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CASE REPORT |
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| Year : 2006 | Volume
: 1
| Issue : 1 | Page : 27-30 |
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Acute carotid artery injury
Suresh K Sankhla
Consultant Neurosurgeon, Dr. Balabhai Nanavati Hospital & Research Centre Vile Parle, Mumbai, India
Correspondence Address:
Suresh K Sankhla
503-A, Chaitanya Towers, Appasaheb Marathe Road, Prabhadevi, Mumbai - 400 025
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1817-1745.22945
A case of acute carotid artery injury with unusual presentation is described. Although the clinical and radiographic examinations were in favor of a large cerebral infarction, the initial angiogram in this patient failed to demonstrate any intracranial or extracranial vascular injury. A subsequent angiogram, however, demonstrated a pseudoaneurysm of the left common carotid artery which was treated surgically. He made an excellent recovery in his neurological functions postoperatively.
Keywords: Aneurysm, carotid injury, dissection, pseudoaneurysm
How to cite this article:
Sankhla SK. Acute carotid artery injury. J Pediatr Neurosci 2006;1:27-30 |
| Introduction | |  |
The extracranial carotid artery is susceptible to multiple injuries after penetrating trauma to the neck. Such injuries include laceration, tear, dissection and pseudoaneurysm formation. Clinical symptoms are usually acute and result from cerebral ischemia secondary to vessel wall disruption, dissection, luminal narrowing, or thromboembolus formation. [1],[2],[3] We report an unusual case who developed hemispheric infarction several day after a gunshot injury to his neck and had no angiographic evidence of vascular injury on presentation.
| Case Report | | |
A 2-year-old boy was brought to the emergency room in unconscious state with a large swelling in his neck. He had sustained a gunshot injury to his neck 6 days ago for which he was treated at a local hospital with suturing of the wound and antibiotics. Six days later he was found to have developed speech disturbances, right hemiparesis and drowsiness, which progressed rapidly over the next 2-3 days. On admission, his Glasgow Coma Scale score was 6 and his left pupil was larger and sluggish in reaction. He had right facial palsy and hemiplegia with intermittent extensor response to pain in the right upper extremity. A healed entrance wound was present behind the angle of the left mandible in the posterior triangle of the neck, surrounded by diffuse soft tissue swelling. Plain x-ray films revealed a small metallic object (bullet) in the right paramedian submandibular soft tissue [Figure - 1]. Magnetic resonance imaging (MRI) of brain demonstrated a large subacute non-haemorrhagic infarct in the left middle cerebral artery territory, associated with surrounding edema, severe mass effect and subfalcine herniation [Figure - 2]. Magnetic resonance angiography (MRA) showed paucity of the peripheral branches of the left middle cerebral artery and otherwise normal intracranial circulation with no evidence of injury to the neck vessels [Figure - 3]. Doppler study of the neck vessels was unremarkable. In view of his rapidly worsening neurologic status, an emergency decompressive left hemicraniectomy was performed with duraplasty to prevent further progression of the life-threatening brain herniation due to the elevated intracranial pressure (ICP). Patient regained consciousness within the next 24 hours and a computed tomographic (CT) scan of brain next day showed marked resolution in the mass effect [Figure - 4]. He also demonstrated a progressive recovery in his sensorium and right hemiplegia postoperatively. A CT angiogram performed on the 10th postoperative day revealed a large pseudoaneurysm (0.7 x 0.9 cm) arising from the distal left common carotid artery proximal to its bifurcation (carotid bulb region) [Figure - 5]. The neck exploration was performed to excise the pseudoaneurysm with repair of the carotid artery using a Gortex patch graft [Figure - 6]. There was no luminal narrowing or thrombus formation and the blood flow was normal. The bullet was also removed from the genioglossus muscle during the same surgery. The patient continued to improve postoperatively and a control CT angiogram showed patent carotid arteries on the left side and normal intracranial circulation [Figure - 7]. At the follow-up 8-weeks later, the child was fully conscious and playful and had grade 3-4 power on the right side with a remarkable improvement in his speech.
| Discussion | | |
Injuries of the carotid artery caused by penetrating wounds of the neck are nearly 10 times as common as those caused by nonpenetrating trauma.[4],[5],[6],[7],[8] Over 10% of all penetrating neck wounds result in significant carotid artery injury[9] and more than 90% of such injuries are secondary to gunshot wounds.[6],[8],[10],[11] In contrast to the blunt trauma which often involves the internal carotid artery, the penetrating injuries of the neck are more frequently associated with injury to the common carotid artery. In the study reported by Richardson and coworkers,[12] the incidence of common carotid artery injury was 29%, followed by the internal carotid artery in 15%.
