Common Carotid Artery Occlusion in a Soccer Player

Abstract

HISTROTY: This patient is an 18 year old female who developed mid-stride syncope while running during soccer try outs for a division one collegiate soccer team. She had no history of exercise induced syncope, although she had reported vasovagal events related to blood draws in the past. The patient had a history of overwhelming life-threatening GBS sepsis as a neonate requiring Extracorporeal Membrane Oxygenation (ECMO), with subsequent carotid artery surgery. The episode of syncope was classic and the patient had full recovery within seconds with no sequelae or traumatic injury. She was evaluated at a local emergency room where she had a normal ECG. The patient was instructed not to return to play until she has been evaluated by the Team Physician who performed the physical examination below. PHYSICAL EXAMINATION: Normal exam save two pertinent positives: Grade II/VI systolic ejection murmur heard best at the base of the heart. Absence of carotid pulse on the right. DIFFERENTIAL DIAGNOSIS: Cardiac Arrhythmia Hypertrophic Cardiomyopathy Vasovagal Syncope Anomalous Coronary Artery Orthostatic Hypotension Neurologic etiologies including atypical seizure and transient ischemic attack. TEST: MRI Brain: Normal MRA neck: There is a total occlusion of the right common carotid artery near its origin. The entire right internal carotid artery is patent, although markedly decreased in diameter. Likely, it is supplied by a retrograde filling of the external carotid artery from the thyrocervical trunk collaterals. Neurology Consultation: No relationship between the patient's common carotid occlusion and syncope. ECG: Normal Cardiac Echo: Normal stress echo: Bruce protocol, 10 minutes with no symptoms, no ECG changes and no evidence of cardiomyopathy or valvular disease. Cardiology Consultation: Exercise-related syncope FINAL/WORKING DIAGNOSIS: Exercise related syncope likely related to dehydration. TREATMENT AND OUTCOMES: This is the first report of right common carotid artery occlusion discovered in a sports medicine evaluation of a syncopal episode, to our knowledge. Comprehensive Cardiac and Neurological evaluation determined that this was unlikely the cause of syncope, and the patient was allowed to return to sports participation without restrictions.