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CASE REPORT - MAXILLOFACIAL SURGERY
Year : 2011  |  Volume : 1  |  Issue : 1  |  Page : 74-76

Acute onset progressive hemiparesis in a case of head and neck injury


1 Department of Neurosurgery, MM Institute of Medical Sciences and Research, Mullana, Ambala, India
2 Department of ENT, MM Institute of Medical Sciences and Research, Mullana, Ambala, India
3 Department of Radiology, Datta Meghe Institute of Medical Sciences, Sawangi, Meghe, Wardha, Maharashtra, India

Date of Web Publication26-Jul-2011

Correspondence Address:
Amit Agrawal
Department of Neurosurgery, MM Institute of Medical Sciences and Research, Mullana, Ambala - 133 203, Haryana
India
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DOI: 10.4103/2231-0746.83160

PMID: 23483667

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  Abstract 

Traumatic carotid artery injury is an increasingly recognized complication of severe blunt head or neck trauma in patients with motor vehicle accidents. A 22-year-old male presented after a high-velocity road traffic accident and sustained head, neck and systemic injuries. Initially the patient was neurologically stable and initial CT scan brain was also apparently normal. Few hours after the injury, the patient developed progressive left hemiparesis. MRI of brain was suggestive of acute infarct involving right internal carotid artery territory. In accordance with the literature and as in present case, it would be emphasized that the patients who develop gross neurological abnormalities after blunt trauma to the head or neck, there should be a high index of suspicion of having sustained injury to the carotid arteries.

Keywords: Blunt injury, carotid injury, hemiplegia, neck injury


How to cite this article:
Agrawal A, Garg LN, Singh BR. Acute onset progressive hemiparesis in a case of head and neck injury. Ann Maxillofac Surg 2011;1:74-6

How to cite this URL:
Agrawal A, Garg LN, Singh BR. Acute onset progressive hemiparesis in a case of head and neck injury. Ann Maxillofac Surg [serial online] 2011 [cited 2019 Sep 23];1:74-6. Available from: http://www.amsjournal.com/text.asp?2011/1/1/74/83160


  Introduction Top


Traumatic carotid artery injury is an increasingly recognized complication of severe blunt head or neck trauma, more common in patients with motor vehicle accidents. [1] The carotid injury in these patients can easily be missed as clinical presentation can be overshadowed by significant intracranial injuries, effects of intoxication and other systemic injuries. [2],[3]


  Case Report Top


A 22-year-old male patient presented two hours after a high-velocity road traffic accident (the vehicle collided with a lorry while he was driving the vehicle). There was history of transient loss of consciousness, oral and nasal bleed with multiple episodes of vomiting. There was no history of seizures. His general and systemic examination was unremarkable. Neurologically Glasgow coma scale was 14/15 (E3, V5, M6-eye opening to call, obeying command and oriented). He was moving all four limbs equally; pupils were bilaterally equal and reacting to light. Local examination revealed multiple lacerations over right side of the neck, massive bruising and swelling over right side of the neck, fracture mandible and massive swelling involving right upper limb [Figure 1]. His blood investigations were normal. X-ray chest was normal, x-ray right shoulder showed comminuted fracture of upper end of right humerus [Figure 2]. Initial computerized tomography scan (CT scan) of the brain showed anterior cranial fossa fractures and pneumocephalus [Figure 3]. CT scan of neck showed massive swelling involving right side of the neck and mandible fracture with normal vertebral column [Figure 4]. The patient was planned to be managed conservatively. Neck wounds were thoroughly cleaned and sutured. About six hours after the injury the patient developed progressively increasing weakness of left upper and lower limbs and became drowsier (GCS-E3, V4, M5). In view of new onset of neurological deficits and initial early normal CT scan a possibility of expanding intracranial hematoma was suspected. As the patient also had significant neck injury a differential diagnosis of blunt carotid injury with thrombo-embolic event was also suspected. Urgent repeat magnetic resonance imaging (MRI) showed evidence of the infarct in the right middle cerebral artery territory [Figure 5]. However, while the patient was recovering he suddenly developed hypotension and tachypnea and features suggestive of pulmonary embolism. In spite of aggressive management he did not recover and succumbed to it.
Figure 1: Clinical photograph showing massive bruising and swelling involving right side of the neck

