Internal Carotid Artery Dissection With Lidocaine Nerve Block During Dental Procedure: A Case Report

Abstract

SESSION TITLE: Nervous System Disorders in the ICU 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Internal carotid artery dissection (ICAD) represents an important cause of cerebrovascular accidents in young and middle-aged patients. In this case report,we aim to describe this rare but potentially life threatening cause of ICA dissection and its unusual presentation. CASE PRESENTATION: 58year old female presented with severe occipital headache and right sided neck pain associated with nausea and lethargy from one week.Denied any head or neck trauma.On examination patient had constricted pupil and ptosis affecting right eye with a blood pressure of 206/98 mmhg and heart rate 59/min. Symptoms started immediately after receiving 2% lidocaine injection for pulpotomy of upper right second bicuspid tooth which was followed by incision and drainage completed later for the dental abscess. Computed tomography angiography revealed right ICA dissection at level of C1-C2 associated with infiltrative changes within carotid space and retropharyngeal space without abscess. Intravenous heparin was started and blood pressure was lowered over 25% every day. Heparin was continued for three days and later switched to xarelto. During the course of hospitalization miosis and ptosis improved and patient discharged home on xarelto. DISCUSSION: ICAD was first recognized in 1947,when Dratz published dissection as a complication from direct injection to the carotid artery(1)Typical signs and symptoms includes pain on one side of the head,face or neck accompanied by a partial Horner's syndrome (oculosympathetic palsy- consists of miosis and ptosis)Facial anhidrosis is absent as the facial sweat glands are innervated by the sympathetic plexus surrounding the external carotid artery. A similar case has been reported in literature by Francesco De Santis et al (2) Understanding the pathogenesis we can state that although carotid artery is anatomically relatively distant from the anesthetic block target areas but there is always a possibility of a needle insertion more posteriorly and medially.Further,cervical hyperextension during a dental procedure can compress the cervical internal carotid artery against upper cervical vertebra and facilitate the needle reaching submandibular capsule.Periodontal infections associated with secretion of inflammatory cytokines,free radicals and proteases which further lead to vessel wall weakening and increased susceptibility for rupture. CONCLUSIONS: ICAD developing after dental work is a relatively rare scenario and we hope that this case report can help intensivists better recognize this uncommon cause of this life threatening disease. Reference #1: Dratz HMW,Traumatic Dissecting Aneurysm of Left Internal Carotid, Anterior Cerebral and Middle Cerebral Arteries.Journal of Neuropathology & Experimental Neurology. 1947;6(3):286-291. Reference #2: Francesco De Santiset al:Internal Carotid Artery Dissection After Inferior Alveolar Nerve Block for Third Molar Dental Care Presented as Hypoglossal Nerve Palsy:Vascular and Endovascular Surgery 46(7) DISCLOSURE: The following authors have nothing to disclose: Naureen Narula, Faraz Siddiqui, Michel Chalhoub No Product/Research Disclosure Information