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Squash injury to the internal carotid artery
EurJ Vase 8urg 1. 285-287 (1987)
CASE REPORT Squash Injury to the Internal Carotid A r t e r y D. J. Sherlock, S. N i g h t i n g a l e , T. I. M . Gardecki and J. D. H a m e r
Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, B1 7 2TQ, U.K.
Introduction N o n - p e n e t r a t i n g injuries of the carotid a r t e r y a r e r a r e b u t h a v e been appreciated for over a c e n t u r y 1 a n d s u b s e q u e n t reviews h a v e a c c u m u l a t e d a p p r o x i m a t e l y o n e - h u n d r e d cases. 2, 3 Whilst the m a j o r i t y are associated w i t h forceful t r a u m a , infrequently these injuries follow mild t r a u m a to the neck a n d c a n h a v e a p r o t e a n m o d e of p r e s e n t a t i o n . 2 The d e v e l o p m e n t of s u c h a n i n j u r y in a y o u n g m a n whilst p l a y i n g s q u a s h is described a n d the p a t h o p h y s i o l o g y discussed.
Case Report A 3 9 - y e a r - o l d m a n was a d m i t t e d following t h e developm e n t of n e u r o l o g i c a l s y m p t o m s two d a y s after p l a y i n g squash. D u r i n g the game, he developed a s u d d e n discomfort in the r i g h t side of the neck, b u t recalls n e i t h e r a b l o w n o r a n u n u s u a l twisting i n j u r y to the head. Several h o u r s following t h e game, he developed a frontal h e a d a c h e for w h i c h he took analgesia, a n d a l t h o u g h this h a d resolved by the following day, the t e n d e r n e s s o n the r i g h t side of the n e c k persisted. F o r t y - e i g h t h o u r s after t h e injury, he g r a d u a l l y b e g a n to develop left sided w e a k n e s s a n d d y s a e s t h e s i a w i t h r e c u r r e n c e of t h e h e a d a c h e . He w a s a d m i t t e d for investigation a n d a CT s c a n at this time was n o r m a l . The following day, his condition deteriorated, progressing rapidly to a dense left sided paralysis w i t h h e m i a n o p i a a n d focal m o t o r seizures a n d he b e c a m e b a r e l y rousable. He w a s transferred for specialised a t t e n tion, a n d a n a r t e r i o g r a m d e m o n s t r a t e d a dissection of the i n t e r n a l carotid a r t e r y (Fig. 1). This e x t e n d e d from a b o v e 0950-821X/87/040285 + 03 $03.00/0
© 1987 Grune & 8tratton Ltd
Fig. 1. Carotid Arteriogram (Lateral view); demonstrating a dissection of the internal carotid artery from above the carotid sinus to end as a taper before the tonsilar loop of the internal carotid artery.
286
D . J . S h e r l o c k eta/.
Fig. 2. Carotid Arteriogram (Lateral Cerebral View) demonstrating occlusion of anterior cerebral artery with poor flow in middle cerebral artery and loss of temporal lobe side branches.
Fig. 3. CT Scan (Transverse Cut) demonstrating large fronto-lateral infarction. Eur] Vasc Surg Vol 1, August 1987
Squash Injury to the Internal Carotid Artery
the c a r o t i d sinus u p to t h e t o n s i l a r loop of t h e i n t e r n a l carotid a n d w a s associated w i t h signs of c e r e b r o v a s c u l a r e m b o l i s m (Fig. 2). There w a s a s h a r p "cut-off" of t h e a n t e r i o r c e r e b r a l a r t e r y due to e m b o l i s m p r o x i m a l to t h e a n t e r i o r c o m m u n i c a t i n g a r t e r y (associated w i t h p o o r flow in the middle cerebral a r t e r y a n d loss of t h e t e m p o r a l lobe b r a n c h e s possibly as a result of m i c r o - e m b o l i s m (Fig. 2). He w a s treated w i t h d e x a m e t h a s o n e a n d a n t i c o n v u l s a n t s a n d a further CT s c a n a n d radio-isotope s c a n d e m o n s t r a t e d a n extensive r i g h t f r o n t o - l a t e r a l cerebral infarction (Fig. 3). His c o n d i t i o n i m p r o v e d w i t h a r a p i d r e c o v e r y of consciousness w i t h i n 4 8 h. Upon review twelve m o n t h s after injury, he h a s r e g a i n e d his speech a n d m o s t l o w e r limb function, b u t still h a s a disabilitating paralysis of the left arm.
