ILLUSTRATIVE CASE
Blunt Intraoral Trauma Resulting in Internal Carotid Artery Dissection and Infarction in a Child Chris Bent, MD,* Peter Shen, MD,* Brian Dahlin, MD,* and Kevin Coulter, MD† Abstract: A 16-month-old child fell forward onto her toothbrush sustaining minor oropharyngeal injury. The following day, she became acutely lethargic with localizing neurologic signs of a cerebrovascular infarct. CTA and MR imaging demonstrated occlusion of the right internal carotid artery with a large right middle cerebral artery territory infarction. She was treated with decompressive craniectomy and anticoagulation but remained weak on the left side. Pediatric oropharyngeal injuries can rarely be complicated by internal carotid artery injury with dissection, thrombosis, or embolization to the cerebral circulation. For the best outcome, carotid dissection treatment requires prompt diagnosis at the initial onset of neurologic symptoms. However, further research is needed to determine the best management and advanced imaging work-up for neurologically intact children. Key Words: stroke, carotid dissection, oropharyngeal trauma, infarct (Pediatr Emer Care 2015;00: 00–00)
CASE A 16-month-old girl was brushing her teeth when her brother knocked her down while playing, causing her to fall with the toothbrush in her mouth. Per her father, she initially had minimal intraoral bleeding which quickly resolved. The next afternoon, approximately 16 hours later, she vomited. At approximately 22 hours post event, the patient was found lethargic. She was immediately taken to a community ED before transferring to the university medical center. At time of transfer, she was moving all 4 extremities with diminished left extremity movement, had dysconjugate gaze, and fluctuating mental status (GCS 10–12). Head computed tomography (CT) (Fig. 1A) showed large right middle cerebral artery (MCA) territory infarction with midline shift. Hypertonic saline to decrease intracranial pressure and Keppra (levetiracetam) for seizure prophylaxis were started. CT angiography of the neck identified complete occlusion of the proximal right internal carotid artery consistent with traumatic dissection and thrombosis (Fig. 2A). Because carotid dissection uncommonly occurs in the pediatric population, the patient was initially evaluated for nonaccidental trauma. A small abrasion was noted above her left eyelid but there were no other signs or history to suggest nonaccidental trauma. Now, approximately 28 hours after the event, the patient became acutely nonresponsive, unable to protect her airway. She was intubated and taken for decompressive craniectomy. Postoperative oropharyngeal evaluation by otolaryngology confirmed a mild 2.5-cm ecchymosis along the right posterior pharyngeal wall and the superior pole of the right tonsil. Postoperative MRI (Figs. 1B and 2B) redemonstrated the MCA infarct with improved midline shift. Anticoagulation for the dissection was initiated. Cardiac and hypercoagulable etiologies for carotid occlusion were negative. Given the lack of supporting evidence, nonaccidental trauma From the *Departments of Radiology and † Pediatrics, University of California Davis, Sacramento, CA. Disclosure: The authors declare no conflict of interest. Reprints: Chris Bent, MD, 4860 Y Street, Suite 3100, Sacramento, CA 95817 (e‐mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
was excluded. Four months after the event, patient is ageappropriate, responding to name and simple commands, and able to walk with some difficulty. On examination, she exhibits 4/5 motor weakness in the left upper and lower extremities.
