Total Occlusion of Left Internal Carotid Artery Diagnosed in Late Period Following Blunt Cervical Trauma
A Özelçi, U Yetkin, A Sars?lmaz, M Apayd?n, ? Yürekli, A Gürbüz
Citation
A Özelçi, U Yetkin, A Sars?lmaz, M Apayd?n, ? Yürekli, A Gürbüz. Total Occlusion of Left Internal Carotid Artery Diagnosed in Late Period Following Blunt Cervical Trauma. The Internet Journal of Thoracic and Cardiovascular Surgery. 2007 Volume 12 Number 1.
Abstract
A 21 - year- old male was admitted to our outpatient clinic with vertigo. In his anamnesis there was a non-penetrating blunt left sided neck trauma. Vehicular trauma was the mechanism of this injury. The injury was caused by lateral hyperflexion of the neck. Nonpenetrating trauma to the carotid arteries carries significant morbidity and mortality rates. A search for carotid artery injury should be performed in patients with a history of neck or head trauma. Heightened awareness of this injury is important for early diagnosis. Duplex ultrasound detects many of these injuries, but this does not demonstrate its utility as a screening tool. Anticoagulant therapy appears to be associated with a better outcome
Case Report
A 21 - year- old male was admitted to our outpatient clinic with vertigo. In his anamnesis there was a non-penetrating blunt left sided neck trauma. Vehicular trauma was the mechanism of this injury. The injury was caused by lateral hyperflexion of the neck. Carotid ultrasonography revealed occlusion of the left internal carotid artery. Magnetic resonance angiography at this time revealed no areas of cerebral infarction.
Digital subtraction angiography (DSA) showed total occlusion of the left internal carotid artery initiating from very proximal segments (Figure 1).
Figure 1
Branches of common and external carotid arteries could be visualized whereas all the segments of left internal carotid artery were invisible (Figure 2).
Figure 2
Left middle cerebral artery was filling from posterior (Figure 3).
Figure 3
Axial reformatted magnetic resonance angiography images showed the discontinuation in cranial and cervical segments of left internal carotid artery. Left middle cerebral artery and its branches showed retrograde filling –as it was seen in DSA- from right carotid system (Figure 4).
Figure 4
Both common carotid and vertebral arteries and right internal carotid artery were patent (Figure 5).
Figure 5
We treated our patient only by clopidogrel without surgical therapy. This drug caused no complication. He had a good outcome without symptoms related to hypoperfusion syndrome.
Comments
Blunt injury to the carotid arteries in the neck, either by direct or indirect forces, is rare but may produce a devastating outcome with long term morbidity(1). Non-penetrating trauma to the internal carotid artery presenting as an immediate or delayed neurological deficit is an uncommon clinical entity. It has a high reported morbidity and mortality(2).Asymptomatic carotid artery injury can easily go undetected during clinical assessment of head and neck trauma(3,4).
The condition carries high morbidity and mortality rates, due to occlusion of the internal carotid artery. The diagnosis is often delayed, as the symptoms of carotid injury frequently are mistakenly attributed to head injury. The insidious course, with neurologic deficit developing in an alert patient prior to lowering of consciousness, distinguishes blunt carotid artery injury from head injury(5). Neuroimaging may be helpful in assessing the presence and extent of the vascular lesion(4). Digital subtraction angiography(DSA) provided a more precise assessment. Aortic arch angiography is crucial for the diagnosis, and should be frequently performed in patients who have sustained blunt cervical trauma. Normal computed tomography of the brain does not exclude ischaemic cerebral infarction, visualization of which requires several days(5).
Besides collective reviews, very few series pertaining to this pathologic condition exist in the literature; however, some report good overall results. These reports comprise a high proportion of asymptomatic cases; the internal injury is usually only discovered incidentally on thoracic aortograms or by scanning the neck during head computed tomography scans(6).
In the serie of Prêtre et al. seven patients had eight injuries to the carotid arteries. Arterial damage included dissection (four cases), pseudoaneurysm (two cases), local contusion (one case), and occlusion (one case)(6).
In a multicenter study arterial lesion was managed nonsurgically 79% of cases, the majority with systemic anticoagulation(7).
In conclusion; nonpenetrating trauma to the carotid arteries carries significant morbidity and mortality rates. A search for carotid artery injury should be performed in patients with a history of neck or head trauma(6). Heightened awareness of this injury is important for early diagnosis(5). Duplex ultrasound detects many of these injuries, but this does not demonstrate its utility as a screening tool. Anticoagulant therapy appears to be associated with a better outcome(8).
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