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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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Matsumoto Y, Nakae R, Matano F, Kubota A, Morita A, Murai Y, Yokobori S. A Case of Ruptured Carotid Traumatic Blood Blister-like Aneurysm. NMC Case Rep J 2023; 10:259-263. [PMID: 37869375 PMCID: PMC10584784 DOI: 10.2176/jns-nmc.2023-0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/28/2023] [Indexed: 10/24/2023] Open
Abstract
Ruptured cerebral aneurysms that occur in the anterior wall of the internal carotid artery (ICA) are known as blood blister-like aneurysms (BBAs); they have been reported to account for 0.3% to 1% of all ruptured ICA aneurysms. In this report, we describe the treatment of an unusual traumatic BBA (tBBA) with high-flow bypass using a radial artery graft, which resulted in a favorable outcome. A 59-year-old female suffered from an acute epidural hematoma, traumatic subarachnoid hemorrhage, and traumatic carotid-cavernous sinus fistula (tCCF) after being involved in a motor vehicle accident. Her angiography results showed tCCF and a tBBA on the anterior wall of the right ICA. On the fourth day after injury, we found rebleeding from the tBBA and performed an emergency high-flow bypass using a radial artery graft with lesion trapping as a curative procedure for the tCCF and tBBA. Postoperatively, right abducens nerve palsy appeared, but no other neurological symptoms were noted; the patient was thereafter transferred to a rehabilitation hospital 49 days after injury. Traumatic ICA aneurysms commonly occur close to the anterior clinoid process, form within 1 to 2 weeks of injury, and often rupture around 2 weeks after trauma. This case was considered rare as the ICA was likely injured and bleeding at the time of injury, resulting in a form of tBBA; this allowed early detection and appropriate treatment that resulted in a good outcome.
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Affiliation(s)
- Yoshiyuki Matsumoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Fumihiro Matano
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Asami Kubota
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
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Vertebrobasilar and internal carotid arteries dissection in 188 patients. J Clin Neurosci 2021; 93:6-16. [PMID: 34656262 DOI: 10.1016/j.jocn.2021.07.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/24/2021] [Accepted: 07/25/2021] [Indexed: 11/21/2022]
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ARIYADA K, SHIBAHASHI K, HODA H, WATANABE S, NISHIDA M, HANAKAWA K, MURAO M. Bilateral Internal Carotid and Left Vertebral Artery Dissection after Blunt Trauma: A Case Report and Literature Review. Neurol Med Chir (Tokyo) 2019; 59:154-161. [PMID: 30880295 PMCID: PMC6465530 DOI: 10.2176/nmc.cr.2018-0239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 12/28/2018] [Indexed: 11/30/2022] Open
Abstract
Multi-vessel cervical arterial injury after blunt trauma is rare, and its pathophysiology is unclear. Although blunt cerebrovascular injury is a common cause of cerebral ischemia, its management is still controversial. We describe a 23-year-old man in previously good health who developed three-vessel cervical arterial dissections due to blunt trauma. He was admitted to our emergency and critical care center after a motor vehicle crash. Computed tomography showed a thin, acute subdural hematoma in the right hemisphere and fractures of the odontoid process (Anderson type III), pelvis, and extremities. He was treated conservatively, and about 1 month later, he developed bleariness. Computed tomography angiography showed bilateral internal carotid and left vertebral artery dissection. Aspirin therapy was started immediately, and then clopidogrel was added to the regimen. Two weeks later, magnetic resonance angiography (MRA) showed improved blood flow of the vessels. Only aspirin therapy was continued. About 3 months after discharge, MRA demonstrated further improvement of the blood flow of both internal carotid arteries, but the dissection flap on the right side remained. Therefore, we extended the duration of antiplatelet therapy. On the basis of our experience with this case, we think that antithrombotic therapy is crucial for the management of multi-vessel cervical arterial injury, and agents should be used properly according to the injury grade and phase; however, further study is needed to confirm this recommendation.
