J Bone Joint Surg [Br] 2009;91-B:536-9.Received 4 November 2008; Accepted 18 December 2008
We report a 30-year-old patient who was involved in a high-velocity road traffic accident and developed a left-sided hemiparesis, which was noted in the post-operative period following bilateral femoral intramedullary nailing. CT scanning of the brain revealed infarcts in the right frontal and parietal lobes in the distribution of the right middle cerebral artery. CT angiography showed occlusion of the right internal carotid artery consistent with internal carotid artery dissection. He was anticoagulated and nine months later was able to walk independently.
An awareness of this injury is needed to diagnose blunt trauma to the internal carotid artery. Even in the absence of obvious neck trauma, carotid artery dissection should be suspected in patients with a neurological deficit in the peri-operative period.
Carotid artery dissection following bluntinjury is a significant cause of morbidity in allage groups. It can occur spontaneously or fol-lowing major trauma, but a high level ofawareness is required to make this difficultdiagnosis. Only 0.08% to 0.67% of patientsadmitted to hospital after a road traffic acci-dent have blunt carotid injury;1,2 however, thesigns and symptoms of carotid artery dis-section may be delayed for up to six days afterinjury.3 We report a case of carotid artery dis-section in a previously healthy man who wasinvolved in a high-velocity motor vehicle acci-dent and developed a dense left-sidedhemiparesis.
Case reportA 30-year-old right-handed foreign national,who did not speak English, was involved in ahigh-impact road traffic accident. He was therestrained driver of a car in a head-on colli-sion with another car, requiring extractionfrom the scene by the emergency services.There was no loss of consciousness and hewas assessed and resuscitated according toadvanced trauma life support protocols.4 Hisinjuries included right-sided rib fractures withunderlying lung contusion, a left-sidedpneumothorax requiring insertion of a thora-costomy tube, an open right femoral fracture,a closed right fracture of the femoral neck,and a left diaphyseal femoral fracture (Fig. 1).He did not have early CT imaging of his headas there was no neurological deficit. He
underwent fixation of both femora withineight hours of injury with left cephalomedul-lary nailing on the left and retrogradeintramedullary nailing on the right (Fig. 2).
Six hours post-operatively it was noted thathe had a complete left-sided hemiparesis andleft-sided facial weakness. Blood testsrevealed anaemia with a haemoglobin con-centration 8.7 g/dl, and slight hyponatraemiawith a sodium 131 mmol/1. Electrocardiogra-phy showed a normal sinus rhythm with nopost-operative changes, and arterial bloodgases were normal. A CT scan of the brainshowed wedge-shaped infarcts in the rightfrontal and parietal lobes (Fig. 3) and furtherscans at five days showed more pronounced,multiple low-density areas in the watershedareas in the right frontal and parietal lobes.
Transthoracic echocardiography showedan atrial septal defect with normal left andright ventricular size and function. A para-doxical fat embolus was postulated at thisstage, and transoesophageal echocardiogra-phy revealed a large patent foramen ovalewith evidence of a left-to-right shunt but noright-to-left shunt, thus making a paradoxicalembolus unlikely.
Subsequent CT angiography of the vascula-ture neck showed occlusion of the right inter-nal carotid artery 1.5 cm from its origin(Fig. 4). The left internal carotid and bothcommon carotid arteries were normal. Basedon these findings, the patient was diagnosedas having carotid artery dissection. He was
DELAYED PRESENTATION OF CAROTID ARTERY DISSECTION FOLLOWING MAJOR ORTHOPAEDIC TRAUMA 537
VOL. 91-B, No. 4, APRIL 2009
treated with warfarin (dosage adjusted to maintain aninternational normalised ratio between 2.0 and 3.0), butthree months later there was no evidence of improvementof the left hemiparesis. However, at nine months he hadrecovered enough to walk independently.
