Presentation
Patient had a motor vehicle accident and was admitted to a small peripheral hospital. He released himself against medical advice. A few hours later, the patient developed right sided hemiparesis and was brought to our hospital.
Patient Data
FINDINGS: There is an area of decreased density with loss of grey-white matter differentiation and effaced sulci in the left parietal lobe . Small hypodensity in the left caudate head.
No acute haemorrhage, no relevant midline shift, no other acute findings.
CONCLUSION: acute ischaemic infarction in the territory of the left middle cerebral artery, questionably also in the anterior cerebral artery territory (caudate head).
FINDINGS: Approximately 2.5 cm distal to the left carotid bifurcation, the lumen of the internal carotid artery (ICA) tapers significantly with extremely poor opacification of the remainder of the vessel. A string sign is visualised. The preterminal segment of the ICA is again opacified, yet poorer than on the right side.
The remainder of the brain-supplying and intracerebral arteries appear normal. The right ICA has a unusual, very tortuous course before entering the skull base.
Bilateral cervical lymphadenopathy is noted. Degenerative changes of the cervical spine with multisegmental intervertebral disc degenerative disease and intervertebral disc vacuum phenomena.
CONCLUSION: Left internal carotid artery dissection approximately 2.5 cm distal to the carotid bifurcation.
An MRI was performed the next day to visualise the degree of brain infarction and the mural haematoma in the vessel.
FINDINGS: DWI demonstrates a large area of increased signal in the left temporal and parietal lobe with cortical and subcortical dominance, partly with gyriform pattern. Besides, hyperintensities are visualised in the caudate head and body and there are patchy hyperintensities scattered over the entire left hemisphere.
FLAIR shows corresponding hyperintense signal in the above mentioned areas.
T1 SPIR demonstrates a crescent-shaped hyperintensity in the course of the left ICA.
No other brain abnormalities.
NB: mucosal swelling in the maxillary sinus bilaterally. Bilateral cervical lymphadenopathy is noted.
CONCLUSION: Large ischaemic infarction in the left hemisphere predominantly in the temporal and parietal lobes in keeping with an occlusion/ dissection of the left ICA.
Case Discussion
A somewhat tragic case. A middle-aged patient with no prior neurological pathologies was brought to a small hospital after a motor vehicle accident, a facility that was not equipped to handle trauma patients in the first place. The reasons for that are unknown to the author.
Secondly, the patient discharged himself against medical advice. Some hours later he developed neurological symptoms. The patient could have been treated earlier had he stayed in a suitable medical facility and maybe such severe damage to the brain could have been reduced by earlier intervention.
Thirdly, due to the tortuous course of the patient's ICA, the vessel was prone to traumatic injury, in this case likely due to the seat belt which might have cut into the patient's left neck during the accident.
Image-wise, classic signs of a carotid dissection can be seen on CTA, namely the string sign, and on MRI, the crescent sign within the wall of the vessel.
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