1276
Internal Carotid Artery Dissection
After Remote Surgery
Iatrogenic Complications of Anesthesia
Daniel B. Gould, MD; Kathleen Cunningham, BS
Downloaded from http://stroke.ahajournals.org/ by guest on June 17, 2017
Background Subintimal dissection with acute occlusion of
the internal carotid artery resulting in acute cerebral infarction has not been reported as an iatrogenic complication of
general anesthesia.
Case Descriptions An anesthetist stretched the neck of a
44-year-old man by anchoring an anesthesia mask posterior to
the angle of the jaw with overlying fingers as the patient
struggled during an insufficient inhalational mask anesthetic.
A 33-year-old man received an endotracheal anesthetic without struggle, but as he was turned from a supine to a prone
position, his head and neck were not immobilized to rotate
with his torso during the move. The next day both patients
suffered acute cerebral infarctions secondary to ICA dissections and occlusions (angiographically demonstrated).
Conclusions Stretching the soft neck tissues of anesthetized
patients can cause internal carotid artery dissection and acute
cerebral infarction. (Stroke. 1994;25:1276-1278.)
N
light plane of anesthesia. The patient's head (ie, occiput) was firmly restrained on the operating table
under the anesthesia mask held by the anesthetist's left
hand. Sufentanil and more atracurium were given intravenously to deepen the anesthesia.
After surgery the patient awakened and complained of
pain on the left side of his neck. No external abnormalities were apparent, and he was released from the
hospital. Eleven hours later he suddenly became aphasic
and had right hemiparesis and right central facial palsy.
On his immediate return to the hospital, carotid angiography was performed that demonstrated an occluded left
internal carotid artery. The pattern of a conical, tapering
lumen produced by subintimal dissection started at the
level of the third cervical vertebra; flow ceased at C-2
(see Figure). No filling of the left carotid siphon was seen
from antegrade flow or from collateralized filling retrograde to the ophthalmic artery. The aortic arch and other
cervical vessels were normal; computed tomography
(CT) of the head also appeared normal.
Heparin therapy was given after transfer to another
hospital. Right-sided hemiparesis resolved in 2 days;
intellectual function and fluent speech did not recover.
CT of the brain then revealed acute infarction of the left
temporal and parietal lobes in the territory supplied by
the middle cerebral artery. Repeat carotid arteriography
6 days after the acute event demonstrated persistent
occlusion of the left internal carotid artery and collateral
blood supply to the left cerebral hemisphere from the
anterior and posterior communicator branches. The patient requires continuous custodial care.
o report in the literature links the position of an
anesthetized patient's head and neck or the
forcible holding of an anesthesia mask to a
struggling (insufficiently anesthetized) patient with the
complication of carotid artery intimal tearing, dissection, and occlusion. The complication of carotid artery
occlusion and cerebral infarction typically is delayed
after the initial carotid artery injury and the beginning
of dissection1-2 and may therefore divert attention from
the physical rendering of a general anesthetic as the
cause of such events. The following accounts describe
the circumstances preceding these adverse events.
Case Reports
Case 1
A 44-year-old man weighing 185 lb, normotensive and
without systemic disease, underwent surgical removal of
a cactus thorn from his hand. An initial 5 mg atracurium
and 350 mg thiopental followed by 100 mg succinylcholine was administered intravenously. An anesthesia
mask was held in place on the patient's face by the
anesthetist's left hand. Laryngoscopy, attempted once,
could not expose the larynx, although the patient's
anatomy was normal. Tracheal intubation was not pursued. Oxygenation was well maintained, as confirmed by
pulse oximetry. Nitrous oxide (50%) and inspired enflurane (2%) were administered through the mask, with
an oral airway in place. Upon surgical incision the
patient moved strenuously. Assisted ventilation through
the mask was maintained, while the patient produced
high-pitched vocalization, another manifestation of a
Received February 18, 1994; final revision received March 22,
1994; accepted March 22, 1994.
From the Department of Anesthesiology, St. Louis (Mo) Regional Medical Center (D.B.G.), and Meyer and Williams, Attorneys at Law, PC (K.C.), Jackson, Wyo.
Correspondence to Daniel B. Gould, MD, 515 North Mosley
Road, Creve Coeur, MO 63141.