Injuries to the extracranial carotid arteries from penetrating trauma can occur via two basic mechanisms. In the first type, the projectile, or weapon, can directly penetrate the vessel wall and interrupt continuity of the wall to various degrees. This type of injury typically results in dissection or transaction of the artery with thrombosis. In the other type, the percussive force of the projectile interacts with the tissue and can disrupt the vessel wall in varying degrees, without directly striking the vessel itself. This mechanism is more likely to cause a dissection through intimal disruption and subsequent formation of a false channel and thrombus formation. The most common injury to the cervical carotid artery is a tangential or partial laceration of the artery and total transaction is less frequent.[6],[7],[10],[13] The nature of carotid artery injury in the patient reported here is unique and difficult to understand because the patient remained asymptomatic for 6 days after a penetrating injury to his neck and when he developed clinical manifestations of cerebrovascular insufficiency, the angiography and Doppler study of the neck vessels demonstrated no evidence of any vascular injury.
The timing of the manifestation of symptoms varies with the nature and extent of the carotid artery injury. As compared to the nonpenetrating neck injuries, the symptoms of the penetrating trauma are more acute and severe.[3],[14] Injury to the carotid artery may result in signs and symptoms related to blood loss, mass effect of neck hematoma, or cerebral ischemia. Patients with a complete disruption of the artery owing to missile injury are frequently seen in the emergency room with hypovolemic shock[8] or severe airway obstruction due to compression of the trachea by hematoma, or symptoms of acute cerebral ischemia or infarction.[6],[7],[10],[11] In contrast, patients with blunt or nonpenetrating trauma to the neck sustain indirect injuries or incomplete vessel wall damage and often manifest a delayed course.[15],[16],[17],[18],[19] In a study reported by Yamada and colleagues,[17] there was delayed appearance of symptoms in 94% of the patients who had a history of blunt trauma to the carotid artery. Delayed clinical presentation following carotid artery injury due to a high velocity penetrating trauma to neck, as described in our patient, is unusual and not seen commonly. No firm data exist in the literature to support the notion of late manifestation of carotid injury in penetrating trauma.[20]
The initial evaluation of such patients universally include CT scanning. Although a necessary initial investigation, the CT image may only provide clues that indicate a major vascular injury. The gold standard for detection of major vascular disruption remains cerebral angiography - the digital subtraction angiography (DSA). Currently, less invasive diagnostic methods are being pursued in lieu of the standard angiogram. Magnetic resonance (MR) imaging is gaining wider application in all areas of diagnostic imaging. MR angiography has been found in several studies to detect reliably an intramural hematoma and a false lumen, demonstrating its utility in both diagnosis and follow-up of the cases with vascular injury.[18],[21],[22] Sue et al[23] in 1992 reported more than 90% accuracy of MR angiography in the detection of cervical carotid artery dissections. Carotid artery injury such as a laceration, tear, dissection, thrombosis, or luminal narrowing severe enough to produce acute hemispheric infarction can be identified easily on MRA. However, the vascular studies in our patient did not show any intracranial or extracranial carotid artery injury despite an MRI proven cerebral infarction. Normal angiography in this patient after symptomatic penetrating injury to the cervical carotid artery is unusual and difficult to explain.
We therefore conclude that a high index of suspicion for cerebrovascular trauma in the setting of a penetrating injury to the neck or face is needed to result in a high detection rate of occult major intracranial and extracranial vascular injuries. A combination of technology including MRA, CTA, DSA and Doppler study should be utilized appropriately to improve diagnosis. Because early identification of the vascular injury and prompt treatment can prevent major stroke and associated morbidity in the vast majority of patients harboring such injury.
| References | | |
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Figures
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
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