DISCUSSION Young children often transport objects in their mouths and if they are pushed or fall, as in our case, the object can be driven posteriorly injuring the palate or oropharynx. Most common injuries are minor even in the event of penetrating trauma. A case series of over 130 pediatric palatal traumas found no patients with neurologic sequel.1 Most carotid artery dissections in the presence of blunt trauma usually occur at the skull base secondary to fracture. Pediatric oropharyngeal injury causing carotid dissection is a rare occurrence and only reported in 50 instances within the English literature.2,3 The average pediatric age at presentation is 7 years old with the vast majority of patients presenting with a normal lucid interval of 12 hours to several weeks before onset of neurologic symptoms. Of these cases, only 9, including this case, are the result of intraoral trauma.2,3 Our patient is the youngest at 16 months of age with the second youngest at 22 months of age who injured his left tonsil with a toy arrow.3 Given our patient's mechanism of injury, the oropharyngeal blunt trauma most likely caused an intimal tear/dissection of the internal carotid followed by occlusive thrombosis (Fig. 2A). Propagation of the clot subsequently occurred to the MCA explaining the increased density in the MCA on CT and loss of flow-related contrast on MRA (Fig. 2B). As most children are thought to be able to tolerate unilateral internal carotid occlusion due to an intact circle of Willis,4 this delayed thrombus formation and extension to the intracranial vasculature likely explains the latency in the onset of neurologic symptoms. Given that the reported incidence of stroke from intraoral trauma is extremely small, less than 1%,5,6 the immediate role for advanced imaging in neurologically intact children is unclear. In the past, the work-up for traumatic carotid injury has been varied including carotid Doppler sonography, CT angiography, MR
FIGURE 1. Large right middle cerebral territory infarct. (A) Initial presenting noncontrast head CT. (B) Diffusion weighted sequence magnetic residence imaging after decompression craniotomy. White arrowheads demonstrate extent of acute large right middle cerebral artery infarct. www.pec-online.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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Bent et al
led to additional surgical or medical therapy.7 This has led to the recent suggestion that the long-term risks of CT radiationinduced malignancy may outweigh the potential stroke risk in neurologically intact children.6 Although MR angiography could be an alternative without radiation risk, its lack of universal emergent availability, its need for general anesthesia for uncooperative pediatric patients, and relatively high cost make MRA usage difficult in the emergent setting. Current recommendations for advanced imaging are reserved for patients with large intraoral laceration, persistent bleeding, expanding hematoma, and neurologic deficits.5–7 In the absence of these symptoms, close neurologic monitoring and caregiver awareness is paramount as a “lucid interval” of 3 to 60 hours is common before a cerebrovascular event,7 as typified by our reported case. Current pediatric recommendations for carotid artery dissection is systemic anticoagulation bridging to long-term anticoagulation or antiplatelet therapy with surgical and endovascular treatments reserved for those who have failed medical therapy.8 REFERENCES 1. Hellmann JR, Shott SR, Gootee MJ. Impalement injuries of the palate in children: Review of 131 cases. Int J Pediatr Otorhinolaryngol. 1993;26:157. 2. Chamoun RB, Mawad ME, Whitehead WE, et al. Extracranial traumatic carotid artery dissections in children: a review of current diagnosis and treatment options. J Neurosurg Pediatr. 2008;2:101–108. 3. Pitner SE. Carotid thrombosis due to intraoral trauma: an usual complication of a common childhood accident. N Engl J Med. 1966;774:764. 4. Alpers BJ, Berry RG, Paddison RM. Anatomical studies of the circle of Willis in normal brain. Arch Neurol Psychiatry. 1959;81:409.
FIGURE 2. Right internal carotid dissection with right middle cerebral artery occlusion. (A) CT neck angiogram multiplanar reformatted image demonstrates an occlusive “flame-shaped” internal carotid artery dissection (arrow) just distal to the carotid bulb. (B) Magnetic resonance angiogram of the head demonstrates propagation of thrombus from the occluded right internal carotid artery (white arrowheads) into the right middle cerebral artery (black arrowheads). 2,3
