Zusammenfassung
Wir berichten über den Fall eines 33-jährigen Mannes, der uns über den Notarztdienst in der Rettungsstelle unseres Klinikums vorgestellt wurde, nachdem er im Rahmen eines Verkehrsunfalls ein Hochrasanztrauma erlitten hatte. Neben einer Skaphoidfraktur bestand initial keine weitere neurologische Ausfallsymptomatik. Nach mehreren Stunden symptomfreien Intervalls entwickelte der Patient eine Dysarthrie als Akutmanifestation einer lokalen zerebralen Ischämie aufgrund einer traumatischen Dissektion der A. carotis interna rechts. Unter der eingeleiteten PTT-wirksamen Therapie mit unfraktioniertem Heparin kam es zu einer raschen kompletten Remission der neurologischen Symptome. Im Verlauf kam es zur Ausbildung eines Dissektionsaneurysmas. Der Patient blieb bislang unter der antikoagulativen Behandlung mit Phenprocoumon beschwerdefrei.
Wir möchten diesen Artikel nutzen, um neben der Darstellung dieses interessanten Falles das Diagnostik- und Therapieregime im Falle einer auftretenden Dissektion eines supraaortalen Gefäßes zu beleuchten, um dieser seltenen aber potenziell gefährlichen Komplikation rasch und suffizient begegnen zu können.
Abstract
We report on the case of a 33-year-old male patient who was brought to the emergency room of our hospital after suffering a high-energy trauma due to an automobile accident. Besides a scaphoid fracture there were no signs of any neurological deficits. After several hours without clinical symptoms the patient developed dysarthria as the first manifestation of local cerebral ischemia based on a traumatic dissection of the internal carotid artery. Under systemic high-dose heparin therapy, fast and complete remission of all neurological disorders could be achieved. In the course of time a dissecting aneurysm developed. Temporary anticoagulation with phenprocoumon was started in the meantime and no further complications have appeared up to now.
Besides presenting this absorbing case, this article highlights the diagnostic and therapeutic regime in cases of a traumatic dissection of supra-aortal arteries for rapid and adequate management of this rare but potentially dangerous complication.
Literatur
Alecu C, Fortrat JO, Ducrocq X et al (2007) Duplex scanning diagnosis of internal carotid artery dissections. A case control study. Cerebrovasc Dis 23:441–447
Arnold M, Baumgartner RW, Stapf C et al (2008) Ultrasound diagnosis of spontaneous carotid dissection with isolated Horner syndrome. Stroke 39:82–86
Bachmann R, Nassenstein I, Kooijman H et al (2007) High-resolution magnetic resonance imaging (MRI) at 3.0 Tesla in the short-term follow-up of patients with proven cervical artery dissection. Invest Radiol 42:460–466
Beletsky V, Nadareishvili Z, Lynch J et al (2003) Cervical arterial dissection: time for a therapeutic trial? Stroke 34:2856–2860
Benninger DH, Gandjour J, Georgiadis D et al (2007) Benign long-term outcome of conservatively treated cervical aneurysms due to carotid dissection. Neurology 69:486–487
Benninger DH, Georgiadis D et al (2006) Accuracy of color duplex ultrasound diagnosis of spontaneous carotid dissection causing ischemia. Stroke 37:377–381
Benninger DH, Georgiadis D, Kremer C et al (2004) Mechanism of ischemic infarct in spontaneous carotid dissection. Stroke 35:482–485
Biffl WL, Moore EE, Elliott JP et al (2000) The devastating potential of blunt vertebral arterial injuries. Ann Surg 231:672–681
Bouzat P, Francony G, Brun J et al (2010) Detecting traumatic internal carotid artery dissection using transcranial Doppler in head-injured patients. Intensive Care Med 36:1514–1520
Caplan LR (2008) Dissections of brain-supplying arteries. Nat Clin Pract Neurol 4:34–42
Cervera A, Justicia C, Reverter JC et al (2004) Steady plasma concentration of unfractionated heparin reduces infarct volume and prevents inflammatory damage after transient focal cerebral ischemia in the rat. J Neurosci Res 77:565–572
Clarot F, Vaz E, Papin F, Proust B (2005) Fatal and non-fatal bilateral delayed carotid artery dissection after manual strangulation. Forensic Sci Int 149:143–150
Cothren CC, Moore EE, Biffl WL et al (2004) Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg 139:540–546
Dittrich R, Dziewas R, Ritter MA et al (2006) Negative ultrasound findings in patients with cervical artery dissection. Negative ultrasound in CAD. J Neurol 253:424–433
Droste DW, Junker K, Stogbauer F et al (2001) Clinically silent circulating microemboli in 20 patients with carotid or vertebral artery dissection. Cerebrovasc Dis 12:181–185
DuBose J, Recinos G, Teixeira PG et al (2008) Endovascular stenting for the treatment of traumatic internal carotid injuries: expanding experience. J Trauma 65:1561–1566
Dziewas R, Konrad C, Drager B et al (2003) Cervical artery dissection–clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 250:1179–1184
Edgell RC, Abou-Chebl A, Yadav JS (2005) Endovascular management of spontaneous carotid artery dissection. J Vasc Surg 42:854–860
