Traumatic dissection of the internal carotid artery at the atlantoxial level, secondary to nonpenetrating injury.

Abstract

THE INTERNAL carotid artery may be occluded intracranially or in the neck following open or closed (penetrating or nonpenetrating) injury to the head, face, or neck. Stenotic and occlusive lesions of the cervical segment of the internal carotid artery caused by penetrating wounds are well known and most commonly sustained in time of war (9, 22). Occasionally they have been reported as a complication of injuries to the fauces and pharynx (14, 23, 29)) following tonsillectomy (4, 2:3) and other surgery to the face and neck. Stenosis and occlusion of the common and internal carotid arteries due to thrombosis and/or mural dissection resulting from arterial needle puncture and, less frequently, from arterial catheterization are also well known. In contrast, lesions of the cervical segments of the carotid arteries resulting from blunt, non penetrating injuries are quite rare. The first such case appears to have been recorded by Verneuil (34) in 1872 and the next report did not appear until 1933 (8). Increasing numbers of reports have appeared since then, as angiography has assumed a progressively greater role in the evaluation of injuries to the head and neck. Yamada et al. (36), in a recent comprehensive review of the subject, however, were able to find only 51 recorded cases of proved occlusion of the cervical portions of the carotid arteries secondary to nonpenetrating injury. To these they added 1 case. The 2 cases presented here, seen within a period of a few months, are reported for the following reasons: the relative rarity of the condition; the fact that carotid injury in the neck from nonpenetrating trauma hasrarely been suspected before diagnosis by angiography, surgery, or autopsy; and the characteristics of the internal carotid lesions demonstrated by angiography in these 2 cases . Also, in the patient in CASE I, there is an apparently unique demonstration of the condition of the internal carotid artery before injury, a few hours after injury, and again four months later. CASE REPORTS CASE 1. : V. D., a 48-year-old femal e, had been admitted to hospital following a subarachnoid hemorrhage. Bilateral carotid angiography revealed multiple aneurysms (left carotid siphon and "trifur-aneurysm, slight red uction in size of the other, and moderate lateral ventricular dilatati on. Eleven months afte r surgery the pati ent was admitted to another hospital a few minutes after being involved in an automobile accident. She had been riding in the right-hand front seat and was found lying under the dashboard. At physical examinati on, she was in coma, with complete flaccidity. There was a 5 em irregular lacera tion of th e forehead, with the face sustaining lesser lacerations which contained glass fragment s. There were also a contusion of the left sternoclav icular region with superior mediastinal effusion and fractures of the left first rib, left wrist , and both tibi al plateaux. The pupils were fixed and unequal, the left larger than the right.