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MESH Headings
- Angiography, Digital Subtraction
- Carotid Artery, Internal, Dissection/diagnosis
- Carotid Artery, Internal, Dissection/etiology
- Carotid Artery, Internal, Dissection/therapy
- Humans
- Magnetic Resonance Angiography
- Male
- Vertebral Artery Dissection/diagnosis
- Vertebral Artery Dissection/etiology
- Vertebral Artery Dissection/therapy
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/therapy
- Young Adult
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Affiliation(s)
- Kenichi ARIYADA
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Keita SHIBAHASHI
- Department of Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Hidenori HODA
- Department of Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Shinta WATANABE
- Department of Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masahiro NISHIDA
- Department of Emergency and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kazuo HANAKAWA
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masahiko MURAO
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Avila SV, Noy BV, Karsy M, Alexander M, Rolston JD. Bilateral blunt cerebrovascular injury resulting in direct carotid-cavernous fistulae: A case report and review of the literature. Surg Neurol Int 2018; 9:229. [PMID: 30568844 PMCID: PMC6262944 DOI: 10.4103/sni.sni_210_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 09/10/2018] [Indexed: 12/14/2022] Open
Abstract
Background Bilateral blunt cerebrovascular injury (BCVI) has been documented in 32 patients in the English-language literature and bilateral carotid-cavernous fistulae (CCFs) have been reported in only 1 patient. Here, we present a case of severe, unexpected bilateral BCVI with bilateral direct CCF and review the literature of BCVI, particularly cases of bilateral injury. Case Description A 65-year-old woman with episodic bradycardia presented after a motor vehicle accident. On arrival, she had a Glasgow Coma Scale of 3T and progressive dilation of her right pupil. Computed tomography imaging showed a 1.8-cm right epidural hematoma (EDH) with 6 mm of right-to-left shift. No acute skull-base fracture or injury in the area of the carotid canal was noted. The patient was treated with 3% hypertonic saline and mannitol before being taken to the operating room for emergent decompression of the hematoma. Although the patient initially presented with an EDH, significant intraoperative hemorrhage was identified during surgical evacuation and later confirmed as bilateral direct CCFs during angiographic evaluation. Because of the patient's devastating injuries, life-extending measures were not continued and the patient died. Conclusions A review of the literature indicates that bilateral CCFs are rare, having been reported only once previously. As this case demonstrates, CCFs may occur in high-energy injuries and should be considered even if the patient does not meet traditional screening criteria.
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Affiliation(s)
- Stephanie V Avila
- Department of Neurobiology and Anatomy, Clinical Neurosciences Center, Salt Lake City, Utah, USA
| | - Brooke Van Noy
- Department of Neurobiology and Anatomy, Clinical Neurosciences Center, Salt Lake City, Utah, USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, Salt Lake City, Utah, USA
| | - Matthew Alexander
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - John D Rolston
- Department of Neurosurgery, Clinical Neurosciences Center, Salt Lake City, Utah, USA
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Iampreechakul P, Tirakotai W, Tanpun A, Wattanasen Y, Lertbusayanukul P, Siriwimonmas S. Spontaneous resolution of direct carotid-cavernous fistulas: case series and literature review. Interv Neuroradiol 2018; 25:71-89. [PMID: 30244626 DOI: 10.1177/1591019918800220] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Spontaneous regression of direct carotid-cavernous fistulas (CCFs) is extremely rare. Most of the patients with direct CCFs are usually treated using endovascular techniques. Spontaneous obliteration of the direct fistulas probably results from thrombosis of the venous drainage and/or cavernous sinus. We report spontaneous closure of nine direct CCFs in nine patients. From literature review, we found another 37 patients with 43 fistulas due to spontaneous obliteration of bilateral lesions in six cases. There was no spontaneous closure in large-sized fistula. The factors associated with spontaneous thrombosis of the fistulas may be low-flow and small-sized fistula, hypotension, severe ocular manifestations, dissections or spasm of carotid artery, and increased intracranial pressure. Spontaneous healing of direct traumatic CCFs should be confirmed with cerebral angiography. Conservative treatment of direct CCFs should be carefully restricted in patients with normal vision or minimal visual impairment, and the patients must be monitored closely for any changes in visual function. Prompt endovascular treatment for complete obliteration of the fistula should be performed in patients with rapidly progressive visual loss. Venous thrombosis can still effect vision and rerouting towards cortical veins remains a concern. Because spontaneous resolution cannot be reliably predicted, the fistula then should be treated rather than waiting for spontaneous thrombosis.