Discussion I n j u r y to t h e carotid a r t e r y t h r o u g h sporting activities h a s b e e n recorded, b u t u s u a l l y results from a direct b l o w to t h e h e a d in c o n t a c t sports s u c h as boxing.2, 3 The l a t e n t period t h a t is associated w i t h n o n - p e n e t r a t i n g injuries of the i n t e r n a l carotid a r t e r y is also a p p a r e n t in this case, s y m p t o m s developing h o u r s or even d a y s after t h e initial injury.* The m a j o r i t y o f cases are associated w i t h r o a d traffic accidents 2 a n d a classification of t h e different i n j u r y types is described; Table 1.2, s The likely m e c h a n i s m in this case r e p o r t involves a s t r e t c h i n g i n j u r y to the i n t e r n a l carotid a r t e r y as a result of e x t r e m e r o t a t i o n a n d h y p e r e x t e n s i o n of the n e c k (Type II). T h e i n t e r n a l carotid a r t e r y in this p o s t u r e is s t r e t c h e d a n d c o m p r e s s e d a g a i n s t the l a t e r a l m a s s of t h e atlas, s This occurs p a r t i c u l a r l y in the y o u n g , s w h o lack the tort u o u s c h a n g e s w h i c h t e n d to o c c u r w i t h age in the in-
Table 1. Types of non-penetrating carotid injuries Type I: Type II: Type III: Type IV:
Direct blow to artery Stretching with compression over lateral mass of atlas Intraoral trauma Fracture'through base of skull
287
t e r n a l carotid artery. 4 As a result, b o t h the i n t i m a a n d m e d i a of the arterial w a l l are disrupted a n d dissection or a n e u r y s m f o r m a t i o n m a y o c c u r leading to a c u t e s y m p toms. It is the d e v e l o p m e n t of t h r o m b o s i s at this site, w i t h the s u b s e q u e n t variable period until e m b o l i s m occurs, t h a t a c c o u n t s for t h e delay in p r e s e n t a t i o n of t h e m a j o r i t y of cases, a, 4 U n f o r t u n a t e l y in this patient, the n a t u r e of the carotid i n j u r y w a s n o t a p p r e c i a t e d u n t i l e m b o l i s m w i t h cerebral infarction h a d occurred. Earlier r e c o g n i t i o n a n d e v a l u a t i o n b y a r t e r i o g r a p h y could h a v e given a n opport u n i t y for surgical intervention. T h e published results of t r e a t m e n t are poor, a n d are largely due to the delay in diagnosis, d e a t h o c c u r r i n g in over a third a n d o n l y a m i n o r i t y recover completely. 2 S u r g e r y to r e m o v e the t h r o m b o s i s soon after t h e developm e n t of m a j o r n e u r o l o g i c a l s y m p t o m s c a n result in imp r o v e m e n t in b o t h m o r t a l i t y a n d n e u r o l o g i c a l deficit. 2 Dissections a p p e a r to be suitable for c o n s e r v a t i v e medical m a n a g e m e n t , a n g i o g r a p h i c c h a n g e s resolving w i t h i n 3 m o n t h s , 6 h o w e v e r , s u r g e r y is n e c e s s a r y for a n e u r y s m s w h i c h inevitably r u p t u r e . 7 Despite t h e r a r i t y of this condition, a n increased a w a r e n e s s m a y result in earlier diagnosis a n d t r e a t m e n t so r e d u c i n g t h e m o r t a l i t y a n d m o r b i d i t y in a n often y o u n g g r o u p of patients.
References 1 VERNEUILM. Contusions multiples; delire violent; hemiplegie adroite signs de compression cerebrale Bull. Acad. Nat. (Paris) 1872;1: 46-56. 2 KRAIEWSKIL, HERTZERN. Blunt carotid artery trauma. Report of two cases and review of the literature Ann Surg 1980; 191 : 3 4 1 - 3 4 6 3 YAMADAS, KINDTG, YOUMANSJ. Carotid artery occlusion due to non-penetrating injury. J Trauma 1967; 7: 333-344 4 LITTLE]M, VANDERHELOGK, MAYJ. et al. Traumatic thrombosis of the internal carotid artery. Lancet 1969; 2 : 926-930. 5 BOLDEREYE, MAASSL, MILLERE. Role of atlantoid compression in the etiology of internal carotid thrombosis. ] Neurosurg 1956; 13 : 127 139 6 FRmOMANWA, DAYAV, QUISLINGRG. et al. Cervial carotid dissecting aneurysms. Neurosurgery 1980; 7: 207-214 7 TEALiS, BERCERONRT, RUMBAUCHCL. et al. Aneurysms of the cervical portion of the internal carotid artery associated with non-penetrating neck trauma. Radiology 1972 ; 105: 353-358 Received 19 January 1987
Eurl Vasc Surg Vol 1, August 1987
CASE REPORT Squash Injury to the Internal Carotid A r t e r y D. J. Sherlock, S. N i g h t i n g a l e , T. I. M . Gardecki and J. D. H a m e r
Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, B1 7 2TQ, U.K.
