Blunre

            

                       

nt traumaesulting i

      

atic injurin a strok

ry of the ke - A ra

  

innominaare prese

ate arterentation 

ry

ww.sciencedirect.com

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e3

Available online at w

ScienceDirect

journal homepage: www.elsevier .com/locate/apme

Case Report

Blunt traumatic injury of the innominate arteryresulting in a stroke e A rare presentation

Dhavapalani Alagappan*, N.R. Ganesh

Apollo Hospitals, Chennai, India

a r t i c l e i n f o

Article history:

Received 16 April 2014

Accepted 2 May 2014

Available online xxx

Keywords:

Blunt arterial injury

Innominate artery injury

Pseudo aneurysm

* Corresponding author.E-mail addresses: dhavapalani@hotmail.

Please cite this article in press as: Alagappe A rare presentation, Apollo Medicine (2

http://dx.doi.org/10.1016/j.apme.2014.05.0040976-0016/Copyright ª 2014, Indraprastha M

a b s t r a c t

Introduction: Blunt traumatic injury of innominate artery is uncommon and has been re-

ported only in 132 cases. In the literature there has been a solitary case report of a stroke

resulting from an innominate artery injury. We present a case of traumatic injury of the

innominate artery resulting in an ischemic stroke.

Case presentation: A 20-year-old gentleman ejected from a two wheeler and run over by a

truck presented to us with multiple bleeding facial wounds and severe crush injury of his

upper torso. Bedside chest X-ray revealed a widened mediastinum and multiple rib frac-

tures with pneumothoraces bilaterally which were drained with intercostal tubes. An hour

into his stay in the ED he developed left hemiparesis. CT brain showed infarcts in right

temporo-parietal and occipital regions. CT angiogram of neck vessels revealed an avulsion

injury at the origin of the right innominate artery with pseudoaneurysm formation.

Discussion: The innominate artery is the 2nd most common site of great vessel injury after

the ascending aorta. 71% die before reaching the hospital. Patients who present to the ED

are often stable with associated major injuries including rib fractures, pneumothorax and

closed head injuries. The diagnosis is aided by a thorough clinical examination or a chest

X-ray revealing a widened mediastinum as seen in our patient.

Lessons learnt: Severe upper torso injuries involving the clavicle and upper ribs with pulse

deficits or unexplained neurology should always raise a strong suspicion of major vascular

injuries warranting further evaluation.

Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Blunt traumatic injury of innominate artery is uncommon and

has been reported only in 132 cases.1 In the literature there

has been a solitary case report of a stroke resulting from an

innominate artery injury.2 We present a case of traumatic

injury of the innominate artery resulting in an ischemic

stroke.

com, drdhavapalani_a@ap

anD, GaneshNR, Blunt014), http://dx.doi.org/1

edical Corporation Ltd. A

2. Case presentation

A 20-year-old gentleman ejected from a two wheeler and ran

over by a truck presented to us with multiple bleeding facial

wounds and severe crush injury of his upper torso. However

he did not have any hemodynamic compromise. Bedside

chest X-ray revealed a widenedmediastinum andmultiple rib

fractures with pneumothoraces bilaterally which were

ollohospitals.com (D. Alagappan).

traumatic injury of the innominate artery resulting in a stroke0.1016/j.apme.2014.05.004

ll rights reserved.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e32

drained with intercostal tubes. An hour into his stay in the ED

he developed left sided hemiparesis. Subsequently he was

intubated for airway protection. CT brain showed infarcts in

right temporo-parietal and occipital regions. CT angiogram of

neck vessels revealed an avulsion injury at the origin of the

right innominate artery with pseudoaneurysm formation. He

was immediately shifted to theater for exploration where he

was found to have intimal transection of innominate artery

with a large intraluminal clot completely obstructing the

lumen with no ante grade flow. The vessel was divided and

repaired successfully. Post-operative recovery was uneventful

and he was discharged on the tenth post operative day with

minimal residual neurological deficit.

