LESSON OF THE MONTH: Misdiagnosed Post-traumatic Occlusion of the Internal Carotid Artery in a Young Woman

Abstract

Introduction and the right second rib associated with findings indicative of lung contusion in the right upper lobe. Non-penetrating carotid injury occurs in less than 1 There was no evidence of pneumoor haemothorax. of 1000 blunt injuries. Acute occlusion due to disShe was admitted into the surgical ward for obsection of the internal carotid artery (ICA) is the most servation. Twelve hours later the patient developed a common consequence after blunt injury of the neck in left-sided hemiparesis which progressed within 1 h to young individuals without history of atherosclerosis. complete hemiplegia involving both the upper and However, ICA thrombosis after blunt trauma may lower limb and the left side of the face. occur without a preceding dissection. The diagnosis The first brain (CT) scan done half an hour after the of this uncommon entity can be easily missed on initial development of symptoms and signs was normal, examination because early signs and symptoms may whereas a subsequent brain CT scan carried out 4 h be masked by the presence of coexistent brain and later showed a small mildly hypodense area in the spinal injuries. middle-cerebral artery territory of the right hemiWe present a case of a misdiagnosed ICA thrombosis sphere. A diagnosis of brain contusion as a result of after blunt trauma in order to highlight the diagnostic direct injury was made and the patient was treated clues that the practising clinician should bear in mind conservatively with Fraxiparine (nadroparine calcium) and to discuss issues concerning the management of 0.3 ml twice daily, subcutaneously, Tazocin (piperthis entity. acillin 4 g+tazobactam 0.5 g) 4.5 mg 8-hourly, intravenously and Romidon (propoxyphene Hcl) 75 mg 6hourly, intramuscularly. Physiotherapy was initiated the next day and the patient remained stable with no Case Presentation neurological deterioration the following days. By the tenth day she was in good condition, and could slightly A 35-year-old woman sitting in the front passenger move the lower limb. The patient was discharged from seat of a motor vehicle, and wearing a seat-belt with the hospital without any further medication and after a diagonal strap, was involved in a road traffic ac1 month of intense physiotherapy she was able to cident. The patient was transferred to our hospital in bend the knee and to rotate the left lower limb. At a good general condition, fully conscious, haemothat time she was referred to a vascular surgeon. The dynamically stable, having few bruises in the face, the patient’s history and the mechanism of the trauma right temporal area and the right upper chest. X-ray raised the suspicion of a traumatic occlusion of the examination revealed a fracture of the right clavicle internal carotid artery. Thus, the patient was subjected to a brain magnetic resonance imaging (MRI) scan 40 days after the accident, which showed a large infarct ∗ Please address all correspondence to: D. Giannoukas, Division of in the middle cerebral artery territory of the right Vascular Surgery, University Hospital of Heraklion, Heraklion, Crete, Greece. hemisphere (Fig. 1a). A subsequent brain magnetic