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Blunt traumatic injury of the innominate artery resulting in a stroke – A rare presentation
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 4 0 e1 4 2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
Blunt traumatic injury of the innominate artery resulting in a stroke e A rare presentation Dhavapalani Alagappan*, N.R. Ganesh Apollo Hospitals, Chennai, India
article info
abstract
Article history:
Introduction: Blunt traumatic injury of innominate artery is uncommon and has been re-
Received 16 April 2014
ported only in 132 cases. In the literature there has been a solitary case report of a stroke
Accepted 2 May 2014
resulting from an innominate artery injury. We present a case of traumatic injury of the
Available online 11 June 2014
innominate artery resulting in an ischemic stroke. Case presentation: A 20-year-old gentleman ejected from a two wheeler and run over by a
Keywords:
truck presented to us with multiple bleeding facial wounds and severe crush injury of his
Blunt arterial injury
upper torso. Bedside chest X-ray revealed a widened mediastinum and multiple rib frac-
Innominate artery injury
tures with pneumothoraces bilaterally which were drained with intercostal tubes. An hour
Pseudo aneurysm
into his stay in the ED he developed left hemiparesis. CT brain showed infarcts in right temporo-parietal and occipital regions. CT angiogram of neck vessels revealed an avulsion injury at the origin of the right innominate artery with pseudoaneurysm formation. Discussion: The innominate artery is the 2nd most common site of great vessel injury after the ascending aorta. 71% die before reaching the hospital. Patients who present to the ED are often stable with associated major injuries including rib fractures, pneumothorax and closed head injuries. The diagnosis is aided by a thorough clinical examination or a chest X-ray revealing a widened mediastinum as seen in our patient. Lessons learnt: Severe upper torso injuries involving the clavicle and upper ribs with pulse deficits or unexplained neurology should always raise a strong suspicion of major vascular injuries warranting further evaluation. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
Blunt traumatic injury of innominate artery is uncommon and has been reported only in 132 cases.1 In the literature there has been a solitary case report of a stroke resulting from an innominate artery injury.2 We present a case of traumatic injury of the innominate artery resulting in an ischemic stroke.
2.
Case presentation
A 20-year-old gentleman ejected from a two wheeler and ran over by a truck presented to us with multiple bleeding facial wounds and severe crush injury of his upper torso. However he did not have any hemodynamic compromise. Bedside chest X-ray revealed a widened mediastinum and multiple rib fractures with pneumothoraces bilaterally which were
* Corresponding author. E-mail addresses: [email protected], [email protected] (D. Alagappan). http://dx.doi.org/10.1016/j.apme.2014.05.004 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
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drained with intercostal tubes. An hour into his stay in the ED he developed left sided hemiparesis. Subsequently he was intubated for airway protection. CT brain showed infarcts in right temporo-parietal and occipital regions. CT angiogram of neck vessels revealed an avulsion injury at the origin of the right innominate artery with pseudoaneurysm formation. He was immediately shifted to theater for exploration where he was found to have intimal transection of innominate artery with a large intraluminal clot completely obstructing the lumen with no ante grade flow. The vessel was divided and repaired successfully. Post-operative recovery was uneventful and he was discharged on the tenth post operative day with minimal residual neurological deficit.
CT angiogram reconstructed image showing e avulsion injury at the origin of the right innominate artery with pseudo aneurysm formation. Innominate artery is not visualized. Right common carotid artery shows reduced flow.
3.
Chest X-ray showing widened upper mediastinum fracture of 1st, 2nd, 3rd and 4th ribs on right side, subcutaneous emphysema on right side, with bilateral chest drains in situ.
CT scan of brain plain showing a hypo dense lesion suggestive of infarct in right temporo-parietal, occipital and high parietal region.
