Bilateral internal carotid and vertebral artery dissection after a horse-riding injury

It's in the game: A review of neurological lesions associated with sports

INTRODUCTION

The practice of sports may lead to neurological injuries. While relatively uncommon (overall incidence of approximately 2.5%), and mostly benign and transient, some conditions may be life-threatening and permanent. Thus, both clinical neurologists and sports physicians should be aware of their existence and relevance. We aimed to review all sports-related neurological injuries and illnesses reported in the literature.

METHODS

Following SANRA guidelines, we performed a narrative review and searched PubMed and Scopus databases. Relevant sports were selected based on their recognition as an Olympic sport by the International Olympic Committee. Chronic traumatic encephalopathy (CTE) and other neurodegenerative disorders were not included.

RESULTS

A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries have also been extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, e.g. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, e.g. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma.

CONCLUSION

Sports-related neurological injuries are increasingly receiving more social and medical attention and are an important cause of morbidity and mortality. This review may serve as a guide to physicians managing these challenging situations.

Traumatic Internal Carotid Artery Injuries: Do We Need a Screening Strategy? Literature Review, Case Report, and Forensic Evaluation

Internal carotid artery dissection (ICAD) represents the cause of ictus cerebri in about 20% of all cases of cerebral infarction among the young adult population. ICAD could involve the extracranial and intracranial internal carotid artery (ICA). It could be spontaneous (SICAD) or traumatic (TICAD). It has been estimated that carotid injuries could complicate the 0,32% of cases of general blunt trauma and the percentage seems to be higher in cases of severe multiple traumas. TICAD is diagnosed when neurological symptoms have already occurred, and it could have devastating consequences, from permanent neurological impairment to death. Thus, even if it is a rare condition, a prompt diagnosis is essential. There are no specific guidelines regarding TICAD screening. Nevertheless, TICAD should be taken into consideration when a young adult or middle-aged patient presents after severe blunt trauma. Understanding which kind of traumatic event is most associated with TICAD could help clinicians to direct their diagnostic process. Herein, a review of the literature concerning TICAD has been carried out to highlight its correlation with specific traumatic events. TICAD is mostly correlated to motor vehicle accidents (94/227), specifically to car accidents (39/94), and to direct or indirect head and cervical trauma (76/227). As well, a case report is presented to discuss TICAD forensic implications.

Stent-Assisted Angioplasty in Spontaneous Bilateral Extracranial Internal Carotid Artery Dissection

Internal carotid artery dissection (ICAD) results from a tear in the intima or rupture of the vasa vasorum with bleeding within the media resulting in separation of the vessel wall layers and a false lumen. It may cause arterial stenosis, occlusion, or dissecting pseudoaneurysm. Currently, the treatment of ICAD is controversial, including drug therapy and endovascular stent implantation. Simultaneous spontaneous dissection of bilateral carotid artery is rarely reported. We reported a 39-year-old-man with bilateral ICAD. Although the long-term durability of endovascular stent remains to be determined, for ICAD failed with active drug treatment and combined with hemodynamic impairment, early endovascular stent should be considered.

Vertebral Artery Dissection in Sport: A Systematic Review

BACKGROUND

Vertebral artery dissection (VAD) is a potentially catastrophic injury that may occur during sports participation. A comprehensive review is needed to collate documented cases to improve understanding and inform future preventative approaches.

OBJECTIVE

This review aimed to understand the extent of VAD in sport and characterise trends suggestive of mechanisms of injury.

METHODS

Electronic databases were searched using terms related to VAD and sport. Records were included if they described one or more cases of VAD attributed to sport.

RESULTS

A total of 79 records described 128 individual cases of VAD in sport, of which 118 were confirmed by imaging or autopsy and included in analyses. Cases were attributed to 43 contact and non-contact sports. The median age of cases was 33 years (IQR 22-44), and 75% were male. There were 22 cases of fatal injury, of which ten involved an impact to the mastoid region and seven involved an impact to the head or neck. Non-fatal cases of VAD were attributed to impact to the head or neck (not mastoid region), movement or held position without impact, and in some cases no reported incident.

CONCLUSIONS

VAD attributed to sports participation is uncommonly reported and the mechanisms are varied. Impact to the mastoid region is consistently implicated in fatal cases and should be the focus of injury prevention strategies in sport. Efforts may also be directed at improving the prognosis of cases with delayed presentation through clinical recognition and imaging. The review was registered on the international prospective register for systematic reviews ( http://www.crd.york.ac.uk/PROSPERO ) (CRD42018090543).

