Multiple acute cerebral infarctions after blunt cerebrovascular injury

Noriatsu Ohtsuka; Toshihiro Hatakeyama; Atsuki Hayamizu

doi:10.15441/ceem.24.276

A male automobile driver in his 50s was taken by ambulance to an emergency department due to a traffic accident. His seatbelt had not been fastened, and the airbag failed to deploy. The patient’s medical history included no risk factors for cerebrovascular disease. Computed tomography (CT) revealed a fracture of the second cervical spine (Fig. 1) as well as multiple fractures of the left facial bones including the left orbital floor (Fig. 2), fractures of the 10th, 11th, and 12th left dorsal ribs, and dislocation of the proximal interphalangeal joint of the left fourth finger. Neither the initial nor a subsequent CT revealed cerebral hemorrhage. The patient complained of diplopia just after the accident. An abnormal vertical movement was observed in the right eye, unrelated to orbital floor fractures. Additionally, the patient complained of numbness in both hands, which was not explained by the second cervical spine fracture, and on day 2 he manifested disorientation. Because neither physical findings nor verbal complaints coincided with CT findings, we performed magnetic resonance imaging, which showed multiple acute cerebral infarctions (Fig. 3). Further examinations including transthoracic echocardiography, carotid vessel ultrasound, and contrast-enhanced CT showed no thrombi. Holter electrocardiography revealed no arrhythmias. We thus diagnosed the patient with traumatic cerebral infarction. With rehabilitation, diplopia and other symptoms improved, and the patient was discharged on day 24.

Blunt cerebrovascular injuries comprise approximately 1% to 2% of traumatic injuries [1,2]. Although relatively infrequent, approximately 10% of blunt cerebrovascular injuries are reported to cause traumatic cerebral infarctions [1]. Most of these injuries result from traffic accidents [3], and may occur with or without skull fractures. In the present case, obstructed blood flow may have caused multiple acute cerebral infarctions when the vertebral artery sustained injury in the described traffic accident. Traumatic cerebral infarction should be considered when we encounter unexplained neurological symptoms in cases of blunt cerebrovascular injury with neck injury.

NOTES

Ethics statement

Informed consent for publication of the research details and clinical images was obtained from the patient.

Author contributions

Conceptualization: TH; Project administration: TH; Resources: NO; Supervision: AH; Visualization: NO, TH; Writing–original draft: NO, TH; Writing-review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

Toshihiro Hatakeyama received an overseas scholarship from Dokkyo Medical University (Koshigaya, Japan). Dokkyo Medical University had no role in the conduct of this research. The authors have no other conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Acknowledgments

The authors thank Professor Hisao Matsushima (Department of Emergency Medicine and Critical Care, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan) for his continuous support. They are also grateful to emergency physician Dr. Fumihito Fukushima, ophthalmologist Dr. Masatoshi Hanada, neurologist Dr. Machiko Yajima, and radiologist Dr. Kazuo Miida of the Saiseikai Kazo Hospital, Social Welfare Organization Saiseikai Imperial Gift Foundation Inc (Kazo, Japan) for their helpful discussions and comments regarding diagnosis.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

REFERENCES

1. Weber CD, Lefering R, Kobbe P, et al. Blunt cerebrovascular artery injury and stroke in severely injured patients: an international multicenter analysis. World J Surg 2018; 42:2043-53.

2. Hundersmarck D, Slooff WM, Homans JF, et al. Blunt cerebrovascular injury: incidence and long-term follow-up. Eur J Trauma Emerg Surg 2021; 47:161-70.

3. Lytle ME, West J, Burkes JN, et al. Limited clinical relevance of vertebral artery injury in blunt trauma. Ann Vasc Surg 2018; 53:53-62.

Fig. 1.

Computed tomography scan shows a fracture of the second cervical spine (arrowhead) indicating trauma due to a traffic accident, which may have caused vascular damage and multiple subsequent cerebral infarctions.

Fig. 2.

Computed tomography scan shows a fracture of the left orbital floor (arrowhead). No fractures were found on the right side, although the eye movement disorder was more severe on the right side than on the left side.

Fig. 3.

Diffusion-weighted magnetic resonance imaging of multiple cerebral infarctions (arrowheads). Each infarction was independent of vascular territories. (A) Infarctions of the frontal lobe in the territory of the anterior cerebral artery. (B) Infarction of the cerebellum in the territory of the vertebrobasilar artery. (C) Infarction of the cerebral peduncle in the territory of the vertebrobasilar artery. The infarction may be related to the vertical eye movement disorder. The vertical movement disorder of the right eye did not coincide with expected neurological findings based on the left orbital floor fractures.