Key Words • anesthesia
infarction • dissection
carotid arteries
cerebral
Case 2
A 33-year-old normotensive man, 6' 6" tall, with unconfirmed suspicion of Klinefelter syndrome (XXY chromosome and variants) and symptomatic lumbar disc
herniation, was anesthetized for lumbar laminectomy in
the prone position. Laryngoscopy and tracheal intuba-
Gould and Cunningham ICA Dissection After Remote Surgery
...,-. I
Downloaded from http://stroke.ahajournals.org/ by guest on June 17, 2017
Selective left carotid arteriogram (patient 1) demonstrating subintimal dissection of the left internal carotid artery manifested by
an elongated, conical, tapered stenosis beginning at the level of
the third cervical vertebra and cessation of flow at the petrous
portion of that vessel.
tion were unremarkable; hemodynamics remained stable
throughout the anesthesia. The patient's recovery from
the anesthetic was uneventful until the next day, when he
suddenly developed right hemiparesis.
Left internal carotid artery dissection was confirmed
by immediate angiography; CT of the brain showed
ischemic infarction of the territory of the left middle
cerebral artery. The patient has a permanent right
hemiparesis and Broca's aphasia.
Discussion
The mechanism of hyperextension of the neck with
axial rotation of the head and neck is the proposed
mechanism of injury to the carotid artery that causes
the dissections described above. In case 1 the forceful
restraint of the patient's head as his torso strained
against the operating table may well have stretched the
internal carotid artery "across the transverse process of
the third cervical vertebra or the bony mass of the first
and second cervical vertebrae. This results in rupture of
the intima and media at the level of the third cervical
vertebra with preservation of the more elastic adventitia."2 The fourth and fifth fingers of the left hand
holding the anesthesia mask might also directly traumatize the artery, as they anchor the mask by extending
over the mandible and encroaching on the carotid
bifurcation.
In case 2 the tracheal intubation entailed no apparent
difficulties, and an adequate depth of anesthesia was
maintained. Unrecognized movement of the neck when
the patient was turned to the prone position or when the
head and neck were positioned with the patient prone
(such as 90° axial rotation or extension instead of
flexion) may have caused internal carotid artery damage. The potential for injury to the carotid artery exists
from "cervical rotation and hyperextension,"3 perhaps
enhanced for anesthetized patients unprotected by nor-
1277
mal muscle tone. Reports of patients with Klinefelter
syndrome with ruptured cerebral aneurysms,4-5 coupled
with a propensity for gravitational leg ulcers at an early
age, "lend support to the concept of a more fundamental vascular abnormality" in this disorder.5 The second
patient might have been at increased risk from anesthesia positioning because of this constitutional factor.5
The possibility that tracheal intubation might produce carotid artery dissection3 or vertebral artery dissection1-6 also has been suggested. The case report of a
44-year-old woman with left internal carotid artery
dissection and cerebral infarction attributes the catastrophe to childbirth.7 However, her hemiparesis occurred 3 hours after general anesthesia for cesarean
section.
A wide variety of physical stresses on the carotid
artery capable of causing its dissection have been identified.1-8 Manual manipulation of the neck has caused
carotid artery9 and vertebral artery10 dissection. Volitional strenuous neck movement also can produce carotid artery dissection.11 The complaint of neck pain,
voiced by the patient described above in case 1, is
infrequent in this entity; headache is a commonly
experienced symptom.12 Although one survey of carotid
dissection reports "an excellent or complete recovery"
in 85% of the cases,12 a larger series emphasizes the
likelihood of significant morbidity.13 Spontaneous dissections of cervical internal carotid arteries, causing
cranial nerve palsies, have recently been reported.14-15
Catastrophic cerebral infarction was not a feature of
these patients.1415 The yearly incidence of spontaneous
internal carotid artery dissection is estimated to be 2.6
per 100 000.16 Only one third of those affected in the
survey16 had ischemic strokes, and the majority of these
patients made a complete neurological recovery.16
Intraoperative brain infarctions carry a graver prognosis. Postsurgical infarctions of the brain stem and
cerebellum arising in cardiovascular surgical subjects
from cardiac or aortic embolization, or in noncardiovascular surgical subjects from "position-related vertebral
artery thromboses," produced severe neurological impairment in all cases.17
Two examples of acute dissection of left internal
carotid arteries with irreversible ischemic cerebral infarction from occlusion following general anesthesia are
newly presented. Vigilance against operating room conditions capable of causing carotid artery intimal tears
recommends itself. Surveillance for the briefly delayed
clinical presentation of this complication will define its
true incidence as a complication of mask anesthesia
administration and the turning and malpositioning of an
anesthetized patient (possibly with an additional risk
factor, as in case 2) lying prone on the operating room
table.