Spontaneous Bilateral Cervical Internal Carotid Artery Dissection Treated with Simultaneous Bilateral Carotid Artery Stenting: A Case Report

Spontaneous cervical internal carotid artery dissection (CICAD) is occasionally treated with conservative management, mainly using antithrombotics. However, we have to consider emergency interventions for bilateral CICAD occurring simultaneously and accompanied by progressive cerebral ischemia. A 46-year-old woman was brought to our hospital with a complaint of left-handed clumsiness, blurred vision in the left eye, and right hemiplegia. Acute cerebral infarction in bilateral cerebral hemispheres was evident on brain magnetic resonance imaging. Bilateral internal carotid arteries were barely visible on time-of-flight magnetic resonance angiography. Subsequent cerebral angiography demonstrated that cervical internal carotid arteries on both sides were tapered off immediately after the bifurcations, indicating CICAD. Despite management with intravenous antithrombotic agents and hydration, neurological status gradually deteriorated. After insertion of a transvenous temporary pacemaker, we performed simultaneous bilateral carotid artery stenting (sbCAS) 3 days after admission. The patient first suffered slight right-sided hemiplegia and hoarseness, but symptoms resolved after rehabilitation, and modified Rankin Scale was 0 as of 2 years after the procedure. Bilateral CICAD causes severe insufficiency of cerebral blood flow, and symptoms often persist even after administration of antithrombotic agents. In such refractory cases, early intervention should be considered, and sbCAS can be safely performed. During the procedure, a transvenous temporary pacemaker maintains hemodynamic stability and might be a favorable option.

Bilateral Internal Carotid and Left Vertebral Artery Dissection after Blunt Trauma: A Case Report and Literature Review

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.

Bilateral blunt cerebrovascular injury resulting in direct carotid-cavernous fistulae: A case report and review of the literature

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.

Bilateral Carotid and Vertebral Artery Dissection from Blunt Trauma

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).

Cervical artery dissection after sports - An analytical evaluation of 190 published cases

Introduction

Cervical artery dissections may be preceded by mechanical trigger events, often related to sports.

Methods

Using the MEDLINE database, we identified case reports and case series of sports-related cervical artery dissections. Information of the type of sport, age and gender of the patient, affected vessels, associated infarction, time delay, and neurological sequelae were extracted. Demographic and clinical characteristics were compared between sport groups using analysis of variance and Chi square tests. Differences were further assessed with adjusted post hoc tests and homogenous subsets.

Results

A total of 115 reports describing 190 patients with cervical artery dissections related to 45 different sports were identified. The mean age of all patients was 35 years; 26% of all patients were women. Anterior and posterior circulation, as well as left and right side were affected with similar frequency. Patients belonging to different sport categories differed significantly with regard to age (p < 0.001), gender (p < 0.001), and affected circulation (anterior vs. posterior, p = 0.02). The posterior circulation was most often affected in golf players (88%) and least often in individuals engaging in exercise (23%) and scuba divers (29%). Laterality (left vs. right) and mortality were similar between sport groups.

Discussion

We performed a comprehensive review and analytical evaluation of case reports describing patients with cervical artery dissections after sport. Confirmation of our findings in prospective studies is needed.

Conclusion

Cervical artery dissection has been described in relation to a wide variety of sports. The risk of injury to particular neurovascular structures may depend on the type sport involved. Discipline-specific incidence rates are not known.

Spinal Trauma is Never without Sin: A Tetraplegia Patient Presented Without any Symptoms

Spinal cord injuries are amongst the most dangerous injuries, leading to high mortality and morbidity. Injured patients are occasionally faced with life-threatening complications and quality-of-life changing neurological deficits. Thoracic and cervical spinal segments are the most effected sites of injury and a wide range of complications including paraplegia, respiratory and cardiovascular compromise secondary to autonomic dysfunction or tetraplegia may ensue. We aim to draw attention to the progressive nature of the neurological deficits in a patient admitted asymptomatically. Also, we would like to discuss the importance of swift diagnosis and management in such patients. In asymptomatic patients in whom no fractures are diagnosed with CT scans, a neurological examination should be repeated several times to exclude any neurological injuries that were missed. MRI should be ordered in an emergency setting even though it is not frequently used as a diagnostic modality. This should be done especially in patients without any fractures on CT but with neurological signs.

Traumatic Dissection of Four Brain-Supplying Arteries without Neurologic Deficit

Study Design Case report and review of the literature. Objectives Case report of a traumatic dissection of all major brain-supplying arteries resulting from a horseback-riding accident. Overview of the literature on diagnostic and therapeutic recommendations. Methods Case presentation. For the discussion, handpicked articles and PubMed database research with the keywords "dissection," "vertebral artery," "spine trauma," "computed tomography," "magnetic resonance imaging," and "angiography" were used. Results Despite high-energy induced acute lesion of all four cervical arteries, this 45-year-old patient did not demonstrate signs of microemboli nor suffer from stroke. Conclusion In case of high-energy trauma of the head and/or the neck, emergency physicians must consider traumatic cervical artery dissection (TCAD). Thus, emergency care algorithms should routinely include computed tomography angiography and magnetic resonance imaging. Although the incidence of TCAD-induced stroke is low, antiplatelet therapy is recommended in the presence of TCAD.

Spontaneous resolution of ophthalmologic symptoms following bilateral traumatic carotid cavernous fistulae

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.

A case of traumatic intracranial vertebral artery injury presenting with life-threatening symptoms

Traumatic intracranial vertebral artery injury is a relatively rare but potentially fatal disease. We present a case of a 63-year-old man who presented with sudden onset of loss of consciousness after hitting his head. After immediate resuscitation, he showed quadriplegia and absence of spontaneous breathing. Brain and cervical spine magnetic resonance imaging revealed an atlantoaxial subluxation, fractured C2 odontoid process, left vertebral artery occlusion, and bilateral extensive ischemia in the medulla oblongata and high cervical spinal cord. Digital subtraction angiography demonstrated left vertebral artery dissection just below the level of vertebral body C2.