Delayed presentation of carotid artery dissection following major orthopaedic trauma resulting in dense hemiparesis

S. P. Edmundson, K. M. Hirpara, R. S. Ryan, T. O'Malley, P. O'Grady
2009 Journal of Bone and Joint Surgery  
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
more » ... ection. 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 blunt injury is a significant cause of morbidity in all age groups. It can occur spontaneously or following major trauma, but a high level of awareness is required to make this difficult diagnosis. Only 0.08% to 0.67% of patients admitted to hospital after a road traffic accident have blunt carotid injury; 1,2 however, the signs and symptoms of carotid artery dissection may be delayed for up to six days after injury. 3 We report a case of carotid artery dissection in a previously healthy man who was involved in a high-velocity motor vehicle accident and developed a dense left-sided hemiparesis. Case report A 30-year-old right-handed foreign national, who did not speak English, was involved in a high-impact road traffic accident. He was the restrained driver of a car in a head-on collision with another car, requiring extraction from the scene by the emergency services. There was no loss of consciousness and he was assessed and resuscitated according to advanced trauma life support protocols. 4 His injuries included right-sided rib fractures with underlying lung contusion, a left-sided pneumothorax requiring insertion of a thoracostomy 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 head as there was no neurological deficit. He underwent fixation of both femora within eight hours of injury with left cephalomedullary nailing on the left and retrograde intramedullary nailing on the right (Fig. 2) . Six hours post-operatively it was noted that he had a complete left-sided hemiparesis and left-sided facial weakness. Blood tests revealed anaemia with a haemoglobin concentration 8.7 g/dl, and slight hyponatraemia with a sodium 131 mmol/1. Electrocardiography showed a normal sinus rhythm with no post-operative changes, and arterial blood gases were normal. A CT scan of the brain showed wedge-shaped infarcts in the right frontal and parietal lobes (Fig. 3) and further scans at five days showed more pronounced, multiple low-density areas in the watershed areas in the right frontal and parietal lobes. Transthoracic echocardiography showed an atrial septal defect with normal left and right ventricular size and function. A paradoxical fat embolus was postulated at this stage, and transoesophageal echocardiography revealed a large patent foramen ovale with evidence of a left-to-right shunt but no right-to-left shunt, thus making a paradoxical embolus unlikely. Subsequent CT angiography of the vasculature neck showed occlusion of the right internal carotid artery 1.5 cm from its origin (Fig. 4) . The left internal carotid and both common carotid arteries were normal. Based on these findings, the patient was diagnosed as having carotid artery dissection. He was
doi:10.1302/0301-620x.91b4.22008 pmid:19336818 fatcat:rpnpu3mf4zd5hpx7lhgdtrrl7q