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[Dissection of the internal carotid artery]
Insights
Closed internal carotid artery injuries are rare but serious, often missed in trauma patients. Early surgical intervention significantly improves outcomes, while delayed diagnosis leads to severe complications.
Area of Science:
- Traumatology
- Vascular Surgery
- Neurology
Background:
- Closed internal carotid artery injuries are uncommon, accounting for only 4% of carotid system lesions.
- Diagnosis is challenging due to subtle initial signs often masked by severe polytrauma.
- High mortality and severe sequelae characterize these injuries.
Observation:
- Three drivers involved in road traffic accidents presented with associated bone, abdominal, head, and chest trauma.
- Unilateral mydriasis and fluctuating consciousness levels prompted neurological investigation.
- Computerized axial tomography suggested the injury, confirmed by carotid arteriography.
Findings:
- Early surgical repair in two patients yielded excellent results.
- In non-surgical cases, carotid dissection exacerbated cerebral edema secondary to hemispheric contusion.
- Injury mechanism likely involves neck rotation/flexion, compressing the artery against cervical vertebrae or mandible, potentially exacerbated by seatbelt use.
Implications:
- Emphasizes the need for heightened clinical suspicion for internal carotid artery injury in polytrauma patients.
- Highlights the critical role of early diagnosis and surgical intervention for favorable outcomes.
- Suggests a potential link between seatbelt use and the mechanism of internal carotid artery injury in traffic accidents.
Abstract:
Closed injury of the internal carotid artery is rare, as it represents only 4% of all the lesions affecting the carotid system. Diagnosis of this injury is difficult, the first signs often being missed as they usually occur in severely injured patients, with the neurological signs appearing later. The death rate remains high, and the sequelae very heavy. After a road traffic accident, three patients, all drivers wearing their seat-belts, presented with bone and/or abdominal lesions, a head injury and a left anterolateral flail chest. All three cases showed an unilateral mydriasis; the variations in their conscious levels led to further neurological investigations. The diagnosis was suggested in one patient by computerized axial tomography, and confirmed in all three by carotid arteriography. The results were excellent when early surgery could be performed (2 cases). However, in the absence of surgery, carotid dissection could only be a major contributing factor for the cerebral oedema associated with the previous hemispheric contusion. The mechanism of these carotid injuries would appear to involve rotation and extension or flexion movements of the neck, crushing the internal carotid artery against the transverse processes of the cervical vertebrae or the mandible: a possible part played by the seat-belt would explain the frequent association of the injury with chest trauma.