Chest X-ray showing widened uppermediastinum fracture

of 1st, 2nd, 3rd and 4th ribs on right side, subcutaneous

emphysema on right side, with bilateral chest drains in situ.

CT scan of brain plain showing a hypo dense lesion sug-

gestive of infarct in right temporo-parietal, occipital and high

parietal region.

Please cite this article in press as: Alagappan D, GaneshNR, Blunte A rare presentation, Apollo Medicine (2014), http://dx.doi.org/1

CT angiogram reconstructed image showing e avulsion

injury at the origin of the right innominate artery with

pseudo aneurysm formation. Innominate artery is not

visualized. Right common carotid artery shows reduced flow.

3. Discussion

The innominate artery is the 2nd most common site of great

vessel injury, the most common being the aortic isthmus

distal to the left subclavian artery.3 It is usually an avulsion or

transection injury found at the origin of the vessel from the

aortic arch and can be caused by deceleration or crush injuries

secondary to a motor vehicle crash or fall from a great height.

However, penetrating injuries more frequently cause innom-

inate artery disruptions. The postulated mechanism of injury

is an anteroposterior compression of the mediastinum be-

tween the sternum and the vertebrae that displaces the heart

posteriorly and to the left. This increases the curvature of the

arch and causes tension on the outlet vessels. 71% die before

reaching the hospital. Patients who present to the ED are often

stable with associated major injuries including rib fractures

(46%), pneumothorax (36%) and closed head injuries.4

The diagnosis is aided by a thorough clinical examination

(bruit, supraclavicular hematoma, pulse deficit, blood pres-

sure discrepancy between arms or a shoulder-belt sign) or a

chest X-ray revealing a widened mediastinum.5 Bleeding and

traumatic injury of the innominate artery resulting in a stroke0.1016/j.apme.2014.05.004

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e3 3

hemorrhagic shock may not be evident in blunt innominate

artery injury as the hematoma is usually contained in the

upper mediastinum

4. Lessons learnt

Severe upper torso injuries involving the clavicle and upper

ribs with pulse deficits or unexplained neurology should al-

ways raise a strong suspicion of major vascular injuries war-

ranting further evaluation.

Conflicts of interest

All authors have none to declare.

Please cite this article in press as: AlagappanD, GaneshNR, Blunte A rare presentation, Apollo Medicine (2014), http://dx.doi.org/1

r e f e r e n c e s

1. Hirose H, Moore E. Delayed presentation and rupture of aposttraumatic innominate artery aneurysm: case report andreview of the literature. J Trauma. 1997;42:1187e1195.

2. Kanwar M, Desai D, Joumaa M, Guduguntla V. Traumaticbrachiocephalic pseudoaneurysm presenting as stroke in aseventeen-year-old. Clin Cardiol. 2009 Nov;32(11):E43eE45.

3. Al-Khaldi A, Robbins RC. Successful repair of blunt injury ofaortic arch branches in the setting of bovine arch. J Vasc Surg.2006;43:396e398.

4. Stover S, Holtzman RB, Lottenberg L, Bass TL. Bluntinnominate artery injury. Am Surg. 2001;67(8):757e759.

5. Chen MY, Regan JD, D’Amore JM, Routh WD, Meredith JW,Dyer RB. Role of angiography in the detection of aortic branchvessel injury after blunt thoracic trauma. J Trauma.2001;51:1166e1171.

traumatic injury of the innominate artery resulting in a stroke0.1016/j.apme.2014.05.004

Apollo hospitals: http://www.apollohospitals.com/Twitter: https://twitter.com/HospitalsApolloYoutube: http://www.youtube.com/apollohospitalsindiaFacebook: http://www.facebook.com/TheApolloHospitalsSlideshare: http://www.slideshare.net/Apollo_HospitalsLinkedin: http://www.linkedin.com/company/apollo-hospitalsBlog:Blog: http://www.letstalkhealth.in/