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Figure 2: X-ray right shoulder showing comminuted fracture of upper end of right if humerus

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Figure 3: Initial CT scan brain showing anterior cranial fossa fractures and pneumocephalus and normal brain parenchyma

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Figure 4: Initial CT scan showing massive swelling over right side of neck and fracture of mandible

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Figure 5: MRI brain showing hyperintense signal changes in right internal capsule and basal ganglionic region

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  Discussion Top


In spite of increasing awareness about the carotid dissection following blunt injury to the neck, the diagnosis may not be apparent initially and often delayed until the patients develop features of cerebral ischemia and focal neurological deficits. [4],[5],[6],[7] The mechanism of injury to the carotids can be direct blow, hyperextension of neck with contralateral rotation of head, blunt intraoral trauma or skull base fracture. [3] The clinical presentation in patients with carotid injury is influenced by the extent of arterial damage and often there is a lucid interval between the injury and appearance of neurological symptoms (usually of less than 24 h). [7] Intimal damage can cause dissection and subsequent thrombosis that may present as transient ischemic attack or stroke. [5],[8] At the time of presentation to the casualty the patient did not have any neurological deficits, however in view of significant systemic injuries and high-velocity impact mechanism a CT scan of brain and spine was performed that showed extensive neck swelling on right side and normal brain parenchyma and cervical spine. [8] In view of new neurological deficits in a patient of head and neck injury with initial normal CT scan, expanding intracranial hematomas (e.g. extradural or subdural) or contusions or as in present case thrombo-embolic event secondary to carotid artery injury were considered. [1],[2],[3],[4],[5],[6],[7] In literature the indications to investigate for carotid artery injury include "hemorrhage of potential arterial origin originating from the nose, ears, mouth, or a wound, expanding cervical hematoma, cervical bruit in a patient >50 years of age, evidence of acute infarct at brain imaging; unexplained central or lateralizing neurological deficit or transient ischemic attack, or Horner syndrome or neck or head pain". [1] Non-invasive diagnostic modalities including carotid color Doppler ultrasound, computerized tomography angiography of the neck and magnetic resonance angiography with each method having its diagnostic limitations have been identified as the modalities of choice. [1],[9] Duplex ultrasound can be used as the primary diagnostic modality; it would be cost-saving and have patient friendly characteristics. [10] As a rapid screening test for blunt carotid artery injury, in addition to a whole-body CT trauma scan, the integration of multidetector CTA is recommended. [11],[12] CT angiography is shown to be 98.6% sensitive and 100% specific, however it can underestimate subtle lesions such as intimal flaps. [13] MR angiography gives additional information on brain damage but it requires the patient to be stable and compliant. It is of limited value in depiction of concurrent osseous injuries, not readily available in all centers, and the degree of definition may not be adequate to recognize subtle injuries. [13],[14],[15] Still the catheter angiography is the gold standard diagnostic procedure in evaluating vascular trauma and can be combined with intervention where suitable expertise is available. [13] Management of blunt carotid artery injury depends on the type and extent of the injury. [16] The mainstay of treatment for these injuries is antithrombotic therapy and the majority of injuries will resolve with medical management. [7] Although anticoagulants and antiplatelet drugs may prevent ischemic stroke, but these may cause bleeding from traumatized tissues. [1] Surgical repair remains the gold standard in managing rupture of the carotid artery; however, emergency surgery in the setting of acute hemorrhage although very challenging will be life saving. [17] Apart from the surgical repair in centers where the required expertise and infrastructure is available, endovascular stenting have obvious advantage particularly in terms of morbidity. [17] In accordance with the literature and as in present case, it would be emphasized that in patients who develop gross neurological abnormalities after blunt trauma to the head or neck until proven otherwise, injury to the carotid arteries should be considered. [18]

 
  References Top

1.Nedeltchev K, Baumgartner RW. Traumatic cervical artery dissection. Front Neurol Neurosci 2005;20:54-63.   Back to cited text no. 1
    
