Malignant Middle Cerebral Artery Infarction Secondary to Traumatic Bilateral Internal Carotid Artery Dissection. A Case Report

Abstract

Traumatic bilateral dissection of the carotid arteries is a rare condition with potentially life-threatening complications. The case of a 57-year-old male patient with acute onset left sided hemiparesis, twelve hours after a blunt head injury, caused by a horse kick, is reported. A cerebral CT scan revealed right middle cerebral artery (MCA) territory infarction. Based on Duplex ultrasound and Angio CT scan findings, a diagnosis of bilateral ICA dissection was established. Despite antithrombotic treatment, the patient presented with a progressive worsening of his neurological status. The control CT scan evidenced malignant right MCA territory infarction that required decompressive craniotomy. The patient was discharged with significant neurological deficits. Together with this case, the aetiologies, clinical manifestations, diagnostic and therapeutical options and outcome of carotid artery dissection are discussed.

Keywords: carotid artery dissection; malignant infarction; traumatic.

Figure 1

Native cerebral CT scan, axial sections revealing right middle cerebral territory infarction, without significant midline shift. Hyperdense middle cerebral artery sign is visible (a, yellow arrow).

Figure 2

Ultrasound examination of the carotid arteries. a: color mode examination of the right ICA, longitudinal section, without stenotic lesions; b: real-time triplex display (Color Doppler+ Pulsed Spectral Doppler) of the right ICA revealing high-resistance flow signal, with low and short systolic flow and completely absent diastolic flow, indicative of near occlusion or occlusion of the distal segment of ICA; c: color-mode examination of the left ICA revealing irregular stenosis caused by the hypoechoic mural hematoma; d: triplex mod examination of the left ICA, revealing high flow velocities suggestive of significant stenosis.

Figure 3

Angio CT scan examination of the right ICA, curved planar reformatted images, revealing long-segment highgrade stenosis (string sign) of the distal segment of the vessel, indicative of dissection.

Figure 4

Native cerebral CT scan, axial sections revealing right middle cerebral territory infarction, with important mass effect and significant midline shift. Hyperdense middle cerebral artery sign is visible (a, yellow arrow).

Figure 5

Native cerebral CT scan, axial sections after decompressive craniectomy, revealing right middle cerebral territory infarction, with slightly diminished midline shift.