A Sudden Unilateral Visual Field Loss in a Recreational Tennis Player: Cervical Internal Carotid Artery Dissection Associated With Low-Impact Sports

Abstract

Traumatic cervical internal carotid artery dissection (CICAD) is a rare condition caused by blunt trauma to the neck, often through automobile- or sports-related collisions, assaults, or falls. Herein, we report an unusual case in which engaging in a low-impact sport (tennis) caused CICAD, without a direct injury. A 56-year-old man with hypertension suddenly experienced a visual field loss in his right eye while playing tennis. Carotid echocardiography revealed severe stenosis of the right internal carotid artery (ICA). Angiography revealed severe and irregular stenosis of the right ICA from the bifurcation to the petrous portion, suggesting CICAD. Upon admission, the patient had left upper visual field defects in his right eye and neck pain. Antiplatelet therapy was initiated with prasugrel (3.75 mg/day), with the intent to treat surgically if the stenosis or symptoms progressed. Follow-up angiography and magnetic resonance imaging showed gradual resolution of the stenosis, and the patient was discharged on day 28 with a modified Rankin Scale score of 1. The CICAD should be considered as a diagnosis for neurological symptoms, even in the context of low-impact sports such as tennis. Antithrombotic therapy is a reasonable first-line treatment for stable CICAD.

Keywords: anticoagulants; antiplatelets; cervical arterial dissection; internal carotid artery dissection; low-impact sports; tennis.

Figure 1. Initial imaging studies.

Magnetic resonance angiography (MRA) on day 4 after onset showed poor visualization of the right internal carotid artery (ICA) compared with the left ICA (A and B arrows). A "double lumen" was observed in the petrous portion of the right ICA (B arrow). Digital subtraction angiography on day 5 revealed irregular stenosis from the origin to the petrous portion of the right ICA (C-E arrows).

Figure 2. Follow-up imaging studies.

Magnetic resonance angiography on day 22 after the onset showed improved visualization of the right internal carotid artery (ICA) (A and B arrows). Right carotid angiography on day 25 after onset showed irregularity of the ICA wall, but partial resolution of the stenosis (C and D arrows).

Figure 3. Outpatient follow-up imaging studies.

Magnetic resonance angiography performed on day 42 after onset revealed almost no abnormal findings in the right internal carotid artery (A and B arrows). Single-photon emission computed tomography with 123I-isopropyl-p-iodoamphetamine on the same day showed no hypoperfusion area (C: rest and D: acetazolamide stress).