2.Ballard JL, Teruya TH. Carotid and Vertebral artery injuries. In: Rutherford RB, editor. Vascular Surgery. 6 th ed. Saunders; 2005. p. 1009-12.  Back to cited text no. 2
    
3.Ozsvath KJ, Darling RC 3 rd , Tabatabai L, Hamdani S, Davies AH, Meryl D. Vascular trauma. In: Davies AH, Brophy CM, editors. Vascular Surgery. 1 st ed. Springer; 2005. p. 127.  Back to cited text no. 3
    
4.Prins WB, Kuiper MA, Aerdts SJ. Dissection of the carotid artery following blunt trauma: Still a pitfall. [Article in Dutch] Ned Tijdschr Geneeskd 2008;152:1549-54.  Back to cited text no. 4
    
5.Agrawal A, Kumar A, Tiwari A, Sinha A, Patel A. Low velocity traumatic dissection of the internal carotid artery presenting as a stroke after a slash injury. Singapore Med J 2007;48:e127-9.  Back to cited text no. 5
    
6.Fabian TC, Patton JH, Croce MA Jr, Minard G, Kudsk KA, Pritchard FE. Blunt Carotid Injury: Importance of early diagnosis and anticoagulant therapy. Ann Surg 1996;223:513-25.  Back to cited text no. 6
    
7.Arthurs ZM, Starnes BW. Blunt carotid and vertebral artery injuries. Injury 2008;39:1232-41.   Back to cited text no. 7
    
8.Brown CV, Zada G, Salim A, Inaba K, Kasotakis G, Hadjizacharia P, et al. Indications for routine repeat head computed tomography (CT) stratified by severity of traumatic brain injury. J Trauma 2007;62:1339-44.  Back to cited text no. 8
    
9.Yang ST, Huang YC, Chuang CC, Hsu PW. Traumatic internal carotid artery dissection. J Clin Neurosci 2006;13:123-8.  Back to cited text no. 9
    
10.Ginzburg E, Montalvo B, LeBlang S, Nunez D, Martin L. The use of duplex ultrasonography in penetrating neck trauma. Arch Surg 1996;131:691-3.  Back to cited text no. 10
    
11.Borisch I, Boehme T, Butz B, Hamer OW, Feuerbach S, Zorger N. Screening for carotid injury in trauma patients: Image quality of 16-detector-row computed tomography angiography. Acta Radiol 2007;48:798-805.  Back to cited text no. 11
    
12.Utter GH, Hollingworth W, Hallam DK, Jarvik JG, Jurkovich GJ. Sixteen-slice CT angiography in patients with suspected blunt carotid and vertebral artery injuries. J Am Coll Surg 2006;203:838-48.   Back to cited text no. 12
    
13.Múnera F, Soto JA, Palacio DM, Castañeda J, Morales C, Sanabria A, et al. Penetrating neck injuries: Helical CT angiography for initial evaluation. Radiology 2002;224:366-72.  Back to cited text no. 13
    
14.Kirsch E, Kaim A, Engelter S, Lyrer P, Stock KW, Bongartz G, et al. MR angiography in internal carotid artery dissection: Improvement of diagnosis by selective demonstration of the intramural haematoma. Neuroradiology 1998;40:704-9.   Back to cited text no. 14
    
15.James CA. Magnetic resonance angiography in trauma. Clin Neurosci 1997;4:137-45.  Back to cited text no. 15
    
16.Britt LD. Neck Injuries: Evaluation and Management. In: Moore EE, Feliciano DV, Mattox KL, editors. Trauma. 5 th ed. Mc-Graw Hill Professional; 2004. p. 451-2.  Back to cited text no. 16
    
17.Thakore N, Abbas S, Vanniasingham P. Delayed rupture of common carotid artery following rugby tackle injury: A case report. World J Emerg Surg 2008;3:14.   Back to cited text no. 17
    
18.Lin JJ, Chou ML, Lin KL, Wong MC, Wang HS. Cerebral infarct secondary to traumatic carotid artery dissection. Pediatr Emerg Care 2007;23:166-8.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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