ICA (petrous) injury with its sequele

Case contributed by Dr Talal F M Abdullah

Presentation

Fight with left orbital stab wound by a screwdriver, facial trauma and bleeding per nose and mouth. Patient is dizzy and vomiting blood. No neurological defecit.

Patient Data

Age: 25
Gender: Male

Initially it was thought to be an isolated facial and sinus trauma.

Contrast was given once petrous canal irregularity noted whilst the patient was on the CT scanner table.  Irregularity of the arterial wall of the horizontal petrous part of the right internal carotid artery.

CT angiogram of the neck (not shown) was unremarkable.  

The case was managed conservatively.  The next day a follow-up non-contrast CT brain showed an unexpected right MCA territory infarct.  This is explained by arterial spasm/dissection secondary to trauma.

Case Discussion

A very odd way for internal carotid artery injury, while the direct trauma was through the left orbital socket and injured the right ICA.  Amazingly it did miss the left orbit.

The fracture tract, raised bony chip of the petrous canal, irregular wall of the petrous ICA and suspected minimal contrast extravasation; all raised the potential of arterial injury.  Being a tiny bony canal rendered full assessment of the vessel hard by CT; though the aforementioned findings highly raised the possibility.

Again being in a bony canal mostly saved the patient from a catastrophic bleed, as it was "contained" by tamponade effect.

Secondary spasm of the right ICA due to the direct trauma could have caused the right MCA infarct within less than 24 hours.  Another theory is dissection extending into the right MCA.

The patient shifted to a neuroradiology center where carotid angiogram showed pseudoaneurysm formation.

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Case information

rID: 58107
Published: 31st Jan 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

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