DiscussionCarotid artery dissection following a road traffic accident israre and difficult to diagnose as symptoms can be delayed.It occurs when a small tear forms in the tunica intima,enabling blood to enter the vessel wall, raising the intimaand causing stenosis. This in turn leads to a thrombus,which can occlude the vessel with haemodynamic compro-mise,5 or produce effects via an embolic mechanism.6 One
proposed mechanism of injury to the internal carotid arteryis rapid deceleration, with resultant hyperextension androtation of the neck which stretches the artery over theupper cervical vertebrae, producing an intimal tear.7
Another proposed mechanism of injury is direct trauma.2
The increased use of shoulder-strap seatbelts due tostatutory requirement may be producing a changing pat-tern of injury. Prior to 1980 only 96 cases of blunt traumato the carotid artery were reported; however, there arenow a total of 480 reported cases in the literature, with242 during the last five years.2,8
The patient who we describe was driving a right-hand-drive car, with the strap passing across his right shoulder, andthe injury was to his right internal carotid artery, in keeping
Fig. 1b
Pre-operative anteroposterior radiographs showing a) the pelvis and b) both femora.
Fig. 1a
Fig. 2b
Post-operative anteroposterior radiographs showing a) the pelvis and b) both femora.
Fig. 2a
538 S. P. EDMUNDSON, K. M. HIRPARA, R. S. RYAN, T. O’MALLEY, P. O’GRADY
THE JOURNAL OF BONE AND JOINT SURGERY
with this theory. Four previous case reports have showncarotid artery dissection on the same side as the seatbelt,assuming the cars being driven were not imported.9-12 Othercase reports have been of bilateral carotid artery dissectionfollowing a road traffic accident, but the brain ischaemia wasonly found on the same side as the seatbelt.13,14
This injury can be asymptomatic and may go undiag-nosed. It may present with ipsilateral headache, neck pain,transient episodic blindness, ptosis with miosis, neckswelling, a reduction in the sensation of taste, pulsatiletinnitus, and focal weakness.15 Physical signs are impor-tant, as a detailed history is often difficult following high-velocity trauma. These include focal neurological deficit,hemiparesis, partial Horner’s syndrome, cranial nervepalsy, cervical bruit, haematoma formation in the neckand massive epistaxis.9,15 Mortality from blunt carotidinjury is between 20% and 40%, and permanent neuro-logical deficit is seen in 40% to 80% of cases.16,17
Angiography remains the standard for identification ofcarotid injuries but carries risks, including bleeding, con-trast nephropathy, embolus, and further vascular injury.18
Magnetic resonance angiography, duplex ultrasoundscanning and CT angiography are other less invasive tech-niques may be used.19-21 The advantage of CT angiogra-phy as used in this case is that it is readily available and isnot operator dependent.22
There is a wide differential diagnosis for patients present-ing with stroke following acute trauma (Table I). Embolioriginating in the heart should be considered, and
paradoxical embolism is possible if the patient has a con-genital heart defect.23 Thromboemboli may develop in the
Fig. 3
Selected axial image from a non-contrast CT scan of the brain one dayafter injury showing wedge-shaped areas of low density in the rightinternal carotid vascular territory, in keeping with established foci ofinfarction.
Fig. 4b
CT angiogram at 14 days post injury showing a) occlusion of the rightinternal carotid artery approximately 1.5 cm from the carotid bifurcation(arrow), and b) a patent left internal carotid artery with an absent contral-ateral right internal carotid artery at the same coronal level.
Fig. 4a
Table I. Differential diagnosis for delayed-onset hemiparesisfollowing trauma
DELAYED PRESENTATION OF CAROTID ARTERY DISSECTION FOLLOWING MAJOR ORTHOPAEDIC TRAUMA 539
VOL. 91-B, No. 4, APRIL 2009
post-operative period, and fat emboli may be produced as aresult of long bone fractures and intramedullary nailing.24
Diagnosis in this case could have been delayed owing tothe difficulty of assessing a multiply injured patient whospoke no English.
This case highlights the serious consequence of carotidartery dissection following a high-velocity vehicularaccident.
No benefits in any form have been received or will be received from a commer-cial party related directly or indirectly to the subject of this article.
