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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 152-154

Blunt aortic dissection and bilateral internal carotid dissection in the setting of polytrauma: A case report


1 The Lewis Katz School of Medicine at Temple University 3500 N Broad, St. Philadelphia, Bethlehem, PA, USA
2 2Department of Acute Care Surgical Services, St. Luke's University Hospital, Bethlehem, PA, USA

Date of Submission07-Feb-2020
Date of Acceptance05-May-2020
Date of Web Publication22-Sep-2020

Correspondence Address:
Dr. Roberto C Castillo
Department of Acute Care Surgical Services, St. Luke's University Hospital, 801 Ostrum Street, Bethlehem, PA 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCIIS.IJCIIS_10_20

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   Abstract 


Severe polytrauma involving multiple organ systems presents a significant challenge to any trauma center. We present a case of a patient presenting simultaneously with a type B aortic dissection, bilateral internal carotid dissections, a brachiocephalic artery dissection, and a splenic laceration among other injuries. In this patient with both solid organ injury and vascular trauma, we discuss how multidisciplinary collaboration was required to prioritize treatment goals and determine the proper initiation of antiplatelet and anticoagulation therapies.

Keywords: Aortic dissection, blunt cerebrovascular injury, polytrauma, solid organ injury


How to cite this article:
Shanker A, Gifford A, Bendas C, Castillo RC. Blunt aortic dissection and bilateral internal carotid dissection in the setting of polytrauma: A case report. Int J Crit Illn Inj Sci 2020;10:152-4

How to cite this URL:
Shanker A, Gifford A, Bendas C, Castillo RC. Blunt aortic dissection and bilateral internal carotid dissection in the setting of polytrauma: A case report. Int J Crit Illn Inj Sci [serial online] 2020 [cited 2020 Oct 24];10:152-4. Available from: https://www.ijciis.org/text.asp?2020/10/3/152/295772




   Introduction Top


Traumatic mechanisms account for a relatively small percentage of reported vascular dissections and are associated with high morbidity and mortality. In cases of carotid artery dissection, trauma accounts for only approximately 4% of identifiable causes. Blunt cerebrovascular artery injuries relating to a single internal carotid artery affect roughly 0.68%–0.86% of all trauma patients.[1],[2] Acute aortic dissection occurs in approximately 3.5–6.0/100,00 patient-years, with just a small fraction being from traumatic causes.[3]

This report presents a case in which concomitant type B aortic dissection, bilateral internal carotid dissection, and multisystem injuries are sustained after blunt trauma. While approximately 20 cases of blunt aortic dissection have been reported, to our best knowledge, no published case report has included four noncontiguous vascular injuries with this mechanism. Treatment of these vascular injuries in the setting of severe polytrauma requires a careful balancing of antiplatelet and anticoagulation therapy in the setting of solid organ injury and multidisciplinary collaboration.


   Case Report Top


A 67-year-old male arrives to a level one trauma center as an unrestrained driver of a single-vehicle collision versus tree. The airbags were deployed, and the patient was unresponsive at GCS 3, wedged between the door and steering wheel. He was intubated in the field by emergency medical services after extrication for airway protection due to decreased mental status. Advanced trauma life support protocol was followed. Following the primary survey, a focused assessment with sonography in trauma examination was positive in the left upper quadrant, and a chest X-ray revealed widened mediastinum. The patient was hemodynamically stable [Table 1] and transported for computed tomography (CT) of his head, neck, chest, abdomen, and pelvis.
Table 1: Summary of injuries present on admission

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Laboratories and imaging revealed the patient had sustained significant multisystem trauma with acute blood loss anemia [Table 2] and [Table 3]. His vascular injuries included a partially thrombosed dissection of the aorta at the level of the left subclavian artery and descending just proximal to the level of the iliac bifurcation. Hypoenhancement of the right kidney secondary to dissection was also noted.
Table 2: Summary of vitals present on admission

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Table 3: Summary of laboratory findings present on admission

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Formal CT angiography (CTA) was done on hospital day 1. The descending aortic dissection had an enlarging intramural hematoma with thrombosis of the false lumen to the inferior mesenteric artery, which was not flow limiting. A stable known ascending aortic aneurysm was visualized. Furthermore, a contained brachiocephalic artery transection [Figure 1], local dissection of the distal cervical right internal carotid artery [Figure 2], and dissection of the left internal carotid artery into the cavernous portion were visualized.
Figure 1: Contained brachiocephalic artery transection

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Figure 2: Local dissection of the distal cervical right internal carotid artery

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A multidisciplinary approach with trauma, cardiothoracic, vascular, and neurosurgical teams was utilized due to the extent of injuries. The aortic dissection was managed conservatively with targeted blood pressure and heart rate control. Bilateral carotid artery dissection was managed with the initiation of antiplatelet therapy once the splenic injury was embolized. However, repeat imaging on hospital day 2 demonstrated new cortical infarcts in the occipital lobe. At this point, full anticoagulation was started.

