Dissection of the internal carotid artery and hemicraniectomy

  • Meheroz H. Rabadi
    Requests for reprints should be addressed to Meheroz H. Rabadi, MD, Weill Medical College of Cornell University, Burke Rehabilitation Hospital, 785 Mamaroneck Ave., White Plains, NY 10605.
    Weill Medical Collge of Cornell University, Burke Rehabilitation Hospital, White Plains, NY.
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      An 18-year-old right-handed student, while playing “war games” with his friends, on sudden turning of his head felt dizzy and fell to the ground. On admission to the local emergency room he was found to have left facial droop and left-sided hemiplegia. Admission head computed tomography scan was normal. Three days later the patient complained of slurred speech and was noted to have a decreased level of consciousness. Emergency head magnetic resonance imaging showed right cerebral hemisphere edema and an acute infarction. Head magnetic resonance arteriography showed dissection of the cervical part of the right internal carotid artery (Figure, panel A). The patient underwent a right hemi-craniectomy to relieve the cerebral edema (Figure, panel B), with placement of the skull bone in between right anterior abdominal wall muscles to preserve the bone flap (Figure, panel C, arrow). The patient was then transferred to our facility for intensive inpatient and later outpatient rehabilitation. The patient made a remarkable neurological recovery, had his cranioplasty 4 weeks later, and is now back to college.
      Figure thumbnail gr1
      FigurePanel A: Head magnetic resonance arteriography shows dissection of the cervical portion of the right internal carotid artery. Panel B: Head computerized tomography shows massive edema in the right middle cerebral artery territory and post hemicraniectomy. Panel C: Plain abdominal x-ray with skull bone flap placed between anterior abdominal muscles for preservation (arrow).
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