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A misdiagnosis of carotid pseudoaneurysm
Injury(1985) 16, 339-340
Printedin
A misdiagnosis R. E. Moulton-Barrett
Great Britain
of carotid
339
pseudoaneurysm
and R. Downing
University Department of Surgery, Queen Efirabeth Hospital, 8irmingham
Summary
We report a case of blunt injury of the neck associated with the use of an imported plastic rock-guard designed for use in motorcycle scrambling. The injury may have important im-
plications for the future use of this particular guard. CASE REPORT A 20-year-old scrambling enthusiast, wearing a protective rock-guard (J.T. Racing, USA; Fig. l), was thrown from his motorcycle and fell onto the back of his head while his right arm was outstretched. He lost consciousness for a few seconds only and on admission to a local hospital had amnesia for the accident and complained of pain and tenderness on the right side of his neck. There was a tender, pulsatile mass 3 x 2cm in the right anterior triangle of the neck with no associated bruit.
The common carotid and superficial temporal pulses were present and no abnormal neurological signs were found. X-ray films of the skull and cervical spine were normal. A presumptive diagnosis of pseudoaneurysm of the carotid artery was made and the patient was transferred to our surgical unit by which time the mass had increased in size to 3 x 4cm; it was duly explored. A longitudinal incision revealed an encapsulated, haemorrhagic mass which was dissected from the underlying carotid bifurcation. The common carotid artery and its branches were patent and intact. The patient made an uneventful recovery and subsequent histological examination of the mass excised revealed a damaged cervical lymph node. DISCUSSION
An enlarging cervical haematoma may signify injury to the carotid artery and is an indication for immediate exploration (Thal et al., 1974). In this case, haemorrhage into a damaged lymph node overlying the carotid bifurcation mimicked a pseudoaneurysm, a condition which most commonly results from penetrating wounds of the neck (Ungar et al., 1980). Blunt injury accounts for less than 10 per cent of all extracranial carotid injuries (Brown et al., 1982) and produces acute arterial thrombosis and infarction of the brain rather than aneurysm formation. The high incidence of stroke in patients with blunt carotid injury (Krajewski and Hertzer, 1980) necessitates urgent assessment by carotid angiography and early vascular reconstruction (Perry et al., 1980). Rock-guards are designed to protect riders from flying stones and comprise a moulded plastic chest-plate from which extensions (‘wings’) pass over each shoulder. Guards are also worn on the upper arms. The particular rock-guard worn by this patient (Fig. 1) had a hinged shoulder extension (‘floating wing’) with an unprotected edge designed to allow increased mobility of the arm and shoulder. However, we believe that this increased mobility subjects riders to the risk of serious injury as abduction of the arm and lateral flexion of the neck allow the inner edge of the wing to be driven against the unprotected lateral aspect of the neck (Fig. 1). Although the manufacturers are unaware of previous injuries associated with the use of the rock-guard, we consider that its design should be improved by secure fixation of the floating wing to the chest plate and adequate padding of its free inner edge. Acknowledgements Fig. I. The mechanism of cervical trauma produced by the shoulder plate is demonstrated.
We thank Miss P. Cole for typing the manuscript and Mr T. Dee for photography.
340
Injury: the British Journal of Accident Surgery (1985) Vol. 1 ~/NO. 5
REFERENCES
Thal E. R., Snyder W. H. and Hays R. J. (1974) Management of carotid artery injuries. Surgery 76, 955. Ungar S. W., Tucker W. S.. Mrdeza M. A et al. (1980) Carotid arterial trauma. Surgery 87, 477.
Brown M. F., Graham J. M.. Feliciano D. V. et al. (1982) Carotid artery injuries. Am. J. Surg. 144, 748. Krajewski L. P. and Hertzer N. R. (1980) Blunt carotid trauma: report of two cases and review of the literature. Ann. Surg. 191, 341. Perry M. O., Snyder W. H. and Thal E. R. (1980) Carotid artery injuries caused by blunt trauma. Ann. Surg. 232, 74.
Requests for reprints should be addressed fo: R. Downing, Department
Paper accepted
8 June 1984.
of Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH.
