CTA-occult traumatic carotid blowout injury
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CE - MEDICAL ILLUSTRATION
CTA‑occult traumatic carotid blowout injury Mougnyan Cox1 · Susanna Howard2 · Puhan He3 · Mark Seamon4 · David Kung5 Received: 10 February 2020 / Accepted: 20 March 2020 © Società Italiana di Medicina Interna (SIMI) 2020
Abbreviations CTA Computed tomography angiogram
Case A 30-year-old man was brought to the Emergency Department following a gunshot wound to the left face, with bleeding from his nose and mouth. Upon arrival in the ED, he was hypotensive, tachycardic, with labored breathing and low oxygen saturations. He was intubated for airway protection, arterial and central venous lines were placed for blood pressure monitoring and resuscitation. An external fixation device was placed over his midface, and his oral cavity was packed with hemostatic material to decrease bleeding. A CTA was performed, which showed nonopacification/occlusion of his left internal and external carotid arteries just beyond the carotid bulb. Given his persistent oozing of blood from his mouth and nose, neurointerventional radiology was consulted for a digital subtraction angiogram (DSA). Surprisingly, the angiogram showed active extravasation from a large tear in the proximal ICA and ECA just beyond the carotid bulb, pouring into a large hematoma in the left face;
findings that were not evident on the CTA performed less than an hour earlier. The ICA and ECA were successfully embolized with coils and ethylene vinyl alcohol copolymer/ Onyx (ev3, Irvine, CA). There was no further extravasation following embolization, and the patient’s hemodynamic parameters improved and stabilized while he was still on the angiography table. The patient survived his injury, and other than some mild weakness of his right hand grip and right leg, was neurologically intact. Carotid blowout injuries can be rapidly lethal, from exsanguination due to uncontrolled bleeding as well as airway compromise from blood in the oral cavity and tracheobronchial tree. Temporary hemostasis, airway protection, and hemodynamic resuscitation must occur immediately and concurrently to give the patient the best chance of survival while efforts for definitive treatment of the vascular injury are underway. Digital subtraction angiography is the gold standard for imaging assessment of vascular injury, and provides the option of endovascular therapy in the same setting. DSA also provides important information prior to surgery, including extent of vascular injury, collateral blood flow, and tests of cerebrovascular reserve such as balloon occlusion testing [1] (Fig. 1).
* Mougnyan Cox [email protected] 1
Section of Neurointerventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
2
Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
3
Department of Oral and Maxillofacial Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
4
Division of Trauma Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
5
Sectio
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