The patient went on to have a lengthy intensive care unit (ICU) course requiring a pacemaker, tracheostomy, and gastrostomy tube placement. CTA head, neck, chest, abdomen, and pelvis repeated on hospital day seven were found to be stable. He was eventually able to be discharged to long-term rehabilitation following his ICU stay. He was ultimately discharged on coumadin for treatment of his carotid dissections and subsequent stroke.


   Discussion Top


Aortic dissection is defined by the formation of an entrance tear in the tunica intima, often in the setting of cystic medial necrosis due to atherosclerotic plaque formation. In the setting of trauma, direct and indirect forces, such as deceleration, compression, and sudden extension of the neck, cause the heart and great vessels to be displaced, leading to injury.[4]

In a 2016 systematic review, the average age of patients presenting with acute aortic dissection ranged from 48 to 67 years, with hypertension and smoking history being the most common comorbidities.[3] While chest or back pain was the most commonly reported presenting symptom (61.6%–84.8%), this cannot always be ascertained in the trauma population.[6] CT, magnetic resonance imaging, and transesophageal echocardiography are relatively comparable in regard to diagnosis, ranging from 90%–95% sensitivity to 80%–96% specificity.[3]

Stanford type B lesions involve only the descending aorta. Treatment for these descending aortic injuries without leak or rupture is typically conservative with blood pressure and heart rate management to control further shearing forces. If an intimal tear were increasing or affecting end-organ perfusion, endovascular and surgical options would have to be considered. Consensus guidelines from the Eastern Association for the Surgery of Trauma note that the use of antihypertensive agents and delayed repair offer similar or better mortality outcomes than immediate repair with thoracic endovascular aortic repair.[5]

Carotid artery dissection demonstrates an age disparity with respect to underlying cause: Traumatic mechanisms affecting younger populations generally under the age of 40, and spontaneous dissections occurring more frequently in older populations.[2] A major complication is the increased risk of cerebral infarction, which has an incidence of up to 24%, making prompt identification of these injuries and consideration of antithrombotic therapy a priority.[6],[7] Treatment is usually conservative with antiplatelet therapy or anticoagulation. Prospective cohort studies have found that therapeutic levels of anticoagulation and antiplatelet therapy were equivalent with regards to rates of cerebral infarction or functional outcomes at 2–3-year follow-up after hospital discharge.[8],[9],[10] Angioplasty and stenting are indicated if there are ongoing ischemic symptoms, or anticoagulation is contraindicated.


   Conclusion Top


In this case, a multidisciplinary approach was essential in formulating a treatment plan that took into consideration the patient's stroke risk versus bleeding risk inherent to polytrauma patients with vascular injuries.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent documentation, and the patient has given permission for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Applicable reporting guideline for case reports (CARE) was followed by the authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR network. The authors also attest that this clinical investigation was determined not to require Institutional Review Board / Ethics Committee review.



 
   References Top

1.
Jansen G, Popp J, Dietrich U, Mertzlufft F, Bach F. Traumatic dissection of the carotid artery: Challenges for diagnostics and therapy illustrated by a case example. Anaesthesist 2013;62:817-23.  Back to cited text no. 1
    
2.
Weber CD, Lefering R, Kobbe P, Horst K, Pishnamaz M, Sellei RM, et al. Blunt cerebrovascular artery injury and stroke in severely injured patients: An International Multicenter Analysis. World J Surg 2018;42:2043-53.  Back to cited text no. 2
    
3.
Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA. Acute aortic dissection and intramural hematoma: A systematic review. JAMA 2016;316:754-63.  Back to cited text no. 3
    
4.
Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 2002;122:311-28.  Back to cited text no. 4
    
5.
Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE Jr., Johnson JL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg 2004;139:540-5.  Back to cited text no. 5
    
6.
Wilson S, Hutchins H. Aortic dissecting aneurysms: Causative factors in 204 subjects. Arch Pathol Lab Med 1982;196:175-80.  Back to cited text no. 6
    
7.
Mimasaka S, Yajima Y, Hashiyada M, Nata M, Oba M, Funayama M. A case of aortic dissection caused by blunt chest trauma. Forensic Sci Int 2003;132:5-8.  Back to cited text no. 7
    
8.
Cothren CC, Biffl WL, Moore EE, Kashuk JL, Johnson JL. Treatment for blunt cerebrovascular injuries: Equivalence of anticoagulation and antiplatelet agents. Arch Surg 2009;144:685-90.  Back to cited text no. 8
    
9.
Edwards NM, Fabian TC, Claridge JA, Timmons SD, Fischer PE, Croce MA. Antithrombotic therapy and endovascular stents are effective treatment for blunt carotid injuries: Results from longterm followup. J Am Coll Surg 2007;204:1007-13.  Back to cited text no. 9
    
10.
Cothren CC, Biffl WL, Moore EE, Kashuk JL, Johnson JL. Treatment for blunt cerebrovascular injuries: Equivalence of anticoagulation and antiplatelet agents. Arch Surg 2009;144:685-90.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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