traumatic carotid dissection

27bseau at one.net.au 27bseau at one.net.au
Thu Jul 3 02:57:48 EST 1997

I am involved with the management of a 23 year-old semi-professional
athlete who suffered a severe right shoulder dislocation in a sporting
accident.  He had an undiagnosed and untreated axillary artery
pseudoaneurysm which caused pain for many months.  Neurological signs
included a partial Volkmann's contracture, clawing of the fingers etc. 
No investigation was done for vascular injury.

Four months post accident he was doing physiotherapy exercises involving
his right arm and shoulder.  He collapsed without warning and was taken
to hospital.

Doppler investigation revealed a large right axillary artery
pseudoaneurysm and also an intimal dissection of the right internal
carotid artery.  He suffered a massive stroke.

The pseudoaneurysm was repaired using a vein patch graft and the pain
that he had had since the injury immediately disappeared.  Unfortunately
his neurological deficit remains.  He has lost the use of his left arm
completely and has severe ataxia due to the deficit in his left leg.  His
athletic career is over.

Retrograde thrombus from the site of the axillary pseudoaneurym is and
unlikely explanation for the stroke.  I am wondering whether there may be
a connection between the physiotherapy exercises together with the
history of pain (and inflammation) which may have aggravated an otherwise
benign injury to the intima suffered during the original accident.

It seems to me that the late onset of the stroke which occurred during
exercise and without prior warning signs (headache etc) implicates the
underlying untreated axillary pseudoaneurysm in some way.

I would be grateful to hear from anyone with expertise in this area to
help me to understand and explain to this fellow what happened.

Thank you.

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