Emerg Radiol DOI 10.1007/s10140-015-1318-5
CASE REPORT
CrossFit-related cervical internal carotid artery dissection Albert Lu 1 & Peter Shen 1 & Paul Lee 1 & Brian Dahlin 1 & Ben Waldau 2 & Anna E. Nidecker 1 & Anoop Nundkumar 1 & Matthew Bobinski 1
Received: 25 February 2015 / Accepted: 9 April 2015 # American Society of Emergency Radiology 2015
Abstract CrossFit is a high-intensity strength and conditioning program that has gained popularity over the past decade. Potential injuries associated with CrossFit training have been suggested in past reports. We report three cases of cervical carotid dissection that are associated with CrossFit workouts. Patient 1 suffered a distal cervical internal carotid artery (ICA) dissection near the skull base and a small infarct in Wernicke’s area. He was placed on anticoagulation and on follow-up has near complete recovery. Patient 2 suffered a proximal cervical ICA dissection that led to arterial occlusion and recurrent middle cerebral artery territory infarcts and significant neurological sequelae. Patient 3 had a skull base ICA dissection that led to a partial Horner’s syndrome but no cerebral infarct. While direct causality cannot be proven, intense CrossFit workouts may have led to the ICA dissections in these patients. Keywords CrossFit . Carotid . Dissection . Stroke
incorporating elements of weightlifting, high-intensity interval training, and gymnastics. In his article Bunderstanding CrossFit,^ the founder describes it as Bconstantly varied, high intensity, functional movement…supportable by measurable facts^ [1]. At this time, CrossFit is practiced by members of over 10,000 affiliated gyms across the USA and all over the world. One of the features that attract people to CrossFit is its emphasis on quantifiable results. A study conducted by Smith et al. found a significant improvement in VO2 max (maximum oxygen consumption) and decreased body fat percentage in CrossFit across all levels of initial fitness [2]. However, the benefits are not without risks. A recent article by Fox and King described a case of carotid dissection that is attributable to an intense CrossFit workout [3]. Other reports have documented cases of rhabdomyolysis after intense CrossFit workouts [4]. We report a series of three cases of cervical internal carotid artery dissection that are associated with CrossFit workouts.
Introduction
Case 1
Since its inception in 1996, CrossFit has gained immense popularity across the world as a competitive fitness sport that promote a varied and high-intensity workout regimen
A young adult male presented to the emergency department (ED) with acute onset of vision changes and speech impairment since earlier that morning. The patient stated that he awoke that morning around 5:15 a.m. and was in his usual state of health. He went to his CrossFit class that morning, where he exercised vigorously with B20 % more weight^ than he had done previously. He did not recall twisting his neck during the exercise but noted that he may have turned it rapidly to one side or the other while lifting weights. While driving home, he noted sudden onset of flashing light in his peripheral vision of both eyes and then a zigzag pattern across his visual field. He was able to drive home without difficulty, and at some point, these visual phenomena ceased.
* Albert Lu [email protected] 1
Department of Radiology, University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA
2
Department of Neurological Surgery, University of California Davis Medical Center, 4860 Y Street, Suite 3740, Sacramento, CA 95817, USA
Emerg Radiol
Later that morning, the patient became alarmed when he could not understand the meaning behind an email he was reading. He also noted that the right half of his visual field appeared blurred. He was concerned about a possible stroke and came in to the ED for evaluation. By the time of evaluation, his symptoms had nearly completely resolved. An MRI of the brain and MRA of the head and neck were obtained, demonstrating a small infarct of the left superior temporal gyrus near Wernicke’s area (Fig. 1). The MRA demonstrated a short segment narrowing in the distal left cervical internal carotid artery just below the skull base, consistent with acute carotid dissection (Fig. 2). The patient was evaluated by neurology and was placed on anticoagulation with Coumadin for 3 months, after which he was transitioned to antiplatelet therapy with aspirin indefinitely. At 1 month follow-up, he had only minimal intermittent word-finding difficulties but is otherwise back to baseline.