Introduction N o n - p e n e t r a t i n g injuries of the carotid a r t e r y a r e r a r e b u t h a v e been appreciated for over a c e n t u r y 1 a n d s u b s e q u e n t reviews h a v e a c c u m u l a t e d a p p r o x i m a t e l y o n e - h u n d r e d cases. 2, 3 Whilst the m a j o r i t y are associated w i t h forceful t r a u m a , infrequently these injuries follow mild t r a u m a to the neck a n d c a n h a v e a p r o t e a n m o d e of p r e s e n t a t i o n . 2 The d e v e l o p m e n t of s u c h a n i n j u r y in a y o u n g m a n whilst p l a y i n g s q u a s h is described a n d the p a t h o p h y s i o l o g y discussed.
Case Report A 3 9 - y e a r - o l d m a n was a d m i t t e d following t h e developm e n t of n e u r o l o g i c a l s y m p t o m s two d a y s after p l a y i n g squash. D u r i n g the game, he developed a s u d d e n discomfort in the r i g h t side of the neck, b u t recalls n e i t h e r a b l o w n o r a n u n u s u a l twisting i n j u r y to the head. Several h o u r s following t h e game, he developed a frontal h e a d a c h e for w h i c h he took analgesia, a n d a l t h o u g h this h a d resolved by the following day, the t e n d e r n e s s o n the r i g h t side of the n e c k persisted. F o r t y - e i g h t h o u r s after t h e injury, he g r a d u a l l y b e g a n to develop left sided w e a k n e s s a n d d y s a e s t h e s i a w i t h r e c u r r e n c e of t h e h e a d a c h e . He w a s a d m i t t e d for investigation a n d a CT s c a n at this time was n o r m a l . The following day, his condition deteriorated, progressing rapidly to a dense left sided paralysis w i t h h e m i a n o p i a a n d focal m o t o r seizures a n d he b e c a m e b a r e l y rousable. He w a s transferred for specialised a t t e n tion, a n d a n a r t e r i o g r a m d e m o n s t r a t e d a dissection of the i n t e r n a l carotid a r t e r y (Fig. 1). This e x t e n d e d from a b o v e 0950-821X/87/040285 + 03 $03.00/0
© 1987 Grune & 8tratton Ltd
Fig. 1. Carotid Arteriogram (Lateral view); demonstrating a dissection of the internal carotid artery from above the carotid sinus to end as a taper before the tonsilar loop of the internal carotid artery.
286
D . J . S h e r l o c k eta/.
Fig. 2. Carotid Arteriogram (Lateral Cerebral View) demonstrating occlusion of anterior cerebral artery with poor flow in middle cerebral artery and loss of temporal lobe side branches.
Fig. 3. CT Scan (Transverse Cut) demonstrating large fronto-lateral infarction. Eur] Vasc Surg Vol 1, August 1987
Squash Injury to the Internal Carotid Artery
the c a r o t i d sinus u p to t h e t o n s i l a r loop of t h e i n t e r n a l carotid a n d w a s associated w i t h signs of c e r e b r o v a s c u l a r e m b o l i s m (Fig. 2). There w a s a s h a r p "cut-off" of t h e a n t e r i o r c e r e b r a l a r t e r y due to e m b o l i s m p r o x i m a l to t h e a n t e r i o r c o m m u n i c a t i n g a r t e r y (associated w i t h p o o r flow in the middle cerebral a r t e r y a n d loss of t h e t e m p o r a l lobe b r a n c h e s possibly as a result of m i c r o - e m b o l i s m (Fig. 2). He w a s treated w i t h d e x a m e t h a s o n e a n d a n t i c o n v u l s a n t s a n d a further CT s c a n a n d radio-isotope s c a n d e m o n s t r a t e d a n extensive r i g h t f r o n t o - l a t e r a l cerebral infarction (Fig. 3). His c o n d i t i o n i m p r o v e d w i t h a r a p i d r e c o v e r y of consciousness w i t h i n 4 8 h. Upon review twelve m o n t h s after injury, he h a s r e g a i n e d his speech a n d m o s t l o w e r limb function, b u t still h a s a disabilitating paralysis of the left arm.
