Abstract
Objectives
Describe the presentation and treatment of a patient who suffered a penetrating cervical trauma resulting in occlusion of the vertebral and internal carotid arteries.
Methods
The electronic medical record was used to collect information pertaining to the patient’s clinical history.
Results
A 20-year-old male suffered a unique penetrating neck injury resulting in simultaneous injuries to the internal carotid and vertebral arteries as demonstrated by pre-operative angiography. Combined endovascular and open surgical approaches were utilized to successfully manage the vascular injuries prior to foreign body extraction.
Conclusion
Complex penetrating cervical trauma is best managed with a multidisciplinary and multimodality approach. In appropriately selected patients, pre-operative angiography is a critical diagnostic modality that can prevent life-threatening hemorrhage following foreign body extraction.
1
Introduction
Penetrating neck injury occurs in approximately 5–10% of all trauma admissions and is associated with a high risk of damage to major nerve, vascular and aerodigestive tract structures . The trauma sustained in the present report occurred within zone III of the neck, a defined anatomic region extending from the skull base to the angle of the mandible. Due to the proximity of the mandible and skull base, zone III injuries can be challenging to access and explore with open surgical approaches . As a result, patients with penetrating zone III trauma typically undergo angiography in the absence of life threatening airway or hemodynamic instability . The angiography results of the case described in this report revealed a unique injury pattern involving the internal carotid and vertebral arteries and were of critical importance in guiding the appropriate treatment strategy.
2
Case report
A 20 year-old male was impaled with a wooden projectile while working with a power saw in a furniture woodshop. The object penetrated the left cheek lateral to the maxilla and medial to the mandibular ramus, passing through the parapharyngeal space where it split into two fragments resulting in fractures through the transverse foramen and anterior and posterior ring of C1 ( Fig. 1 ). Upon initial evaluation at an outside medical facility, the patient was alert and oriented without neurologic deficit. Cervical spine precautions were initiated, a tracheostomy was placed for airway stabilization and the patient was transferred to our tertiary care institution.
Computed tomography and angiography revealed occlusion of the left internal carotid artery at the skull base, occlusion of the left vertebral artery at the level of C1, a comminuted C1 fracture, cervical spine subdural hematoma, and retained foreign body fragments within the neck and spinal canal. Interventional angiography facilitated endovascular coiling of the distal aspect of the injured vertebral artery via the contralateral vertebral artery. The proximal injured segment was accessed via the ipsilateral vertebral artery and coiled. This was followed by an anterior cervical surgical exploration with ligation of the proximal internal carotid artery, parapharyngeal and retropharyngeal space dissection and subsequent foreign body extraction ( Fig. 2 ). The longest wooden fragment was 13 cm and removed in its entirety from the entry wound site ( Fig. 3 ). Moderate bleeding from the skull base at the site of the distal internal carotid artery injury occurred after foreign body extraction. Absorbable hemostatic packing material and an abdominal fat graft were placed to achieve hemostasis and prevent cerebrospinal fluid (CSF) leak at the skull base. Intraoperative ultrasound was used to confirm that all foreign body fragments had been extracted. There was no intraoperative evidence of CSF leak and the wound was closed primarily. A three week course of post-operative parenteral antibiotics was completed. Despite gross contamination of the wound by the foreign body, no post-operative infection was observed. At the most recent two month follow-up evaluation, the patient had a right-sided hemi-paresis secondary to a thromboembolic event involving the left middle cerebral artery, M1 segment.