Case 2 A young adult female, who exercises regularly with CrossFit, presented to the ED with acute right upper extremity weakness. She awoke the morning of presentation at her normal baseline and went to the gym for her routine CrossFit workout. After her workout, she noticed she was having trouble coordinating her right hand to pick up her keys. She was able to call her husband on the phone, who took her to the ED. Non-contrast CT head obtained upon arrival was normal (not shown). MRI of the brain demonstrated punctate foci of ischemic infarcts in subcortical white matter of the left frontal and parietal lobes, which are consistent with subcortical watershed infarctions (Fig. 3). Intravenous tPA was given. Initially, the patient demonstrated improvement but she subsequently worsened, developing expressive aphasia,
Fig. 1 Coronal DWI demonstrating a small infarct of the left superior temporal gyrus near Wernicke’s area (arrow)
Fig. 2 3D reconstruction of MR angiogram of the circle of Willis demonstrates focal narrowing and luminal irregularity in the distal left cervical internal carotid artery (arrow), consistent with a carotid dissection
difficulty following commands, worsening right upper extremity weakness, and new right lower extremity weakness. CT angiography (CTA) head showed no intracranial arterial occlusion in bilateral MCAs. CTA of the neck showed a possible occlusion of the left cervical internal carotid artery. Digital subtraction angiography confirmed complete occlusion of left ICA just after the carotid bifurcation (Fig. 4). There was collateral flow through the ophthalmic artery and posterior communicating artery (not shown). There was no indication for endovascular intervention since the carotid artery was completely occluded. Medical management was continued, with emphasis on maximizing blood pressure and cerebral perfusion. The patient was managed with anticoagulation and permissive hypertension, using IV fluids and vasopressors to maximize collateral flow to her left cerebral hemisphere and
Fig. 3 Axial DWI demonstrates multiple small foci of infarcts in left frontoparietal subcortical white matter Brosary-like pattern,^ consistent subcortical watershed distribution
Emerg Radiol
Fig. 5 Axial T1 fat-saturated sequence demonstrates hyperintense mural thrombus along the wall of a dissected distal left cervical internal carotid near the skull base (arrow) Fig. 4 Digital subtraction angiogram of left common carotid demonstrates rapid tapering and complete occlusion of the proximal left internal carotid artery just distal to the carotid bifurcation (arrow), consistent with acute dissection
allowing her cerebral collateral flow time to build. Her hospital course was complicated by additional watershed infarcts in the left middle cerebral artery territory. Her symptoms were dependent on vertical activity; therefore, she was placed on bedrest. After several weeks of stay at the hospital, she was transferred to rehabilitation and eventually home on bedrest with gradual increase in daily vertical time. One month after discharge, she was able to walk with a cane, had mild right hand weakness, but intact speech.
Case 3 The patient was a middle-aged male who exercises regularly and partakes in CrossFit workouts, including an exercise that requires twisting of his body and throwing a weighted ball. On the day of presentation, he was in his usual state of health when his wife noticed anisocoria and left-sided ptosis. The patient himself noticed miosis of the left pupil. The patient was otherwise neurologically intact without additional neurological deficit. Upon further questioning, the patient denied any focal trauma or neck pain. Urgent MRI of the brain and MRA of the head and neck were obtained and demonstrated a small acute dissection of the distal left cervical internal carotid artery at the skull base, as evidenced by the presence of a Bcrescent sign^ indicating a mural thrombus (Fig. 5) [5]. There was no evidence of ischemic infarct on DWI. CT angiography confirmed a small pseudoaneurysm of the left distal internal carotid artery (Fig. 6). The patient was placed on oral aspirin 325 mg daily for thromboembolic prophylaxis.
Repeat MRI and MRA 6 months later, after abstinence from rigorous exercise including CrossFit, showed resolution of the small left internal carotid dissection and pseudoaneurysm. His Horner’s symptoms had also resolved.
Discussion Critics have pointed out the danger of CrossFit’s emphasis on speed and high-intensity movements and lack of proper guidance on technique [4]. The constant push to increase performance with faster speed and more weights can be especially dangerous. Our first patient reported pushing himself with B20 % more weight^ in his workout the morning of his presentation with carotid dissection and ischemic infarct. It is conceivable that the emphasis on increased weight and speed may lead to further degradation in exercise technique and predisposition to injury.