Discussion
The innominate artery is the 2nd most common site of great vessel injury, the most common being the aortic isthmus distal to the left subclavian artery.3 It is usually an avulsion or transection injury found at the origin of the vessel from the aortic arch and can be caused by deceleration or crush injuries secondary to a motor vehicle crash or fall from a great height. However, penetrating injuries more frequently cause innominate artery disruptions. The postulated mechanism of injury is an anteroposterior compression of the mediastinum between the sternum and the vertebrae that displaces the heart posteriorly and to the left. This increases the curvature of the arch and causes tension on the outlet vessels. 71% die before reaching the hospital. Patients who present to the ED are often stable with associated major injuries including rib fractures (46%), pneumothorax (36%) and closed head injuries.4 The diagnosis is aided by a thorough clinical examination (bruit, supraclavicular hematoma, pulse deficit, blood pressure discrepancy between arms or a shoulder-belt sign) or a chest X-ray revealing a widened mediastinum.5 Bleeding and
142
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 4 0 e1 4 2
hemorrhagic shock may not be evident in blunt innominate artery injury as the hematoma is usually contained in the upper mediastinum
4.
Lessons learnt
Severe upper torso injuries involving the clavicle and upper ribs with pulse deficits or unexplained neurology should always raise a strong suspicion of major vascular injuries warranting further evaluation.
Conflicts of interest All authors have none to declare.
references
1. Hirose H, Moore E. Delayed presentation and rupture of a posttraumatic innominate artery aneurysm: case report and review of the literature. J Trauma. 1997;42:1187e1195. 2. Kanwar M, Desai D, Joumaa M, Guduguntla V. Traumatic brachiocephalic pseudoaneurysm presenting as stroke in a seventeen-year-old. Clin Cardiol. 2009 Nov;32(11):E43eE45. 3. Al-Khaldi A, Robbins RC. Successful repair of blunt injury of aortic arch branches in the setting of bovine arch. J Vasc Surg. 2006;43:396e398. 4. Stover S, Holtzman RB, Lottenberg L, Bass TL. Blunt innominate artery injury. Am Surg. 2001;67(8):757e759. 5. Chen MY, Regan JD, D’Amore JM, Routh WD, Meredith JW, Dyer RB. Role of angiography in the detection of aortic branch vessel injury after blunt thoracic trauma. J Trauma. 2001;51:1166e1171.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Case Report
Blunt traumatic injury of the innominate artery resulting in a stroke e A rare presentation Dhavapalani Alagappan*, N.R. Ganesh Apollo Hospitals, Chennai, India
article info
abstract
Article history:
Introduction: Blunt traumatic injury of innominate artery is uncommon and has been re-
Received 16 April 2014
ported only in 132 cases. In the literature there has been a solitary case report of a stroke
Accepted 2 May 2014
resulting from an innominate artery injury. We present a case of traumatic injury of the
Available online 11 June 2014
innominate artery resulting in an ischemic stroke. Case presentation: A 20-year-old gentleman ejected from a two wheeler and run over by a
Keywords:
truck presented to us with multiple bleeding facial wounds and severe crush injury of his
Blunt arterial injury
upper torso. Bedside chest X-ray revealed a widened mediastinum and multiple rib frac-
Innominate artery injury
tures with pneumothoraces bilaterally which were drained with intercostal tubes. An hour
Pseudo aneurysm
into his stay in the ED he developed left hemiparesis. CT brain showed infarcts in right temporo-parietal and occipital regions. CT angiogram of neck vessels revealed an avulsion injury at the origin of the right innominate artery with pseudoaneurysm formation. Discussion: The innominate artery is the 2nd most common site of great vessel injury after the ascending aorta. 71% die before reaching the hospital. Patients who present to the ED are often stable with associated major injuries including rib fractures, pneumothorax and closed head injuries. The diagnosis is aided by a thorough clinical examination or a chest X-ray revealing a widened mediastinum as seen in our patient. Lessons learnt: Severe upper torso injuries involving the clavicle and upper ribs with pulse deficits or unexplained neurology should always raise a strong suspicion of major vascular injuries warranting further evaluation. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1.
Introduction
Blunt traumatic injury of innominate artery is uncommon and has been reported only in 132 cases.1 In the literature there has been a solitary case report of a stroke resulting from an innominate artery injury.2 We present a case of traumatic injury of the innominate artery resulting in an ischemic stroke.
