Rare case of bilateral traumatic internal carotid artery dissection

Abstract

A 55-year-old man was working in a trench when the wall collapsed in on him, pinning him to the wall. On arrival in the emergency department the patient began reporting of right-sided headache. Neurological examination revealed left-sided reduced sensation with weakness. Whole-body CT scan showed right-sided flail chest and bilateral haemothorax as well as loss of flow and thinning of the distal right internal carotid artery (ICA) and loss of grey white matter differentiation in keeping with traumatic ICA dissection with a right middle cerebral artery (MCA) infarct. He was started on aspirin 300 mg once daily. 3 days postadmission the patient experienced worsening of vision and expressive dysphasia. CT angiogram showed bilateral ICA dissections extending from C2 to the skull base. The patient was managed conservatively in the stroke unit for infarction and was discharged home for follow-up in stroke clinic.

Figure 1

CT scan brain with contrast showing loss of grey white matter differentiation within the right frontal lobe and right insula suggestive of a hyperacute infarct.

Figure 2

Volume-rendered CT angiogram showing bilateral ICA dissections extending from C2 to skull base with distal stenosis (A).

Figure 3

Volume-rendered CT angiogram demonstrating complete remodelling on the left (A) but persisting irregularity on the right with a shallow dissecting aneurysm at the C1/2 level (B) and a larger, saccular dissecting aneurysm at the skull base (C).