angiography, or selective carotid angiography. A retrospective review of 90 lucid patients who underwent CT angiography after penetrating intraoral trauma found that 10% had suspected vascular injury; however, all remained neurologically intact, and none
2
www.pec-online.com
5. Hennelly KE, Fine AM, Jones DT, et al. Risks of radiation versus risks from injury: a clinical decision analysis for the management of penetrating palatal trauma in children. Laryngyscope. 2013;123:1279–1284. 6. Randall DA, Kang DR. Current management of penetrating injuries of the soft palate. Otolaryngol Head Neck Surg. 2006;135:356–360. 7. Hennelly K, Kimia A, Lee L, et al. Incidence of morbidity from penetrating palate trauma. Pediatrics. 2010;126:e1578–e1584. 8. Roach ES, Golomb MR, Adams R, et al.; American Heart Association Stroke Council, Council on Cardiovascular Disease in the Young. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39: 2644–2691.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Blunt Intraoral Trauma Resulting in Internal Carotid Artery Dissection and Infarction in a Child Chris Bent, MD,* Peter Shen, MD,* Brian Dahlin, MD,* and Kevin Coulter, MD† Abstract: A 16-month-old child fell forward onto her toothbrush sustaining minor oropharyngeal injury. The following day, she became acutely lethargic with localizing neurologic signs of a cerebrovascular infarct. CTA and MR imaging demonstrated occlusion of the right internal carotid artery with a large right middle cerebral artery territory infarction. She was treated with decompressive craniectomy and anticoagulation but remained weak on the left side. Pediatric oropharyngeal injuries can rarely be complicated by internal carotid artery injury with dissection, thrombosis, or embolization to the cerebral circulation. For the best outcome, carotid dissection treatment requires prompt diagnosis at the initial onset of neurologic symptoms. However, further research is needed to determine the best management and advanced imaging work-up for neurologically intact children. Key Words: stroke, carotid dissection, oropharyngeal trauma, infarct (Pediatr Emer Care 2015;00: 00–00)
CASE A 16-month-old girl was brushing her teeth when her brother knocked her down while playing, causing her to fall with the toothbrush in her mouth. Per her father, she initially had minimal intraoral bleeding which quickly resolved. The next afternoon, approximately 16 hours later, she vomited. At approximately 22 hours post event, the patient was found lethargic. She was immediately taken to a community ED before transferring to the university medical center. At time of transfer, she was moving all 4 extremities with diminished left extremity movement, had dysconjugate gaze, and fluctuating mental status (GCS 10–12). Head computed tomography (CT) (Fig. 1A) showed large right middle cerebral artery (MCA) territory infarction with midline shift. Hypertonic saline to decrease intracranial pressure and Keppra (levetiracetam) for seizure prophylaxis were started. CT angiography of the neck identified complete occlusion of the proximal right internal carotid artery consistent with traumatic dissection and thrombosis (Fig. 2A). Because carotid dissection uncommonly occurs in the pediatric population, the patient was initially evaluated for nonaccidental trauma. A small abrasion was noted above her left eyelid but there were no other signs or history to suggest nonaccidental trauma. Now, approximately 28 hours after the event, the patient became acutely nonresponsive, unable to protect her airway. She was intubated and taken for decompressive craniectomy. Postoperative oropharyngeal evaluation by otolaryngology confirmed a mild 2.5-cm ecchymosis along the right posterior pharyngeal wall and the superior pole of the right tonsil. Postoperative MRI (Figs. 1B and 2B) redemonstrated the MCA infarct with improved midline shift. Anticoagulation for the dissection was initiated. Cardiac and hypercoagulable etiologies for carotid occlusion were negative. Given the lack of supporting evidence, nonaccidental trauma From the *Departments of Radiology and † Pediatrics, University of California Davis, Sacramento, CA. Disclosure: The authors declare no conflict of interest. Reprints: Chris Bent, MD, 4860 Y Street, Suite 3100, Sacramento, CA 95817 (e‐mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
was excluded. Four months after the event, patient is ageappropriate, responding to name and simple commands, and able to walk with some difficulty. On examination, she exhibits 4/5 motor weakness in the left upper and lower extremities.