2.
Case presentation
A 20-year-old gentleman ejected from a two wheeler and ran over by a truck presented to us with multiple bleeding facial wounds and severe crush injury of his upper torso. However he did not have any hemodynamic compromise. Bedside chest X-ray revealed a widened mediastinum and multiple rib fractures with pneumothoraces bilaterally which were
* Corresponding author. E-mail addresses: [email protected], [email protected] (D. Alagappan). http://dx.doi.org/10.1016/j.apme.2014.05.004 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 4 0 e1 4 2
141
drained with intercostal tubes. An hour into his stay in the ED he developed left sided hemiparesis. Subsequently he was intubated for airway protection. CT brain showed infarcts in right temporo-parietal and occipital regions. CT angiogram of neck vessels revealed an avulsion injury at the origin of the right innominate artery with pseudoaneurysm formation. He was immediately shifted to theater for exploration where he was found to have intimal transection of innominate artery with a large intraluminal clot completely obstructing the lumen with no ante grade flow. The vessel was divided and repaired successfully. Post-operative recovery was uneventful and he was discharged on the tenth post operative day with minimal residual neurological deficit.
CT angiogram reconstructed image showing e avulsion injury at the origin of the right innominate artery with pseudo aneurysm formation. Innominate artery is not visualized. Right common carotid artery shows reduced flow.
3.
Chest X-ray showing widened upper mediastinum fracture of 1st, 2nd, 3rd and 4th ribs on right side, subcutaneous emphysema on right side, with bilateral chest drains in situ.
CT scan of brain plain showing a hypo dense lesion suggestive of infarct in right temporo-parietal, occipital and high parietal region.
Discussion
The innominate artery is the 2nd most common site of great vessel injury, the most common being the aortic isthmus distal to the left subclavian artery.3 It is usually an avulsion or transection injury found at the origin of the vessel from the aortic arch and can be caused by deceleration or crush injuries secondary to a motor vehicle crash or fall from a great height. However, penetrating injuries more frequently cause innominate artery disruptions. The postulated mechanism of injury is an anteroposterior compression of the mediastinum between the sternum and the vertebrae that displaces the heart posteriorly and to the left. This increases the curvature of the arch and causes tension on the outlet vessels. 71% die before reaching the hospital. Patients who present to the ED are often stable with associated major injuries including rib fractures (46%), pneumothorax (36%) and closed head injuries.4 The diagnosis is aided by a thorough clinical examination (bruit, supraclavicular hematoma, pulse deficit, blood pressure discrepancy between arms or a shoulder-belt sign) or a chest X-ray revealing a widened mediastinum.5 Bleeding and
142
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 1 4 0 e1 4 2
hemorrhagic shock may not be evident in blunt innominate artery injury as the hematoma is usually contained in the upper mediastinum
4.
Lessons learnt
Severe upper torso injuries involving the clavicle and upper ribs with pulse deficits or unexplained neurology should always raise a strong suspicion of major vascular injuries warranting further evaluation.
Conflicts of interest All authors have none to declare.
references
1. Hirose H, Moore E. Delayed presentation and rupture of a posttraumatic innominate artery aneurysm: case report and review of the literature. J Trauma. 1997;42:1187e1195. 2. Kanwar M, Desai D, Joumaa M, Guduguntla V. Traumatic brachiocephalic pseudoaneurysm presenting as stroke in a seventeen-year-old. Clin Cardiol. 2009 Nov;32(11):E43eE45. 3. Al-Khaldi A, Robbins RC. Successful repair of blunt injury of aortic arch branches in the setting of bovine arch. J Vasc Surg. 2006;43:396e398. 4. Stover S, Holtzman RB, Lottenberg L, Bass TL. Blunt innominate artery injury. Am Surg. 2001;67(8):757e759. 5. Chen MY, Regan JD, D’Amore JM, Routh WD, Meredith JW, Dyer RB. Role of angiography in the detection of aortic branch vessel injury after blunt thoracic trauma. J Trauma. 2001;51:1166e1171.