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Love bites - An unusual cause of blunt internal carotid artery injury

Authors:
Teddy Wu at Canterbury District Health Board
Teddy Wu
Jonathon Hsiao
Jonathon Hsiao
Jonathon Hsiao
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Edward H Wong
Edward H Wong
Edward H Wong
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THE NEW ZEALAND
MEDICAL JOURNAL
Journal of the New Zealand Medical Association
NZMJ 26 November 2010, Vol 123 No 1326; ISSN 1175 8716 Page 112
URL: http://www.nzma.org.nz/journal/123-1326/4444/ ©NZMA
Love bites—an unusual cause of blunt internal carotid
artery injury
Teddy Y Wu, Jonathon Hsiao, Edward H Wong
We describe an unusual case of blunt neck trauma leading to internal carotid artery
(ICA) thrombosis and subsequent cerebral ischaemic infarct in a 44-year-old Māori
woman.
Case report
A 44-year-old Māori woman presented to the Emergency Department 24 hours after
developing sudden onset of left upper limb monoparesis. The weakness was initially
mild and occurred while the patient was watching television. It had progressed to
moderate weakness with functional impairment precipitating the admission.
On presentation normal vital signs and a Glasgow Coma Scale (GCS) of 15/15 were
recorded. Neurological examination revealed moderate upper motor neurone
weakness in left upper limb. The remaining examination was normal. She was in
sinus rhythm with clinically normal heart sounds.
A small vertical bruise was noted in the right anterior neck, superficial to the upper
third of the sternocleidomastoid muscle. This was attributed to a love bite with the
minor trauma occurring several days prior to the onset of neurological symptoms.
The patient has a history of systemic lupus erythematosis (SLE) controlled with
combination of steroids and methotrexate. She smokes tobacco with occasional use of
marijuana.
She was admitted to hospital and treated for acute ischaemic stroke. A non-contrast
computer tomography (CT) of her brain was normal. Carotid duplex Doppler revealed
an echogenic material thought to be thrombus in the right ICA causing a 65 to 70%
luminal stenosis (Figures 1a and 1b). CT angiography of her cervical vessels
confirmed a partially occlusive luminal thrombus in the right proximal ICA without
arterial dissection (Figure 2a).
She was commenced on intravenous heparin and a follow up repeat CT angiography
seven days later revealed significant reduction of the thrombus size (Figure 2b). The
patient’s neurological symptoms resolved during her admission.
Warfarin was commenced with a target international normalised ratio (INR) of 2 to 3
before a thrombophilia screen was performed. At 1 month follow-up she has remained
free of neurological sequelae. She is to continue warfarin for a total of 3 months.
NZMJ 26 November 2010, Vol 123 No 1326; ISSN 1175 8716 Page 113
URL: http://www.nzma.org.nz/journal/123-1326/4444/ ©NZMA
Figure 1a. Longitudinal view of right
proximal ICA (the luminal thrombus
indicated by white arrow)
Figure 1b. Transverse view of the carotids
(the right ICA and thrombus are marked
by the dotted circular lines; thrombus is
indicated by the white arrow)
Abbreviations: ECA: External carotid artery; ICA: Internal carotid artery; CCA: Common carotid
artery.
Figure 2a. Initial axial CT angiography
with filling defect in the right ICA (shown
by black arrow)
Figure 2b. Follow-up CT angiography
showing reduction in thrombus size
Discussion
Blunt carotid artery injury with subsequent thrombosis and stroke is considered a rare
phenomenon. It was first described by Verneuil in 1872 but remains an uncommon
diagnosis even in the setting of trauma.
1
NZMJ 26 November 2010, Vol 123 No 1326; ISSN 1175 8716 Page 114
URL: http://www.nzma.org.nz/journal/123-1326/4444/ ©NZMA
Recent case series suggested an overall incidence of up to 1% in blunt trauma
victims.
1
Majority of patients in case series have carotid injuries resulting from rapid
deceleration with neck hyper-extension/flexion, predominately caused by motor
vehicle accidents. This causes bony compression of carotid artery;
2
other mechanisms
of injury are intra-oral trauma, direct blows and basal skull fracture.
