Interventional radiologyCase Type
Matea Prenc MD, Vedran Župančić MD, Vladimir Kalousek MDPatient
32 years, female
A 32-year-old female patient presents to the emergency department after suffering head injury from accident in which she has fallen from tractor. There were no signs of neurological damage on physical examination and conventional radiography of the skull showed no distinct pathology. Patient was discharged home and after two hours developed right-sided hemiparesis and ptosis.
Non-enhanced CT (NECT) of the brain showed fracture of the left temporal bone (Fig. 1) and dislocations of both temporomandibular joints (Fig. 2). Left middle cerebral artery (MCA) was hyperdense suggesting thrombus within lumen of the artery (Fig. 3). In suspicion of ischemic stroke CT-angiography (CTA) was indicated and it showed dissection of the cervical (C1) segment of the left internal carotid artery (ICA) and occlusion of the sphenoidal (M1) segment of the left MCA (Fig. 4). The described pathology was confirmed on digital subtraction angiography (DSA) (Fig. 5) followed by mechanical thrombectomy. Using stent retrievers and catheters complete perfusion (TICI 3 grade) was achieved and stent was implanted in the left ICA, on the site of the underlying dissection (Fig 6). Follow-up NECT 24 hours after procedure shows sharply demarcated ischemic zone in left basal ganglia (Fig. 7).
Artery dissection is a tear in the intimal layer of the vessel with formation of intramural hematoma. It can occur spontaneously or after traumatic event . Most dissections of the carotid artery are spontaneous and idiopathic. This type of dissection is usually seen in older patients. Severe trauma is responsible for 4% of dissections and up to 20% of the strokes in younger age group are caused by traumatic carotid artery dissection (TCAD) [2,3] . Ischemia may develop as a result of stenosis by an intramural hematoma with consequent reduction of cerebral blood flow. Another important mechanism of ischemic event is distal migration of thrombus that formed at the site of dissection and eventually caused arterial occlusion  , what was seen in our patient.
TCAD is very rare and often overlooked injury as only in 10% of cases symptoms are manifested instantly. Within the first 24 hours after trauma most patients develop symptoms that in 80% of cases evolve into clinical signs of ischemic stroke within the first week with a mortality rate approaching 40%. This latent period between traumatic event and onset of symptoms is pathognomonic for TCAD. Classic triad of symptoms besides signs of ischemic stroke includes Hörner syndrome and unilateral head and/or neck pain. Clinical presentation, however, depends on the site of dissection so intracranial carotid dissection presents with headache due to subarachnoid haemorrhage while extracranial dissection shows signs of ischemic stroke as a consequence of thromboembolic event .
There are several imaging modalities when neurological deficit develops unexpectedly after trauma and TCAD is suspected. Computed tomography combined with CTA is suitable considering ability of method to detect possible concomitant injuries together with 97% sensitivity in identifying dissection . The most reliable signs on CTA are narrowed eccentric arterial lumen and mural thickening that usually affect mobile segments of carotid artery 2-3 cm distal to the carotid bulb with dissection ending at the base of the skull. DSA besides being golden standard in diagnosing dissection allows further endovascular intervention when needed. Other non-invasive methods such as MR and MR-angiography have similar sensitivity but are not widely accepted as emergency modalities .
Treatment of TCAD remains a controversial issue demanding multidisciplinary approach. Besides conservative approach with antithrombotic medicines, which is still golden standard, continuous advances in endovascular intervention also permit safe and effective stenting or stent supported angioplasty in neurologically impaired patients with promising results.
Teaching Points: traumatic artery dissection should always be considered in traumatized patients with neurological impairment .
Written informed patient consent for publication has been obtained.
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