References
1. Hart RG, Easton JD. Dissections. Stroke. 1985; 16:925-927. Editorial.
2. Crissey MM, Bernstein EF. Delayed presentation of carotid
intimal tear following blunt craniocervical trauma. Surgery. 1974;
75:543-549.
3. Zelenock GB, Kazmers A, Whitehouse WM, Graham LAM,
Erlandson, Cronenwett JL, Lindenauer SM, Stanley JC. Extracranial internal carotid artery dissections. Arch Surg. 1982;117:
425-432.
4. Price WH, Steers AJW, Wilson J. Subarachnoid haemorrhage and
Klinefelter syndrome. Lancet. 1982;2:380. Letter.
1278
Stroke Vol 25, No 6 June 1994
5. Monk B. Vascular abnormality in Klinefelter syndrome'7 Lancet.
1982;2:491. Letter.
6. Caplan LR, Zarins CK, Hemmati M. Spontaneous dissection of
the extracranial vertebral arteries. Stroke. 1985;16:1030-1038.
7. Wiebers DO, Mokri B. Internal carotid artery dissection after
childbirth. Stroke. 1985;16:956-959.
8. Reddy K, Furer M, West M, Hamonic M. Carotid artery dissection
secondary to seatbelt trauma: case report. / Trauma 1990;30:
630-633.
9. Beatty RA. Dissecting hematoma of the internal carotid artery
following chiropractic cervical manipulation. J Trauma. 1911;Y1:
248-249.
10. Sherman DG, Hart RG, Easton JD. Abrupt changes in head
position and cerebral infarction. Stroke. 1981;12:2-6.
11. Jackson MA, Hughes RC, Ward SP, Mclnnes EG. 'Headbanging'
and carotid dissection. Br Med J. 1983;287:1262.
12. Mokri B, Sundt TM, Houser OW, Piepgras DG. Spontaneous
dissection of the cervical internal carotid artery. Ann Neurol. 1986;
19:126-138.
13. Bogousslavsky J, Despland P-A, Regli F. Spontaneous carotid
dissection with acute stroke. Arch Neurol. 1987;44:137-140.
14. Mokri B, Schievink WI, Olsen KD, Piepgras DG. Spontaneous
dissection of the cervical internal carotid artery. Arch Otolaryngol
Head Neck Surg. 1992;118:431-435.
15. Schievink WI, Mokri B, Garrity JA, Nichols DA, Piepgras DG.
Ocular motor nerve palsies in spontaneous dissection of the
cervical internal carotid artery. Neurology. 1993;43:1938-1941.
16. Schievink WI, Mokri B, Whisnant JP. Internal carotid artery dissection in a community. Stroke. 1993;24:1678-1680.
17. Tettenborn B, Caplan LR, Sloan MA, Estol CJ, Pessin MS, DeWitt
LD, Haley C, Price TR. Postoperative brainstem and cerebellar
infarcts. Neurology. 1993;43:471-477.
Downloaded from http://stroke.ahajournals.org/ by guest on June 17, 2017
Internal carotid artery dissection after remote surgery. Iatrogenic complications of
anesthesia.
D B Gould and K Cunningham
Stroke. 1994;25:1276-1278
doi: 10.1161/01.STR.25.6.1276
Downloaded from http://stroke.ahajournals.org/ by guest on June 17, 2017
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1994 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://stroke.ahajournals.org/content/25/6/1276
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in
Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.
Once the online version of the published article for which permission is being requested is located, click Request
Permissions in the middle column of the Web page under Services. Further information about this process is
available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Stroke is online at:
http://stroke.ahajournals.org//subscriptions/