Discussion I n j u r y to t h e carotid a r t e r y t h r o u g h sporting activities h a s b e e n recorded, b u t u s u a l l y results from a direct b l o w to t h e h e a d in c o n t a c t sports s u c h as boxing.2, 3 The l a t e n t period t h a t is associated w i t h n o n - p e n e t r a t i n g injuries of the i n t e r n a l carotid a r t e r y is also a p p a r e n t in this case, s y m p t o m s developing h o u r s or even d a y s after t h e initial injury.* The m a j o r i t y o f cases are associated w i t h r o a d traffic accidents 2 a n d a classification of t h e different i n j u r y types is described; Table 1.2, s The likely m e c h a n i s m in this case r e p o r t involves a s t r e t c h i n g i n j u r y to the i n t e r n a l carotid a r t e r y as a result of e x t r e m e r o t a t i o n a n d h y p e r e x t e n s i o n of the n e c k (Type II). T h e i n t e r n a l carotid a r t e r y in this p o s t u r e is s t r e t c h e d a n d c o m p r e s s e d a g a i n s t the l a t e r a l m a s s of t h e atlas, s This occurs p a r t i c u l a r l y in the y o u n g , s w h o lack the tort u o u s c h a n g e s w h i c h t e n d to o c c u r w i t h age in the in-
Table 1. Types of non-penetrating carotid injuries Type I: Type II: Type III: Type IV:
Direct blow to artery Stretching with compression over lateral mass of atlas Intraoral trauma Fracture'through base of skull
287
t e r n a l carotid artery. 4 As a result, b o t h the i n t i m a a n d m e d i a of the arterial w a l l are disrupted a n d dissection or a n e u r y s m f o r m a t i o n m a y o c c u r leading to a c u t e s y m p toms. It is the d e v e l o p m e n t of t h r o m b o s i s at this site, w i t h the s u b s e q u e n t variable period until e m b o l i s m occurs, t h a t a c c o u n t s for t h e delay in p r e s e n t a t i o n of t h e m a j o r i t y of cases, a, 4 U n f o r t u n a t e l y in this patient, the n a t u r e of the carotid i n j u r y w a s n o t a p p r e c i a t e d u n t i l e m b o l i s m w i t h cerebral infarction h a d occurred. Earlier r e c o g n i t i o n a n d e v a l u a t i o n b y a r t e r i o g r a p h y could h a v e given a n opport u n i t y for surgical intervention. T h e published results of t r e a t m e n t are poor, a n d are largely due to the delay in diagnosis, d e a t h o c c u r r i n g in over a third a n d o n l y a m i n o r i t y recover completely. 2 S u r g e r y to r e m o v e the t h r o m b o s i s soon after t h e developm e n t of m a j o r n e u r o l o g i c a l s y m p t o m s c a n result in imp r o v e m e n t in b o t h m o r t a l i t y a n d n e u r o l o g i c a l deficit. 2 Dissections a p p e a r to be suitable for c o n s e r v a t i v e medical m a n a g e m e n t , a n g i o g r a p h i c c h a n g e s resolving w i t h i n 3 m o n t h s , 6 h o w e v e r , s u r g e r y is n e c e s s a r y for a n e u r y s m s w h i c h inevitably r u p t u r e . 7 Despite t h e r a r i t y of this condition, a n increased a w a r e n e s s m a y result in earlier diagnosis a n d t r e a t m e n t so r e d u c i n g t h e m o r t a l i t y a n d m o r b i d i t y in a n often y o u n g g r o u p of patients.
References 1 VERNEUILM. Contusions multiples; delire violent; hemiplegie adroite signs de compression cerebrale Bull. Acad. Nat. (Paris) 1872;1: 46-56. 2 KRAIEWSKIL, HERTZERN. Blunt carotid artery trauma. Report of two cases and review of the literature Ann Surg 1980; 191 : 3 4 1 - 3 4 6 3 YAMADAS, KINDTG, YOUMANSJ. Carotid artery occlusion due to non-penetrating injury. J Trauma 1967; 7: 333-344 4 LITTLE]M, VANDERHELOGK, MAYJ. et al. Traumatic thrombosis of the internal carotid artery. Lancet 1969; 2 : 926-930. 5 BOLDEREYE, MAASSL, MILLERE. Role of atlantoid compression in the etiology of internal carotid thrombosis. ] Neurosurg 1956; 13 : 127 139 6 FRmOMANWA, DAYAV, QUISLINGRG. et al. Cervial carotid dissecting aneurysms. Neurosurgery 1980; 7: 207-214 7 TEALiS, BERCERONRT, RUMBAUCHCL. et al. Aneurysms of the cervical portion of the internal carotid artery associated with non-penetrating neck trauma. Radiology 1972 ; 105: 353-358 Received 19 January 1987
Eurl Vasc Surg Vol 1, August 1987