive Neurosurg. 2007;50:115–119
- . Flapping of the dissected intima in a case of traumatic carotid artery dissection in a jackhammer worker. J Clin Ultrasound. 2009;37:221–222
PII: S0890-5096(10)00138-X
doi:10.1016/j.avsg.2010.02.042
© 2010 Published by Elsevier Inc.
Volume 24, Issue 8 , Pages 1133.e9-1133.e11, November 2010
