Aeta Neuroehirurgiea 33, 325--329 (1976) 9 b y Springer-Verlag 1976

D e p a r t m e n t of Neurosurgery, Hospital, Walbrzych, Poland

Internal Carotid Artery Occlusion due to Intraoral Trauma Case Report By

J. Holyst W i t h 2 Figures

Summary Traumatic thrombosis of the internal carotid artery following soft palate injury in a 3 8 9 year old boy is reported. Prominent collateral circulation through the circle of Willis and the orbit was a good prognostic sign. The problem of traumatic carotid thrombosis is of considerable practical importance in differential diagnosis from intraeranial haematoma. E x t r a e r a n i a l c a r o t i d a r t e r y t h r o m b o s i s in a d u l t s as a c o m p l i c a t i o n of h e a d or neck t r a u m a has become a s u b j e c t of m u c h clinical interest6-9, 11, 13, 14. T r a u m a t i c cerebral a r t e r i a l occlusion in children, who are p a r t i c u l a r l y liable to a c c i d e n t a l injury, is a r e l a t i v e l y rare lesion, b u t it is being d i a g n o s e d m o r e f r e q u e n t l y as a result of t h e increasing use of cerebral a n g i o g r a p h y in y o u n g p a t i e n t s a-5. T h e y o u n g e s t child w i t h this c o n d i t i o n r e p o r t e d in t h e l i t e r a t u r e was 17 m o n t h s old ( K a k a n d Gordon1~ T h e child aged 2 y e a r s a n d 10 m o n t h s w i t h t r a u m a t i c i n t e r n a l c a r o t i d occlusion, d e s c r i b e d b y T h e r k e l s e n a n d H o r n n e s 15, is of i n t e r e s t b e c a u s e it p r o v i d e s t h e o n l y e x a m p l e of r e s t o r a t i o n of circulation by thrombeetomy. E x t r e m e l y rare is t h e oeeurenee of c a r o t i d a r t e r y t h r o m b o s i s due to i n t r a o r a l t r a u m a in children. A review of t h e l i t e r a t u r e shows only a few eases 1, 3, la. T h e following r e p o r t a d d s f u r t h e r i n f o r m a t i o n on t h e p r o b l e m of d i r e c t d a m a g e to t h e c a r o t i d a r t e r y after p a l a t e i n j u r y .

Case Report W. J., a boy aged 3 years and 7 months, fell downstairs with a pencil in his mouth. He was unconscious for a few moments. The pencil was removed. The child expectorated blood tinged saliva and then continued playing.

326

J. H o l y s t : I n t e r n a l Carotid A r t e r y Occlusion

On admission to hospital he was fully conscious w i t h no a b n o r m a l neurological signs. I n s p e c t i o n of the t h r o a t r e v e a l e d a m i n o r contusion and a 4 m m laceration of the soft palate on the left side (Fig. 1). One day after admission the b e y v o m i t e d and was slightly drowsy. X - r a y s of the skull showed no fracture. L a b o r a t o r y studies were w i t h i n n o r m a l limits. On the second day he developed right hemiparesis, and b e c a m e m o r e drowsy and confused. The carotid pulses were equal. No bruit over t h e h e a d and neck

Fig. 1. I n t r a o r a l v i e w of t h e child. Small laceration a b o v e the superior pole of the left tonsil

was detectable. T h e child was t h o u g h t to h a v e an e x p a n d i n g intracranial process p r o b a b l y a h a e m a t o m a related ~o the m i l d h e a d injury. E c h o e n e e p h a l o g r a p h y showed no shift of t h e midline eerebraI structures. Bilateral carotid a r t e r i o g r a p h y was performed. This r e v e a l e d c o m p l e t e occlusion of the left i n t e r n a l carotid a r t e r y at a p o i n t a b o u t 2.5 am a b o v e t h e bifurcation of the c o m m o n carotid a r t e r y (Fig. 2 a). I n later phases of the a n g i o g r a m there was persistence of t h e c o n t r a s t m e d i u m in the neck in the line of the internal carotid artery. T h e left m i d d l e cerebral a r t e r y was well supplied w i t h c o n t r a s t m e d i u m b y w a y of the collateral circulation t h r o u g h the left external carotid a r t e r y and the o p h t h a l m i c a r t e r y (Figs. 2 a a n d b). There was also a good collateral circulation f r o m cross-filling t h r o u g h t h e a n t e r i o r s e g m e n t of t h e circle of Willis via t h e anterior cerebral a n d anterior c o m m u n i c a t i n g arteries. A left i n t e r n a l carotid t h r o m b e e t o m y was n o t done because the m o t h e r refused permission for operation. A n t i c o a g u l a n t t h e r a p y , vasodilator drugs, massage, and exercises wore started. The boy m a d e an u n e v e n t f u l recovery. There was i m p r o v e m e n t in t h e right hemiparesis. A f t e r one m o n t h he eonld walk well. E l e e t r o e n e e p h a l o g r a p h y showed only m i l d a b o r m a l i t y on the left side in t h e f o r m of focal changes m a n i f e s t e d b y i n t e r m i t t e n t t h e t a discharges in t h e t e m p o r o - o e e i p i t a l region. W h e n last seen two years l a t e r the b o y was a s y m p t o m a t i e , a n d no neurological deficit could be detected, a l t h o u g h he used his left h a n d in preference to the right.