References1. Davis JW, Holbrook TL, Hoyt DB, et al. Blunt carotid artery dissection: incidence,
associated injuries, screening, and treatment. J Trauma 1990;30:1514-17.2. Fabian TC, Patton JH Jr, Croce MA, et al. Blunt carotid injury: importance of early
diagnosis and anticoagulant therapy. Ann Surg 1996;223:513-22.3. Srinivasan J, Newell DW, Sturzenegger M, Mayberg MR, Winn HR. Transcra-
nial Doppler in the evaluation of internal carotid artery dissection. Stroke1996;27:1226-30.
4. No authors listed. Advanced trauma life support for doctors: student course man-ual. Seventh edition. Chicago: American College of Surgeons, 2004.
5. Weiller C, Mullges W, Ringelstein EB, Buell U, Reiche W. Patterns of braininfarctions in internal carotid artery dissections. Neurosurg 1991;14:111-13.
6. Steinke W, Schwartz A, Hennerici M. Topography of cerebral infarction associ-ated with carotid artery dissection. J Neurol 1996;243:323-8.
7. Zelenock GB, Kazmers A, Whitehouse WM Jr, et al. Extracranial internal carotidartery dissections: noniatrogenic traumatic lesions. Arch Surg 1982;117:425-32.
8. Fabian TC, George SM Jr, Croce MA, et al. Carotid artery trauma: managementbased on mechanism of injury. J Trauma 1990;30:953-61.
9. Bell RL, Atweh N, Ivy ME, Possenti P. Traumatic and iatrogenic Horner syndrome:case reports and review of the literature. J Trauma 2001;51:400-4.
10. Babovic S, Zietlow SP, Garrity JA, et al. Traumatic carotid artery dissectioncausing blindness. Mayo Clin Proc 2000;75:296-8.
11. Mason DP, Orgill DP, Schoen FJ, Rizzo RJ. Traumatic carotid artery dissectionof restrained driver and thoracic aorta transection of unrestrained passenger in amotor vehicle accident: case report. J Trauma 1997;43:537-40.
12. Reddy K, Furer M, West M, Hamonic M. Carotid artery dissection secondary toseatbelt trauma: case report. J Trauma 1990;30:630-3.
13. Janjua KJ, Goswami V, Sagar G. Whiplash injury associated with acute bilateralinternal carotid arterial dissection. J Trauma 1996;40:456-8.
14. Duncan MA, Dowd N, Rawluk D, Cunningham AJ. Traumatic bilateral internalcarotid artery dissection following airbag deployment in a patient with fibromuscu-lar dysplasia. Br J Anaesth 2000;85:476-8.
15. Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection: clinical fea-tures, risk factors, therapy and outcome in 126 patients. J Neurol 2003;250:1179-84.
16. Perry MO, Snyder WH, Thal ER. Carotid artery injuries caused by blunt trauma.Ann Surg 1980;192:74-7.
17. Krajewski LP, Hertzner NR. Blunt carotid artery trauma: report of two cases andreview of the literature. Ann Surg 1980;191:341-6.
18. Miller PR, Fabian TC, Bee TK, et al. Blunt cerebrovascular injuries: diagnosisand treatment. J Trauma 2001;51:279-85.
19. Sturzenegger M. Ultrasound findings in spontaneous carotid artery dissection:the value of duplex sonography. Arch Neurol 1991;48:1057-63.
20. Paciaroni M, Caso V, Agnelli G. Magnetic resonance imaging, magnetic reso-nance and catheter angiography for diagnosis of certical artery dissection. FrontNeurol Neurosci 2005;20:102-18.
21. Leclere X, Godefroy O, Salhi A, et al. Helical CT for the diagnosis of extracranialinternal carotid artery dissection. Stroke 1996;27:461-6.
22. Mead CE, Lewis SC, Wardlaw JM. Variability in Doppler ultrasound influencesreferral of patients for carotid surgery. Eur J Ultrasound 2000;12:137-43.
23. Kallina IVC, Probe R. Paradoxical fat embolism after intramedullary rodding: acase report. J Orthop Res 2001;15:442-5.
24. Pape HC, Giannoudis P. The biological and physiological effects of intramedul-lary reaming. J Bone Joint Surg [Br] 2007;89-B:1421-6.
