Images in Vascular Surgery Bilateral Carotid Bifurcation Thrombi Caused by Neck Overextension: Case Report and Review of the Literature Vascular and Endovascular Surgery Volume 42 Number 6 Dec 2008/Jan 2009 599-600 © 2009 SAGE Publications 10.1177/1538574408320528 http://ves.sagepub.com hosted at http://online.sagepub.com Thomas Kotsis, MD, PhD, FACA, Konstantinos G. Moulakakis, MD, Achilleas Aspiotis, MD, and Vasilios Andrikopoulos, MD A 24-year-old man was transferred to the emergency department due to mental confusion following slight alcohol consumption and a fall. Three days before, his car was suddenly hit on its left side by another car at a 90-degree angle; he suffered no external injury. The patient had right hemiplegia and severe dysarthria; he was irrational and semicomatose but hemodynamically stable. There were pulsations in all arteries with a right carotid bruit; no neck trauma was noted. Urgent head and neck computed tomography (CT) scans were negative. Color-coded duplex (CCD) sonography revealed floating thrombi at both internal carotids originating from the bifurcations. Angiography documented an extended contrast filling defect in the left internal carotid artery, causing an incomplete occlusion and a similar defect in the right internal carotid (Figure 1); no dissection was documented. Magnetic resonance imaging (MRI) of the brain, performed 2 days later, showed cortical infarcts in both brain hemispheres (Figure 2). The patient improved and was given dexamethasone and anticoagulation therapy with low molecular weight heparin (enoxaparine 60 mg bid subcutaneously); bed rest with neck immobilization was decided. Twenty-two days after admission, angiography showed complete disappearance of the mural thrombi (Figure 3). The patient was discharged after 23 days with only a small motor deficit of the right thumb. The anticoagulation regimen was changed to acenocoumarol per os. The CCD scan was normal at 20 months after discharge, as well as at 3 years. Bilateral carotid thrombosis following a blunt cervicofacial trauma1-3 is infrequent, and bifurcation of attached thrombi without distal carotid dissection is rarer. In our case, sudden lateral neck overextension due to the automobile accident caused local intimal disrupture in both carotids and development of local thrombi4; 3 days later, thrombi fragments probably detached following the patient’s uncontrolled fall, From the Red Cross Hospital, Vascular Unit, Athens, Greece. Address correspondence to: Thomas Kotsis, MD, PhD, FACA, Department of Vascular Surgery, 2nd Surgical Clinic, School of Medicine, Athens University, Aretaeion Hospital, Athens, Greece; e-mail: kotsisth@otenet.gr. Figure 1. Carotid angiograms illustrating left (A) and right (B) internal carotid artery partial thrombosis. 599 600 Vascular and Endovascular Surgery / Vol. 42, No. 6, December 2008/January 2009 Figure 2. A Magnetic Resonance Imaging (MRI) of the brain demonstrating cerebral cortical infarcts in both brain hemispheres, predominantly in the left. thrombi can be generated; clinical suspicion is essential. Until now, there have been no class I data or accurate criteria to base management decisions for blunt carotid injuries either due to contusion or neck overextension.1-3 The appropriate treatment—surgery, stenting, or anticoagulation— is strictly individualized, guided by the clinical and paraclinical picture and the time from the estimated onset. References Figure 3. Follow-up carotid angiograms demonstrating the complete healing of arterial lesions. creating brain infarcts predominantly in the left hemisphere. Intimal disrupture was limited probably due to the young age or due to the limited neck overextension. Traffic accident victims, even in the absence of a physical trauma, can suffer many inoculated injuries, including carotid intima disrupture due to neck overextension; better lateral neck vehicle support is implied. Following intima laceration, an extended distal or limited dissection with attached 1. Gouny P, Nowak C, Smarrito S, Fadel E, HocquetCheynel C, Nussaume O. Bilateral thrombosis of the internal carotid arteries after a closed trauma: advantages of magnetic resonance imaging and review of the literature. J Cardiovasc Surg (Torino). 1998;39:417-424. 2. Cogbill TH, Moore EE, Meissner M, et al. The spectrum of blunt injury to the carotid artery: a multicenter perspective. J Trauma. 1994;37:473-479. 3. Alimi Y, Di Mauro P, Tomachot L, et al. Bilateral dissection of the internal carotid artery at the base of the skull due to blunt trauma: incidence and severity. Ann Vasc Surg. 1998;12:557-565. 4. Kindelberger D, Gilmore K, Catanese CA, Armbrustmacher VW. Hyperextension and rotation of head causing internal carotid artery laceration with basilar subarachnoid hematoma. J Forensic Sci. 2003;48: 1366-1368.