Printedin
A misdiagnosis R. E. Moulton-Barrett
Great Britain
of carotid
339
pseudoaneurysm
and R. Downing
University Department of Surgery, Queen Efirabeth Hospital, 8irmingham
Summary
We report a case of blunt injury of the neck associated with the use of an imported plastic rock-guard designed for use in motorcycle scrambling. The injury may have important im-
plications for the future use of this particular guard. CASE REPORT A 20-year-old scrambling enthusiast, wearing a protective rock-guard (J.T. Racing, USA; Fig. l), was thrown from his motorcycle and fell onto the back of his head while his right arm was outstretched. He lost consciousness for a few seconds only and on admission to a local hospital had amnesia for the accident and complained of pain and tenderness on the right side of his neck. There was a tender, pulsatile mass 3 x 2cm in the right anterior triangle of the neck with no associated bruit.
The common carotid and superficial temporal pulses were present and no abnormal neurological signs were found. X-ray films of the skull and cervical spine were normal. A presumptive diagnosis of pseudoaneurysm of the carotid artery was made and the patient was transferred to our surgical unit by which time the mass had increased in size to 3 x 4cm; it was duly explored. A longitudinal incision revealed an encapsulated, haemorrhagic mass which was dissected from the underlying carotid bifurcation. The common carotid artery and its branches were patent and intact. The patient made an uneventful recovery and subsequent histological examination of the mass excised revealed a damaged cervical lymph node. DISCUSSION
An enlarging cervical haematoma may signify injury to the carotid artery and is an indication for immediate exploration (Thal et al., 1974). In this case, haemorrhage into a damaged lymph node overlying the carotid bifurcation mimicked a pseudoaneurysm, a condition which most commonly results from penetrating wounds of the neck (Ungar et al., 1980). Blunt injury accounts for less than 10 per cent of all extracranial carotid injuries (Brown et al., 1982) and produces acute arterial thrombosis and infarction of the brain rather than aneurysm formation. The high incidence of stroke in patients with blunt carotid injury (Krajewski and Hertzer, 1980) necessitates urgent assessment by carotid angiography and early vascular reconstruction (Perry et al., 1980). Rock-guards are designed to protect riders from flying stones and comprise a moulded plastic chest-plate from which extensions (‘wings’) pass over each shoulder. Guards are also worn on the upper arms. The particular rock-guard worn by this patient (Fig. 1) had a hinged shoulder extension (‘floating wing’) with an unprotected edge designed to allow increased mobility of the arm and shoulder. However, we believe that this increased mobility subjects riders to the risk of serious injury as abduction of the arm and lateral flexion of the neck allow the inner edge of the wing to be driven against the unprotected lateral aspect of the neck (Fig. 1). Although the manufacturers are unaware of previous injuries associated with the use of the rock-guard, we consider that its design should be improved by secure fixation of the floating wing to the chest plate and adequate padding of its free inner edge. Acknowledgements Fig. I. The mechanism of cervical trauma produced by the shoulder plate is demonstrated.
We thank Miss P. Cole for typing the manuscript and Mr T. Dee for photography.
340
Injury: the British Journal of Accident Surgery (1985) Vol. 1 ~/NO. 5
REFERENCES
Thal E. R., Snyder W. H. and Hays R. J. (1974) Management of carotid artery injuries. Surgery 76, 955. Ungar S. W., Tucker W. S.. Mrdeza M. A et al. (1980) Carotid arterial trauma. Surgery 87, 477.
Brown M. F., Graham J. M.. Feliciano D. V. et al. (1982) Carotid artery injuries. Am. J. Surg. 144, 748. Krajewski L. P. and Hertzer N. R. (1980) Blunt carotid trauma: report of two cases and review of the literature. Ann. Surg. 191, 341. Perry M. O., Snyder W. H. and Thal E. R. (1980) Carotid artery injuries caused by blunt trauma. Ann. Surg. 232, 74.
Requests for reprints should be addressed fo: R. Downing, Department
Paper accepted
8 June 1984.
of Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH.