AJR 2002; 179:1352
© American Roentgen Ray Society
Kinking of Bilateral Internal Carotid Arteries That Mimics Posttraumatic Radiographic Prevertebral Soft-Tissue Widening
Ian C. Duncan,
Basil J. Sher and
Mervyn Pencharz
Sunninghill Medical Institute Sandton, South Africa
A 65-year-old woman was admitted to the trauma unit of our institution
after sustaining a whiplash injury of the neck in a motor vehicle crash. On
the initial lateral shoot-through radiograph of the cervical spine, an
increase in the prevertebral soft-tissue width was noted
(Fig. 3A). CT showed no acute
bony or joint disruption at any level and also failed to provide any further
information about the cause of the prevertebral swelling. Arteriography
(requested by the attending trauma surgeon to exclude a vascular injury in the
neck) showed a clinically occult left vertebral artery occlusion, but no
further injury to the blood vessels. Marked looping of the two internal
carotid arteries was seen, but the importance of this finding was not yet
known (Fig. 3B). Finally, MR
imaging performed the next day clearly showed that the prevertebral thickening
was due to apposition of the two medially kinked internal carotid arteries
lying anterior relative to the cervical spine (Figs.
3C and
3D). No other relevant
abnormalities were noted in the cervical region.
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Fig. 3B. —65-year-old woman who sustained whiplash injury of neck in
motor vehicle crash. Selective digital subtraction arteriogram of left common
carotid artery reveals kinking of internal carotid artery.
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Fig. 3C. —65-year-old woman who sustained whiplash injury of neck in
motor vehicle crash. Axial T2-weighted MR image obtained at C3—C4 level
shows internal carotid arteries lying medially between vertebral column and
pharynx.
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Increased width of the prevertebral soft tissues visualized on lateral
cervical spine radiography is regarded as a highly significant finding after
cervical spine trauma [1,
2]. If bony or joint disruption
is not apparent on initial radiography, further sectional imaging is
mandatory, if this option is available. Paulsen et al.
[3] found kinking in 4.3% of
the internal carotid arteries in 282 anatomic neck specimens; half of these
kinks were related to the pharyngeal wall.
One of the major dangers presented by undiagnosed kinks or loops in the
internal carotid arteries is that they can be mistaken clinically for a tumor
or an abscess and subsequently injured during an attempted biopsy or surgical
excision. This potentially catastrophic complication can easily be avoided by
the use of appropriate sectional imaging before any invasive procedure is
attempted. Fortunately, the initial missed diagnosis did not result in harm to
our patient; however, had the MR imaging been performed at an earlier stage,
conventional arteriography could have been avoided. Despite the rarity of this
vascular anatomic variant, it should nevertheless be considered in the
differential diagnosis of prevertebral soft-tissue widening regardless of
whether or not it is related to trauma.
References
- Edeiken-Monroe B, Wagner L, Harris JH. Hyper-extension dislocations
of the cervical spine. AJR
1986;146:803
-808[Abstract/Free Full Text]
- Silberstein M, Tress BM, Hennessy O. Prevertebral swelling in
cervical spine injury: identification of ligament injury with magnetic
resonance imaging. Clin Radiol
1992;46:318
-323[Medline]
- Paulsen F, Tillmann B, Christofides C, Richter W, Koebke J. Curving
and looping of the internal carotid artery in relation to the pharynx:
frequency, embryology and clinical implications. J
Anat 2000;197:373
-381
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