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Affiliation(s)
| | - Wuttipong Tirakotai
- 1 Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | - Adisak Tanpun
- 1 Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | - Yodkhwan Wattanasen
- 2 Department of Neuroradiology, Prasat Neurological Institute, Bangkok, Thailand
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Bilateral Carotid and Vertebral Artery Dissection from Blunt Trauma. Case Rep Emerg Med 2018; 2018:1919034. [PMID: 29721341 PMCID: PMC5867688 DOI: 10.1155/2018/1919034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/11/2018] [Indexed: 12/03/2022] Open
Abstract
Carotid and vertebral artery injuries are rare following blunt trauma. They can, however, lead to severe consequences with a significant associated rate of stroke and intracranial hemorrhage, particularly if the diagnosis and treatment are delayed. We report a case of a 23-year-old female who presented to the Emergency Department with bilateral carotid and vertebral artery dissection following a motor vehicle collision (MVC).
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Gapsis BC, Ranjit RU, Malavade S, Carey A, Murtagh R, Drucker MD, Pavan PR. Spontaneous resolution of ophthalmologic symptoms following bilateral traumatic carotid cavernous fistulae. Digit J Ophthalmol 2013; 19:33-8. [PMID: 24109248 DOI: 10.5693/djo.02.2013.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 38-year-old woman developed bilateral carotid cavernous fistulae (CCF) following a motor vehicle collision. Her initial ophthalmologic findings included periorbital edema, palsies of the left oculomotor and abducens nerves, and residual dilated pupils. She subsequently developed significant optic disc edema and retinal vascular dilation bilaterally. Patients with similar injuries typically require neurosurgical or vascular intervention. In this case, the patient's signs resolved spontaneously by 21 months after onset, leaving no residual ocular deficits.
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Affiliation(s)
- Briana C Gapsis
- University of Central Florida College of Medicine, Orlando, Florida
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Keilani ZM, Berne JD, Agko M. Bilateral internal carotid and vertebral artery dissection after a horse-riding injury. J Vasc Surg 2010; 52:1052-7. [PMID: 20888534 DOI: 10.1016/j.jvs.2010.05.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 05/13/2010] [Accepted: 05/15/2010] [Indexed: 11/25/2022]
Abstract
Blunt cerebrovascular injuries, defined as blunt injuries to the internal carotid or vertebral arteries, are uncommon and usually occur in victims of high-speed deceleration motor vehicle crashes. A blunt cerebrovascular injury after an equestrian accident is an extremely unusual presentation. In recent years, advances in screening and treatment with pharmacologic anticoagulation before the onset of neurologic symptoms have improved outcomes for these patients. Endovascular stenting and embolization, although unproven, offer a new potential approach for these complex injuries. We present a unique case of four-vessel blunt cerebrovascular injuries after a horse-riding injury that required multidisciplinary management.
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Affiliation(s)
- Zeid M Keilani
- Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.
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Blunt cerebrovascular trauma: distal internal carotid dissection. ACTA ACUST UNITED AC 2009; 67:1127. [PMID: 19546822 DOI: 10.1097/ta.0b013e3181238da8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Imaging of traumatic arterial injuries in the neck with an emphasis on CTA. Emerg Radiol 2009; 17:109-22. [PMID: 19798524 DOI: 10.1007/s10140-009-0835-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Accepted: 09/09/2009] [Indexed: 12/14/2022]
Abstract
Arterial injuries in the neck may be secondary to blunt or penetrating trauma. Because of clinical difficulties in early identification of these injuries as well as their potentially catastrophic consequences, imaging is indispensible in the diagnosis of arterial injuries in the neck. Computed tomography angiography (CTA) has become the initial study of choice in management of these patients. We review the clinical and imaging features of vascular injuries of the neck with special emphasis on CTA.
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Chakrapani AL, Zink W, Zimmerman R, Riina H, Benitez R. Bilateral carotid and bilateral vertebral artery dissection following facial massage. Angiology 2008; 59:761-4. [PMID: 18388028 DOI: 10.1177/0003319707309653] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 50-year-old woman underwent facial massage. After 13 days, she experienced left retro-orbital pain, ptosis, and miosis. Magnetic resonance imaging (MRI) showed stenotic dissection of bilateral cervical internal carotid and vertebral arteries. The intracranial vasculature was intact. She was treated conservatively with long-term oral anticoagulation and remains asymptomatic 18 months later.
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Affiliation(s)
- Andrea L Chakrapani
- Department of Radiology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York 10021, USA.
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