DISCUSSION Young children often transport objects in their mouths and if they are pushed or fall, as in our case, the object can be driven posteriorly injuring the palate or oropharynx. Most common injuries are minor even in the event of penetrating trauma. A case series of over 130 pediatric palatal traumas found no patients with neurologic sequel.1 Most carotid artery dissections in the presence of blunt trauma usually occur at the skull base secondary to fracture. Pediatric oropharyngeal injury causing carotid dissection is a rare occurrence and only reported in 50 instances within the English literature.2,3 The average pediatric age at presentation is 7 years old with the vast majority of patients presenting with a normal lucid interval of 12 hours to several weeks before onset of neurologic symptoms. Of these cases, only 9, including this case, are the result of intraoral trauma.2,3 Our patient is the youngest at 16 months of age with the second youngest at 22 months of age who injured his left tonsil with a toy arrow.3 Given our patient's mechanism of injury, the oropharyngeal blunt trauma most likely caused an intimal tear/dissection of the internal carotid followed by occlusive thrombosis (Fig. 2A). Propagation of the clot subsequently occurred to the MCA explaining the increased density in the MCA on CT and loss of flow-related contrast on MRA (Fig. 2B). As most children are thought to be able to tolerate unilateral internal carotid occlusion due to an intact circle of Willis,4 this delayed thrombus formation and extension to the intracranial vasculature likely explains the latency in the onset of neurologic symptoms. Given that the reported incidence of stroke from intraoral trauma is extremely small, less than 1%,5,6 the immediate role for advanced imaging in neurologically intact children is unclear. In the past, the work-up for traumatic carotid injury has been varied including carotid Doppler sonography, CT angiography, MR
FIGURE 1. Large right middle cerebral territory infarct. (A) Initial presenting noncontrast head CT. (B) Diffusion weighted sequence magnetic residence imaging after decompression craniotomy. White arrowheads demonstrate extent of acute large right middle cerebral artery infarct. www.pec-online.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1
Pediatric Emergency Care • Volume 00, Number 00, Month 2015
Bent et al
led to additional surgical or medical therapy.7 This has led to the recent suggestion that the long-term risks of CT radiationinduced malignancy may outweigh the potential stroke risk in neurologically intact children.6 Although MR angiography could be an alternative without radiation risk, its lack of universal emergent availability, its need for general anesthesia for uncooperative pediatric patients, and relatively high cost make MRA usage difficult in the emergent setting. Current recommendations for advanced imaging are reserved for patients with large intraoral laceration, persistent bleeding, expanding hematoma, and neurologic deficits.5–7 In the absence of these symptoms, close neurologic monitoring and caregiver awareness is paramount as a “lucid interval” of 3 to 60 hours is common before a cerebrovascular event,7 as typified by our reported case. Current pediatric recommendations for carotid artery dissection is systemic anticoagulation bridging to long-term anticoagulation or antiplatelet therapy with surgical and endovascular treatments reserved for those who have failed medical therapy.8 REFERENCES 1. Hellmann JR, Shott SR, Gootee MJ. Impalement injuries of the palate in children: Review of 131 cases. Int J Pediatr Otorhinolaryngol. 1993;26:157. 2. Chamoun RB, Mawad ME, Whitehead WE, et al. Extracranial traumatic carotid artery dissections in children: a review of current diagnosis and treatment options. J Neurosurg Pediatr. 2008;2:101–108. 3. Pitner SE. Carotid thrombosis due to intraoral trauma: an usual complication of a common childhood accident. N Engl J Med. 1966;774:764. 4. Alpers BJ, Berry RG, Paddison RM. Anatomical studies of the circle of Willis in normal brain. Arch Neurol Psychiatry. 1959;81:409.
FIGURE 2. Right internal carotid dissection with right middle cerebral artery occlusion. (A) CT neck angiogram multiplanar reformatted image demonstrates an occlusive “flame-shaped” internal carotid artery dissection (arrow) just distal to the carotid bulb. (B) Magnetic resonance angiogram of the head demonstrates propagation of thrombus from the occluded right internal carotid artery (white arrowheads) into the right middle cerebral artery (black arrowheads). 2,3
angiography, or selective carotid angiography. A retrospective review of 90 lucid patients who underwent CT angiography after penetrating intraoral trauma found that 10% had suspected vascular injury; however, all remained neurologically intact, and none
2
www.pec-online.com
5. Hennelly KE, Fine AM, Jones DT, et al. Risks of radiation versus risks from injury: a clinical decision analysis for the management of penetrating palatal trauma in children. Laryngyscope. 2013;123:1279–1284. 6. Randall DA, Kang DR. Current management of penetrating injuries of the soft palate. Otolaryngol Head Neck Surg. 2006;135:356–360. 7. Hennelly K, Kimia A, Lee L, et al. Incidence of morbidity from penetrating palate trauma. Pediatrics. 2010;126:e1578–e1584. 8. Roach ES, Golomb MR, Adams R, et al.; American Heart Association Stroke Council, Council on Cardiovascular Disease in the Young. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39: 2644–2691.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