Fig. 2. (a) Lateral view of the left carotid angiogram. Thrombosis of in~ernal carotid artery (arrow). The intracranial portion of the internal carotid artery and the middle cerebral artery (2) are filled via the large ophthalmic artery (I). (b) Anteroposterior projection of the left carotid angiogram. Arrow points to the middle cerebral artery and its branches

328

J. ttolyst : Discussion

I t seems important to recognize the possible dangers associated with a penetrating injury in the region of soft palate 2, 13 which may lead to hemiparesis due to traumatic thrombosis of the internal carotid artery. The cause of the traumatic occlusion m a y be direct damage to the artery. I n this case there was arteriographic evidence of dissection of the arterial wall in the form of persistence of contrast medium in the line of the internal carotid artery. Excellent collateral circulation through the circle of Willis and the orbit was proof that the intracranial vessels were not involved, and. was a good prognostic sign. The quick improvement seen in the case reported is probably explained by the patient's youth and by the beneficial effect of the anticoagulant therapy. In the present case there was, to obscure the diagnosis, a 'lucid interval' of twentyfour hours between the time of soft palate injury and the development of neurological symptoms. T h e clinical signs of carotid artery occlusion usually appear after such an interval, and need to be distinguished from those due to a post traumatic expanding intracranial lesion, such as a subdural or extradural haematoma 7-9, 13. The exact diagnosis can be Confirmed only by angiography. References

1. Brando, M., Thrombosis of internal carotid artery in childhood after injuries in region of soft palate. Brit. Med. J. 1 (1956), 665--667. 2. Fairburn, B., Thrombosis of internal carotid artery after softpalate injury. Brit. Med. J. 2 (1957), 750--751. 3. Faris, A.A., Guth, C., Youmans, R.A., Poser, M., Internal carotid artery occlusion in children diagnosed by arteriography. Am. J. Dis. Child. 107 (1964), 188--192. 4. Fisher, R. G., Friodmann, K. R., Hanover, N. H., Carotid artery thrombosis in persons fifteen years of age or younger. J. Am. Med. Ass. 170 (1959), 1918--1919. 5. Frantzen, E., Jacobsen, H. H., Therkelsen, J., Cerebral artery occlusions in children due to trauma to the head and neck. A report of 6 eases verified by cerebral angiography. Neurology (Minneap.) 11 (1961), 695--700. 6. Gleave, J . R . W . , Thrombosis of the carotid artery in the neck in association with head injury. Exeerpta Medica, Int. Cong. Ser. No. 93 (1965), 157. 7. Higazi, J., Post-traumatic carotid thrombosis. Report of a case with intensive angiographie study of the collateral circulation. J. Neurosurg. 20 (1963), 354--359. 8. Hockaday, T . D . R . , Traumatic thrombosis of the internal carotid artery. J. Neurol. Neurosurg. Psychiat. 22 (1959}, 229--23i. 9. Huber, P., Zerebrale Angiographie beim frisehen Seh/~del-Hirn-Trauma. Stuttgart : G. Thieme. 1964.

Internal Carotid Artery Occlusion due to Intraoral T r a u m a

329

10. Kak, V. K , Gordon, D. S., Internal carotid artery thrombosis following head injury in a 17-rnonth-old child. Neurochirurgia 15 (1972), 222--226. 11. Lecuire, J., Goutelle, A., Spay, G., Deehaume, J. P., Indications th@rapeutiques dans les thromboses traumatiques de l'art~re carotide interne (a'propos de i0 observations). Neuro-chir. 11 (1965), 295--302. 12. Olafson, R. A., Christoferson, L. A., The syndrome of carotid occlusion following minor eranioeerebral trauma. J. Neurosurg. 33 (1970), 636--639. 13. Pitner, S. E., Carotid thrombosis due to intraoral trauma. An unusual complication of a common childhood accident. New Engl. J. Med. 274 (1966), 764--767. 14. Schneider, R . C . , Lemmen, L . J . , Traumatic internal carotid artery thrombosis secondary to nonpenetrating injuries to the neck. A problem to the differential diagnosis of craniocerebral trauma. J. 2~Teurosurg. 9 (1952), 495--507. 15. Therkelsen, J., Hornnes, IN., Traumatic occlusion of the internal carotid artery in a child. Restored circulation b y means of thrombectomy. Circulation 28 (1963), 101--104. Author's address : D o c . dr hab. J. Holyst, D e p a r t m e n t of Neurosurgery, Wojew6dzki Szpital GSrniczy, Sokolowskiego 4, 58-309 Walbrzych, Poland.

Internal carotid artery occlusion due to intraoral trauma. Case report.

Aeta Neuroehirurgiea 33, 325--329 (1976) 9 b y Springer-Verlag 1976 D e p a r t m e n t of Neurosurgery, Hospital, Walbrzych, Poland Internal Caroti...
703KB Sizes 0 Downloads 0 Views