|Year : 2014 | Volume
| Issue : 1 | Page : 71-73
Stroke secondary to attempted strangulation
Raghavendra Narayanaswamy, Rahul Kumar Sharma, Manisha Thakur, Umesh Kansra
Department of Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
|Date of Web Publication||4-Jun-2014|
Rahul Kumar Sharma
Department of Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, H. No. 407 - K Street No. 2, Mandawali Fazalpur, Delhi - 110 092
Source of Support: None, Conflict of Interest: None
Stroke is a well-known complication of penetrating neck trauma. Rarely, it can result due to carotid artery thrombosis secondary to non-penetrating blunt pressure over neck. We here discuss the first case report of stroke in a young patient after attempted strangulation.
Keywords: Hemiplegia, stroke, strangulation
|How to cite this article:|
Narayanaswamy R, Sharma RK, Thakur M, Kansra U. Stroke secondary to attempted strangulation. Arch Med Health Sci 2014;2:71-3
| Introduction|| |
Cerebrovascular accident is defined by abrupt onset of a neurologic deficit that is attributable to a focal vascular cause. The clinical manifestations of stroke are highly variable because of complex anatomy of brain and its vasculature. Brain is mainly supplied by paired internal carotid and vertebral arteries. During its course in neck, the carotid artery is quite superficial, making it vulnerable to both penetrating and blunt traumatic injuries.
The majority of extra-cranial injuries to internal carotid artery (ICA) are caused by direct trauma from penetrating injuries. However, a small subset of extra-cranial ICA injuries is caused by blunt trauma, which is mostly associated with head injury. We here report a case of stroke associated with right carotid arterial tree affection caused by attempted strangulation using a piece of cloth. To the best of our knowledge, this is the first case report of stroke resulting from blunt trauma due to strangulation.
| Case Report|| |
A 32-year-old previously healthy male was brought to the emergency department with chief complaints of weakness of left side of the body and inability to speak for one day. Two days prior to his presentation, strangulation was attempted on him by someone using a cloth, following which he lost consciousness immediately. After he regained consciousness after one day, he noticed weakness on left side of his body, difficulty in speaking, and deviation of mouth to right. His past history was not suggestive of any chronic illness (diabetes mellitus, hypertension, bleeding disorder, heart diseases, or connective tissue disorder etc).
On examination, he was afebrile with stable vitals including blood pressure (114/76 mmHg). There were strangulation marks on both sides of neck, with bruising noticed over the occipital region, left elbow, and both legs. His carotid pulsations on the right side were weak with normal left-sided pulsations. On higher mental function examination, he was conscious, oriented to time, place, and person, with dysarthria and left upper motor neuron facial palsy. Motor examination revealed dense left-sided hemiplegia. His pupils were normal in size and light reaction with normal fundus examination. Rest of the systemic examination was unremarkable.
An urgent CT head showed a large hypo-dense area in the vascular territory of the right middle cerebral artery suggestive of infarction. MRI brain confirmed CT findings of a large recent infarct with hemorrhagic transformation along with loss of right internal carotid artery flow suggestive of thrombosis [Figure 1] and [Figure 2]. CT angiogram of head and neck showed thrombosis of the right common and internal carotid artery with occlusion of the right middle cerebral artery (MCA) and A1 part of anterior cerebral artery (ACA) [Figure 3]. No intimal flap was seen in the common or internal carotid artery, thus ruling out arterial dissection. Work up for other secondary causes of young stroke including echocardiography, antinuclear and anticardiolipin antibodies, lupus anticoagulant, inherited thrombophilia syndromes (proteins C and S, anti thrombin III and factor V Leiden mutation ), and infectious etiology (HIV and VDRL) was found to be negative. Patient was started on antiplatelet therapy with low dose aspirin (150 mg) to inhibit the extension of right carotid thrombus, along with other anti-cerebral edema measures. He subsequently improved, became more alert, and was started on physiotherapy and speech therapy.
|Figure 1: MRI of brain showing hemorrhagic transformation of MCA territory infarct|
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|Figure 2: Axial T1W MRI image showing loss of flow of right internal carotid artery (arrow) suggestive of thrombosis|
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|Figure 3: CT angiography shows right internal carotid artery thrombosis, MCA and A1 part of ACA block|
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| Discussion|| |
Strangulation is external compression of neck that may lead to unconsciousness or death by causing an increasingly hypoxic state in brain. The contents of anterior neck region are uniquely vulnerable to external pressure because of a number of vital structures in a relatively confined and unprotected space.  The structures at risk in strangulation include neck vasculature, carotid bodies, larynx and associated cartilages, and crucially the spine. The main causes of early death in strangulation include cardiac arrhythmia (carotid sinus stimulation), asphyxia (laryngeal obstruction), ischemic injury to brain (complete obstruction of carotid blood flow), and impaired respiration and unconsciousness (venous stasis due to pressure over jugular veins). 
Delayed morbidity and mortality has been reported in strangulation due to vascular and respiratory complications. Of these, carotid artery dissection and thrombosis have been described previously as vascular complications. In this case, arterial angiography shows thrombotic occlusion in right common and internal carotid artery. This may be due to traction on arterial structures causing intimal damage and subsequent thrombosis and obstruction.  However, this is a rare finding as shown in an autopsy series of 101 cases of hangings, which failed to demonstrate any intimal tears. 
Traumatic thrombosis of internal carotid artery is reported as being caused by one of the four mechanisms: (a) injury to intrapetrous or cavernous part of the carotid artery during the basal skull fracture, (b) injury to point of emergence of carotid artery from the cavernous sinus as the result of shearing strain, (c) a direct blow to the neck or trauma to paratonsillar area by a foreign object carried in the month, and (d) stretching of the carotid artery by hyperextension and lateral flexion of neck (which probably happened in our case). Secondary symptoms resulting from thrombosis of carotid artery develop most commonly between 12 and 24 hours after the injury. 
It has been suggested that after initial examination and resuscitation, CT scan and color Doppler of head and neck should be done in all cases of neck trauma.  If color Doppler reveals intimal injury, angiography and immediate surgery have been recommended even in absence of neurological deficit. Angiography is recommended in all cases with neurological symptoms after neck trauma.  Thrombolysis has been extensively used in non-traumatic carotid thrombotic occlusion and can be considered as an alternative to surgery in traumatic thrombosis also.  In our case, thrombolysis was not used as patient presented late with loss of crucial window period for thrombolysis.
| Conclusion|| |
This report highlights the need for a high index of suspicion of vascular injury in cases of blunt trauma to neck, especially after attempted strangulation. Such cases should undergo urgent imaging and evaluation for early recognition of ischemic complications. This case report adds to the existing literature on nervous system injury due to strangulation.
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[Figure 1], [Figure 2], [Figure 3]