Fig. 6 Axial CT angiogram demonstrates a small pseudoaneurysm (arrow) of the left distal internal carotid artery
Emerg Radiol
Certain exercises, such as ones that require rapid twisting movements involving weights, may be particularly dangerous, as they may lead to cervical vascular dissection. Two of the patients in our report recalled doing such exercise in their CrossFit workouts, which may have lead to their carotid dissections. A study by Hak and colleagues found that 73.5 % of people have reported sustaining an injury during CrossFit training, 7 % of which requiring surgical intervention [6]. However, no vascular dissection was reported in this series. These statistics were found to be comparable to the reported injury rate for sports such as Olympic weight lifting, power lifting, and gymnastics. The annual incidence of symptomatic spontaneous internal carotid artery dissection is 2.5–3 per 100,000 and accounts for as many as 25 % of ischemic strokes in young and middleaged patients [7]. The actual incidence is likely higher, as some dissections may be asymptomatic and remain undiagnosed. Carotid artery dissection has also been reported after relative trivial activity, such as after treadmill running [8]. As demonstrated in the above cases, consequence of carotid dissection range from relatively mild sequelae such as partial Horner syndrome, to a devastating outcome, as shown by the case of occlusion of the cervical internal carotid artery and extensive cerebral infarct [9]. As CrossFit continues to gain popularity, clinicians should carry a high index of suspicion
for possible cervical vascular injury in patients who engage in this intense workout regimen. Conflict of interest The authors declare that they have no conflict on interest.
References 1. 2.
3. 4. 5.
6. 7. 8. 9.
Glassman G (2007) "Understanding Crossfit". Crossfit Journal Smith MM et al (2013) Crossfit-based high-intensity power training improves maximal aerobic fitness and body composition. J Strength Cond Res 27(11):3159–3172 Fox A, King A (2014) The case files: CrossFit-induced carotid artery dissection. Emergency Medicine News Stephanie Cooperman (2005) "Getting Fit, Even if it Kills You". New York Times Provenzale JM (2009) MRI and MRA for evaluation of dissection of craniocerebral arteries, lessons from the medical literature. Emerg Radiol 16(3):185–193 Hak PT, Hodzovic E, Hickey B (2013) The nature and prevalence of injury during CrossFit training. J Strength Cond Res Schievink WI (2001) Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 344(12):898–906 Macdonald D, McKilop E (2006) Carotid artery dissection after treadmill running. Br J Sports Med 40(4):e10 Rizzo L et al (2006) Dissection of cervicocephalic arteries: early diagnosis and follow-up with magnetic resonance imaging. Emerg Radiol 12(6):254–265
CASE REPORT
CrossFit-related cervical internal carotid artery dissection Albert Lu 1 & Peter Shen 1 & Paul Lee 1 & Brian Dahlin 1 & Ben Waldau 2 & Anna E. Nidecker 1 & Anoop Nundkumar 1 & Matthew Bobinski 1
Received: 25 February 2015 / Accepted: 9 April 2015 # American Society of Emergency Radiology 2015
Abstract CrossFit is a high-intensity strength and conditioning program that has gained popularity over the past decade. Potential injuries associated with CrossFit training have been suggested in past reports. We report three cases of cervical carotid dissection that are associated with CrossFit workouts. Patient 1 suffered a distal cervical internal carotid artery (ICA) dissection near the skull base and a small infarct in Wernicke’s area. He was placed on anticoagulation and on follow-up has near complete recovery. Patient 2 suffered a proximal cervical ICA dissection that led to arterial occlusion and recurrent middle cerebral artery territory infarcts and significant neurological sequelae. Patient 3 had a skull base ICA dissection that led to a partial Horner’s syndrome but no cerebral infarct. While direct causality cannot be proven, intense CrossFit workouts may have led to the ICA dissections in these patients. Keywords CrossFit . Carotid . Dissection . Stroke
incorporating elements of weightlifting, high-intensity interval training, and gymnastics. In his article Bunderstanding CrossFit,^ the founder describes it as Bconstantly varied, high intensity, functional movement…supportable by measurable facts^ [1]. At this time, CrossFit is practiced by members of over 10,000 affiliated gyms across the USA and all over the world. One of the features that attract people to CrossFit is its emphasis on quantifiable results. A study conducted by Smith et al. found a significant improvement in VO2 max (maximum oxygen consumption) and decreased body fat percentage in CrossFit across all levels of initial fitness [2]. However, the benefits are not without risks. A recent article by Fox and King described a case of carotid dissection that is attributable to an intense CrossFit workout [3]. Other reports have documented cases of rhabdomyolysis after intense CrossFit workouts [4]. We report a series of three cases of cervical internal carotid artery dissection that are associated with CrossFit workouts.
Introduction
Case 1
Since its inception in 1996, CrossFit has gained immense popularity across the world as a competitive fitness sport that promote a varied and high-intensity workout regimen
A young adult male presented to the emergency department (ED) with acute onset of vision changes and speech impairment since earlier that morning. The patient stated that he awoke that morning around 5:15 a.m. and was in his usual state of health. He went to his CrossFit class that morning, where he exercised vigorously with B20 % more weight^ than he had done previously. He did not recall twisting his neck during the exercise but noted that he may have turned it rapidly to one side or the other while lifting weights. While driving home, he noted sudden onset of flashing light in his peripheral vision of both eyes and then a zigzag pattern across his visual field. He was able to drive home without difficulty, and at some point, these visual phenomena ceased.
* Albert Lu [email protected] 1
Department of Radiology, University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA
2
Department of Neurological Surgery, University of California Davis Medical Center, 4860 Y Street, Suite 3740, Sacramento, CA 95817, USA
Emerg Radiol
Later that morning, the patient became alarmed when he could not understand the meaning behind an email he was reading. He also noted that the right half of his visual field appeared blurred. He was concerned about a possible stroke and came in to the ED for evaluation. By the time of evaluation, his symptoms had nearly completely resolved. An MRI of the brain and MRA of the head and neck were obtained, demonstrating a small infarct of the left superior temporal gyrus near Wernicke’s area (Fig. 1). The MRA demonstrated a short segment narrowing in the distal left cervical internal carotid artery just below the skull base, consistent with acute carotid dissection (Fig. 2). The patient was evaluated by neurology and was placed on anticoagulation with Coumadin for 3 months, after which he was transitioned to antiplatelet therapy with aspirin indefinitely. At 1 month follow-up, he had only minimal intermittent word-finding difficulties but is otherwise back to baseline.
Case 2 A young adult female, who exercises regularly with CrossFit, presented to the ED with acute right upper extremity weakness. She awoke the morning of presentation at her normal baseline and went to the gym for her routine CrossFit workout. After her workout, she noticed she was having trouble coordinating her right hand to pick up her keys. She was able to call her husband on the phone, who took her to the ED. Non-contrast CT head obtained upon arrival was normal (not shown). MRI of the brain demonstrated punctate foci of ischemic infarcts in subcortical white matter of the left frontal and parietal lobes, which are consistent with subcortical watershed infarctions (Fig. 3). Intravenous tPA was given. Initially, the patient demonstrated improvement but she subsequently worsened, developing expressive aphasia,
Fig. 1 Coronal DWI demonstrating a small infarct of the left superior temporal gyrus near Wernicke’s area (arrow)
Fig. 2 3D reconstruction of MR angiogram of the circle of Willis demonstrates focal narrowing and luminal irregularity in the distal left cervical internal carotid artery (arrow), consistent with a carotid dissection
difficulty following commands, worsening right upper extremity weakness, and new right lower extremity weakness. CT angiography (CTA) head showed no intracranial arterial occlusion in bilateral MCAs. CTA of the neck showed a possible occlusion of the left cervical internal carotid artery. Digital subtraction angiography confirmed complete occlusion of left ICA just after the carotid bifurcation (Fig. 4). There was collateral flow through the ophthalmic artery and posterior communicating artery (not shown). There was no indication for endovascular intervention since the carotid artery was completely occluded. Medical management was continued, with emphasis on maximizing blood pressure and cerebral perfusion. The patient was managed with anticoagulation and permissive hypertension, using IV fluids and vasopressors to maximize collateral flow to her left cerebral hemisphere and
Fig. 3 Axial DWI demonstrates multiple small foci of infarcts in left frontoparietal subcortical white matter Brosary-like pattern,^ consistent subcortical watershed distribution
Emerg Radiol
Fig. 5 Axial T1 fat-saturated sequence demonstrates hyperintense mural thrombus along the wall of a dissected distal left cervical internal carotid near the skull base (arrow) Fig. 4 Digital subtraction angiogram of left common carotid demonstrates rapid tapering and complete occlusion of the proximal left internal carotid artery just distal to the carotid bifurcation (arrow), consistent with acute dissection
allowing her cerebral collateral flow time to build. Her hospital course was complicated by additional watershed infarcts in the left middle cerebral artery territory. Her symptoms were dependent on vertical activity; therefore, she was placed on bedrest. After several weeks of stay at the hospital, she was transferred to rehabilitation and eventually home on bedrest with gradual increase in daily vertical time. One month after discharge, she was able to walk with a cane, had mild right hand weakness, but intact speech.
Case 3 The patient was a middle-aged male who exercises regularly and partakes in CrossFit workouts, including an exercise that requires twisting of his body and throwing a weighted ball. On the day of presentation, he was in his usual state of health when his wife noticed anisocoria and left-sided ptosis. The patient himself noticed miosis of the left pupil. The patient was otherwise neurologically intact without additional neurological deficit. Upon further questioning, the patient denied any focal trauma or neck pain. Urgent MRI of the brain and MRA of the head and neck were obtained and demonstrated a small acute dissection of the distal left cervical internal carotid artery at the skull base, as evidenced by the presence of a Bcrescent sign^ indicating a mural thrombus (Fig. 5) [5]. There was no evidence of ischemic infarct on DWI. CT angiography confirmed a small pseudoaneurysm of the left distal internal carotid artery (Fig. 6). The patient was placed on oral aspirin 325 mg daily for thromboembolic prophylaxis.
Repeat MRI and MRA 6 months later, after abstinence from rigorous exercise including CrossFit, showed resolution of the small left internal carotid dissection and pseudoaneurysm. His Horner’s symptoms had also resolved.
Discussion Critics have pointed out the danger of CrossFit’s emphasis on speed and high-intensity movements and lack of proper guidance on technique [4]. The constant push to increase performance with faster speed and more weights can be especially dangerous. Our first patient reported pushing himself with B20 % more weight^ in his workout the morning of his presentation with carotid dissection and ischemic infarct. It is conceivable that the emphasis on increased weight and speed may lead to further degradation in exercise technique and predisposition to injury.
Fig. 6 Axial CT angiogram demonstrates a small pseudoaneurysm (arrow) of the left distal internal carotid artery
Emerg Radiol
Certain exercises, such as ones that require rapid twisting movements involving weights, may be particularly dangerous, as they may lead to cervical vascular dissection. Two of the patients in our report recalled doing such exercise in their CrossFit workouts, which may have lead to their carotid dissections. A study by Hak and colleagues found that 73.5 % of people have reported sustaining an injury during CrossFit training, 7 % of which requiring surgical intervention [6]. However, no vascular dissection was reported in this series. These statistics were found to be comparable to the reported injury rate for sports such as Olympic weight lifting, power lifting, and gymnastics. The annual incidence of symptomatic spontaneous internal carotid artery dissection is 2.5–3 per 100,000 and accounts for as many as 25 % of ischemic strokes in young and middleaged patients [7]. The actual incidence is likely higher, as some dissections may be asymptomatic and remain undiagnosed. Carotid artery dissection has also been reported after relative trivial activity, such as after treadmill running [8]. As demonstrated in the above cases, consequence of carotid dissection range from relatively mild sequelae such as partial Horner syndrome, to a devastating outcome, as shown by the case of occlusion of the cervical internal carotid artery and extensive cerebral infarct [9]. As CrossFit continues to gain popularity, clinicians should carry a high index of suspicion
for possible cervical vascular injury in patients who engage in this intense workout regimen. Conflict of interest The authors declare that they have no conflict on interest.
References 1. 2.
3. 4. 5.
6. 7. 8. 9.
Glassman G (2007) "Understanding Crossfit". Crossfit Journal Smith MM et al (2013) Crossfit-based high-intensity power training improves maximal aerobic fitness and body composition. J Strength Cond Res 27(11):3159–3172 Fox A, King A (2014) The case files: CrossFit-induced carotid artery dissection. Emergency Medicine News Stephanie Cooperman (2005) "Getting Fit, Even if it Kills You". New York Times Provenzale JM (2009) MRI and MRA for evaluation of dissection of craniocerebral arteries, lessons from the medical literature. Emerg Radiol 16(3):185–193 Hak PT, Hodzovic E, Hickey B (2013) The nature and prevalence of injury during CrossFit training. J Strength Cond Res Schievink WI (2001) Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 344(12):898–906 Macdonald D, McKilop E (2006) Carotid artery dissection after treadmill running. Br J Sports Med 40(4):e10 Rizzo L et al (2006) Dissection of cervicocephalic arteries: early diagnosis and follow-up with magnetic resonance imaging. Emerg Radiol 12(6):254–265