Engelter ST, Brandt T, Debette S et al (2007) Antiplatelets versus anticoagulation in cervical artery dissection. Stroke 38:2605–2611
Flis CM, Jager HR, Sidhu PS (2007) Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol 17:820–834
Fusco MR, Harrigan MR (2011) Cerebrovascular dissections–a review part I: Spontaneous dissections. Neurosurgery 68:242–257
Guillon B, Bousser MG (2002) Epidemiology and pathophysiology of spontaneous cervical artery dissection. J Neuroradiol 29:241–249
Inamasu J, Guiot BH (2006) Vertebral artery injury after blunt cervical trauma: an update. Surg Neurol 65:238–245
Lee VH, Brown RD, Mandrekar JN Jr, Mokri B (2006) Incidence and outcome of cervical artery dissection: a population-based study. Neurology 67:1809–1812
Lyrer P, Engelter S (2010) Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev (Online):CD000255
Lyrer PA (2005) Extracranial arterial dissection: anticoagulation is the treatment of choice: against. Stroke 36:2042–2043
Meyn M, Jenal G, Henkes H, Hupp T (2008) Läsionen der extrakraniellen A.carotis durch Strangulation. Gefasschirurgie 13:197–203
Muller BT, Luther B, Hort W et al (2000) Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg 31:980–988
Mutze S, Rademacher G, Matthes G et al (2005) Blunt cerebrovascular injury in patients with blunt multiple trauma: diagnostic accuracy of duplex Doppler US and early CT angiography. Radiology 237:884–892
Narayanan K, Griffiths PG, Pandit RJ (2010) Transient and subclinical Horner syndrome in internal carotid artery dissection. J Neuroophthalmol 30:342–343
Nebelsieck J, Sengelhoff C, Nassenstein I et al (2009) Sensitivity of neurovascular ultrasound for the detection of spontaneous cervical artery dissection. J Clin Neurosci 16:79–82
Perren F, Loulidi J, Graves R et al (2006) Combined IV-intra-arterial thrombolysis: a color-coded duplex pilot study. Neurology 67:324–326
Pham MH, Rahme RJ, Arnaout O et al (2011) Endovascular stenting of extracranial carotid and vertebral artery dissections: a systematic review of the literature. Neurosurgery 68:856–866
Phan T, Huston J 3rd, Bernstein MA et al (2001) Contrast-enhanced magnetic resonance angiography of the cervical vessels: experience with 422 patients. Stroke 32:2282–2286
Quinn C, Cooke J, O’Connor M, Lyons D (2011) Cervical artery dissection following a turbulent flight. Aviat Space Environ Med 82:995–997
Rao AS, Makaroun MS, Marone LK et al (2011) Long-term outcomes of internal carotid artery dissection. J Vasc Surg 54:370–375
Redekop GJ (2008) Extracranial carotid and vertebral artery dissection: a review. Can J Neurol Sci 35:146–152
Ringer AJ, Matern E, Parikh S, Levine NB (2010) Screening for blunt cerebrovascular injury: selection criteria for use of angiography. J Neurosurg 112:1146–1149
Rosenkranz M, Eckert B, Niesen WD et al (2003) Horner syndrome related to ipsilateral carotid wall hematoma after stent placement for the treatment of carotid stenoses. AJNR Am J Neuroradiol 24:1508–1511
Schelfaut D, Dhondt E, De Raedt S et al (2011) Carotid artery dissection: three cases and a review of the literature. Eur J Emerg Med
Schievink WI (2001) Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 344:898–906
Schievink WI, Debette S (2011) Etiology of cervical artery dissections: the writing is in the wall. Neurology 76:1452–1453
Schneidereit NP, Simons R, Nicolaou S et al (2006) Utility of screening for blunt vascular neck injuries with computed tomographic angiography. J Trauma 60:209–215
Schuster L, Hauser T, Essig M (2010) Significance of MR angiography for imaging diagnostics of carotid artery diseases. Radiologe 50:597–606
Sengelhoff C, Nebelsieck J, Nassenstein I et al (2008) Neurosonographical follow-up in patients with spontaneous cervical artery dissection. Neurol Res 30:687–689
Sparing R, Hesse MD, Schiefer J (2005) Traumatic internal carotid artery dissection associated with triathlon: a rare differential diagnosis. Sportverletz Sportschaden 19:211–213
Sturzenegger M, Mattle HP, Rivoir A, Baumgartner RW (1995) Ultrasound findings in carotid artery dissection: analysis of 43 patients. Neurology 45:691–698
Tascilar N, Ozen B, Acikgoz M et al (2011) Traumatic internal carotid artery dissection associated with playing soccer: a case report. Ulus Travma Acil Cerrahi Derg 17:371–373
Touze E, Randoux B, Meary E et al (2001) Aneurysmal forms of cervical artery dissection: associated factors and outcome. Stroke 32:418–423
Wessem KJ van, Meijer JM, Leenen LP et al (2011) Blunt traumatic carotid artery dissection still a pitfall? The rationale for aggressive screening. Eur J Trauma Emerg Surg 37:147–154
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Lenz, M., Bula-Sternberg, J., Koch, T. et al. Traumatische Dissektion der A. carotis interna nach HWS-Beschleunigungstrauma. Unfallchirurg 115, 369–376 (2012). https://doi.org/10.1007/s00113-011-2130-7
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DOI: https://doi.org/10.1007/s00113-011-2130-7
Schlüsselwörter
- Gefäßdissektion, traumatische
- Supraaortale Gefäße
- A. carotis interna
- Halswirbelsäule
- Beschleunigungstrauma