A Real Pain in the Neck
CASE
Trauma Activation: 17 y/o M with a depressed Glasgow Coma Scale (GCS)
A 17-year-old boy arrives to the trauma bay. He was the unhelmeted driver of a moped that collided with a truck going approximately 40 mph. He was thrown from the moped and lost consciousness. When EMS arrived on scene his GCS was 8, but it had improved during transport. In the trauma bay he has a GCS of 15 and his primary survey is intact. Vital signs are normal. Secondary survey reveals scattered abrasions and lacerations, as well as left anterior neck tenderness. His only complaint is pain in the left anterior neck. A CT panscan is ordered due to the nature of the trauma, and a CTA neck is included given the left anterior neck pain and focal tenderness. An axial image from the CTA neck is below which confirms the diagnosis.
Image 1. Representative image from CTA neck
DIAGNOSIS
Traumatic Carotid Artery Dissection
The CTA shows focal traumatic dissection of the left internal carotid artery caudal to the level of the skull base. There are multiple focal regions of stenosis including a nearly 90% focal narrowing of this vessel. There is an intraluminal intimal flap. The distal aspect of the left carotid artery is patent.
Image 2. Focal traumatic dissection of the left internal carotid artery
DISCUSSION
Background
Traumatic carotid artery dissection is a rare occurrence in pediatrics, thought to affect 1-9% of pediatric patients seen in the emergency department with blunt traumatic injuries. [1] It is an important cause of ischemic stroke in children, with extracranial dissection of cervicocephalic arteries (CCAD) accounting for 5-25% of pediatric acute ischemic strokes. [2] Mortality rates can be as high as 20%. [3]
Pathophysiology
Traumatic carotid artery dissection is often the result of a hyperextension-rotation injury of the head that causes stretching of the vessels, or of direct trauma to the artery itself. [3] Classically, carotid artery dissections are thought to occur due to a tear in the tunica intima of the vessel wall, which leads to hematoma formation and luminal narrowing. [3] However, in children, the dissection can remain in the subadventitial plane, rather than in the subintimal plane. This is more strongly associated with pseudoaneurysm formation and later formation of emboli, which may account for the delayed clinical presentation seen in pediatric patients. [3,4]
Figure 1. Comparison of subadventitial and subintimal carotid injuries. From Brown et al., 1995.
Clinical Manifestations
Symptoms can be vague including headache, neck pain, dysphagia, or tinnitus. Clinical findings most often include cranial nerve palsies, Horner syndrome, or hemiparesis. However, it can take days or even months for these neurologic findings to develop, [3] so many patients will have a normal neurologic examination on first presentation. In fact, almost half of pediatric patients with traumatic carotid artery dissection will have no neurologic symptoms on admission. [3]
Diagnosis
Given the rarity of this injury in pediatrics, and the fact that many will initially present asymptomatic, there has been some research into developing a clinical decision rule to determine which patients are at high risk for blunt cerebrovascular injury, and thus should undergo diagnostic testing. Three scores that were developed for use in adults, the Denver, modified Memphis, and EAST scores, have not been proven to be accurate in pediatric populations. [1] The two scores that have been developed specifically for pediatric patients are the Utah score and the McGovern score. [1] While neither is perfect, knowledge of their components may help increase provider suspicion for blunt cerebrovascular injury.
At this time, conventional angiography remains the gold standard for diagnosis. However, there has been a shift toward MRA and CTA. CTA carries a high risk of radiation that MRA does not, but it is more widely available and in most cases is faster to obtain. CTA is also slightly more sensitive at 98-100% for detecting CCAD in adults (compared with MRA sensitivity of 95%), although its diagnostic performance in children has not been studied as extensively. [2]
Treatment
There is no consensus on the optimal treatment of pediatric traumatic carotid artery dissection. The current American Heart Association Stroke Council recommendation is to treat extracranial CCAD in children with either subcutaneous low molecular weight heparin (LMWH) or warfarin for 3-6 months. Alternatively, an antiplatelet agent may be used. [5] To date there are no randomized trials to support the use of one therapy over the other, and several nonrandomized trials have shown no significant difference between anticoagulation or antiplatelet agent use. [4] Intracranial dissection is a contraindication to anticoagulation. [5] In patients who continue to have symptoms from CCAD despite medical therapy, or who have expanding pseudoaneurysm, endovascular repair should be considered. [5, 6]
Prognosis
Overall the prognosis of traumatic carotid artery dissection in children is fair with approximately 40% of patients having complete recovery. [3]
CASE RESOLUTION
The patient was evaluated by both vascular surgery and neurosurgery, and was ultimately started on a daily baby aspirin. There were no acute surgical interventions. His symptoms improved and he was discharged on hospital day 3. He returned to the emergency department 4 days later with headache, nausea, and vomiting. Repeat CTA showed worsening of his dissection and rapid MRI showed a mild perfusion delay in the left MCA territory. His medical regimen was increased to dual antiplatelet therapy (DAPT) and he was discharged the next day. As of the last clinic follow up, he remains on DAPT.
TAKE-AWAYS
1. Carotid dissection is a rare but clinically significant injury that can be seen after blunt trauma
2. Many cases, especially in pediatrics, may initially have no neurologic deficits
3. Initial management should involve either an antiplatelet agent or anticoagulation, although more research is needed to determine which is superior
4. If medical management fails, or there is an expanding pseudoaneurysm, consider endovascular stenting
Author: Danielle Kerrigan, MD is a third year resident and Chief of Medical Education at Brown University/Rhode Island Hospital
Faculty Reviewer: Kristina McAteer, MD is an attending physician at Rhode Island Hospital and Newport Hospital
KEYWORDS & CATEGORIES
Pediatrics, Trauma, Carotid Dissection, Neurology, Neurosurgery, Vascular
REFERENCES
1. Herbert, J., Venkataraman, S., Turkmani, A., Zhu, L., Kerr, M., & Patel, R. et al. (2018). Pediatric blunt cerebrovascular injury: the McGovern screening score. Journal Of Neurosurgery: Pediatrics, 21(6), 639-649.
2. Stence, N., Fenton, L., Goldenberg, N., Armstrong-Wells, J., & Bernard, T. (2011). Craniocervical Arterial Dissection in Children: Diagnosis and Treatment. Current Treatment Options In Neurology, 13(6), 636-648.
3. Duyu, M., Yıldız, S., Bulut, İ., Karakaya, Z., Buz, A., & Bozbeyoğlu, G. (2020). Internal carotid artery dissection following blunt head trauma: a pediatric case report and review of the literature. The Turkish Journal Of Pediatrics, 62(6), 1077.
4. Chamoun, R., & Jea, A. (2010). Traumatic Intracranial and Extracranial Vascular Injuries in Children. Neurosurgery Clinics Of North America, 21(3), 529-542.
5. Roach, E., Golomb, M., Adams, R., Biller, J., Daniels, S., & deVeber, G. et al. (2008). Management of Stroke in Infants and Children. Stroke, 39(9), 2644-2691.
6. Chern, J., Chamoun, R., Mawad, M., Whitehead, W., Curry, D., Luerssen, T., & Jea, A. (2009). Endovascular stenting of traumatic extracranial carotid artery dissections in the pediatric population: a case report. Cases Journal, 2(1).
7. Brown, J., Danielson, R., Donahue, S., & Thompson, H. (1995). Horner's Syndrome in Subadventitial Carotid Artery Dissection and the Role of Magnetic Resonance Angiography. American Journal Of Ophthalmology, 119(6), 811-813.
8. Chamoun, R., Mawad, M., Whitehead, W., Luerssen, T., & Jea, A. (2008). Extracranial traumatic carotid artery dissections in children: a review of current diagnosis and treatment options. Journal Of Neurosurgery: Pediatrics, 2(2), 101-108.
9. Engelter, S., Traenka, C., Gensicke, H., Schaedelin, S., Luft, A., & Simonetti, B. et al. (2021). Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial. The Lancet Neurology, 20(5), 341-350.