Post-Traumatic Changes in the Internal Carotid Artery and its Branches: An Arteriography Study

The purpose of this paper is to present four cases in which head and neck trauma of various types produced changes in the internal carotid artery and its branches, demonstrated by arteriography. The entity of thrombosis and sometimes cerebral embolism following trauma has been described frequently from the clinical aspect, recent reviews being those of Pitner (7), Shillito (10), and Murray (6). Wolpert and Schechter (12) described post-traumatic occlusion of the middle cerebral artery without reference to internal carotid artery changes. The clinical picture is fairly typical. The patient often suffers an apparently minor injury to the head or neck which may be either penetrating or nonpenetrating. Penetrating injuries imply an open wound, usually intraoral in children, caused by falling with a pointed object in the mouth or by tonsillectomy. There is, however, no apparent perforation of the internal carotid artery. Nonpenetrating injury need not be directly to the artery but may produce its effect by abnormal stretching of the vessel. Following the injury there is usually a latent period of up to twenty-four hours before the onset of signs and symptoms of cerebral damage due to arterial obstruction (7). Of these, hemiplegia is the most common, associated with aphasia if the dominant hemisphere is involved. Convulsions have also been described. The neurological deficit is maximal at the onset, and death may occur (1). In survivors, recovery is gradual and varies in degree. Arteriography establishes the type, site, and extent of the obstruction in the carotid artery system, and characteristic changes may be seen in the vessels. Case I: A 5-year-old male underwent tonsillectomy May 8, 1966, and a left hemiplegia developed the following morning. When seen at the University of Alberta Hospital on May 11, he had a left flaccid hemiplegia, was alert, oriented, and afebrile, and the tonsillar bed was unremarkable. Investigations: Routine investigations, including a complete blood count, the sedimentation rate, and urinalysis were normal. Cerebrospinal fluid was under normal pressure and contained no cells. Radiographic Findings: Right carotid angiography was performed May 11, 1966. Under general anesthesia, the common carotid artery was punctured, and sodium diatrizoate 50 per cent (Hypaque 50 per cent) was injected. The carotid bifurcation appeared normal, but 2 cm distal to its origin the internal carotid artery tapered abruptly to half the previous diameter, and the intimal outline was minimally irregular. The narrowing persisted for the remaining length of the internal carotid artery, and there was complete obstruction at the distal end of the carotid siphon proximal to its bifurcation. The anterior choroidal, posterior communicating, and ophthalmic arteries were filled (Fig. 1). The patient showed gradual improvement and on discharge had residual left-sided weakness.