3
The injury
results in traction on carotid artery leading to tearing of intima or media with platelet
aggregation, thrombosis and cerebral embolisation.
Diagnosis requires a high index of suspicion as there is usually a latency from the
initial trauma to onset of neurological deficit. Over 90% of patients present with
symptoms at least greater than 1 hour from trauma and over a third with a delay of 24
hours or more.
4
Diagnosis is often delayed due to absence of initial neurology or lack
of superficial signs of injury. The delay in onset of neurological symptoms is thought
to be due to progressive thrombosis causing hypoperfusion or subsequent
embolisation.
3,4
Blunt carotid artery injury should be suspected in the following clinical
circumstances: neurological examination incompatible with CT findings; physical
signs of anterior neck injury; development of neurological deficit after hospital
admission; presence of Horner’s Syndrome.
5
CT angiography or Magnetic Resonance angiography are diagnostic tools of choice,
as they are non-invasive and allow assessment of the wall and lumen of the vessel.
Treatment options include surgical revascularisation, anticoagulation or supportive
medical management.
6
Earlier reports advocated surgical revascularisation
6
but recent
research have lent towards conservative management with anticoagulation,
particularly when mild to moderate neurological deficits are present.
8
Patients treated
with anticoagulation seem to also achieve good clinical outcome.
Earlier reports indicate a mortality rate of up to 30%
4
but more recently rate as low as
5% has been observed
7
. This is likely due to earlier diagnosis with advent of non-
invasive imaging such as MRI or CT angiography leading to earlier intervention.
Our patient suffered an uncommon mode of blunt trauma to the neck and internal
carotid artery following a love bite. There was no evidence of arterial dissection but
most likely there was intimal injury from the compression of the internal carotid
artery with subsequent thrombosis.
Conclusion
We report on an interesting case of blunt carotid artery trauma caused by a love bite.
Blunt carotid artery trauma can lead to arterial injury, thrombosis and cerebral
embolisation. It is a rare phenomenon and diagnosis requires a high index of
suspicion. Current literature suggests a conservative approach to treatment with
anticoagulation. Most patients achieve a favourable outcome especially when initial
neurology was non-disabling.
Author information: Teddy Y Wu, Stroke Fellow, Stroke Unit; Jonathon Hsiao,
Medical Registrar, Department of Medicine; Edward H Wong, Consultant
Neurologist, Stroke Unit; Middlemore Hospital, Auckland
NZMJ 26 November 2010, Vol 123 No 1326; ISSN 1175 8716 Page 115
URL: http://www.nzma.org.nz/journal/123-1326/4444/ ©NZMA
Correspondence: Teddy Y Wu, Stroke Fellow, Stroke Unit, Middlemore Hospital,
Private Bag 93311, Otahuhu, Auckland 1640, New Zealand. Fax: +64 (0)9 6222641;
email teddyyhwu@gmail.com
References:
1. Nunnink L. Blunt Carotid Artery Injury. Emergency Medicine (Fremantle) 2002;14;4:412–21.
2. Zelenock G, Kazmers A, Whitehouse W, et al. Extracranial internal carotid artery dissections.
Arch Surg 1982;117:425–432.
3. Crissey MM, Bernstein EF. Delayed presentation of carotid intimal tear following blunt
craniocervical trauma. Surgery 1974;75:543–9.
4. Krajewski LP, Hertzer NR. Blunt Carotid Artery Trauma. Ann Surg; 1980:191;3:341–346.
5. Fabian TC, Patton JH, Croce MA, et al. Blunt Carotid Artery Injury: importance of early
diagnosis and anticoagulant therapy. Ann Surg. 1996:223:513–25.
6. Li MS, Smith BM, Espinosa J, et al. Nonpenetrating trauma to the carotid artery: seven cases
and a literature review. J of Trauma. 1994;36;2:265–272
7. Parikh AA, Luchette FA, Valente JF, et al. Blunt Carotid Artery Injuries. J Am Col Surg.
1997:185:80–86.
... Table 2 provides a compilation of reported studies on love bites in the surveyed medical literature. I could locate two reviews 21,22) , five original papers 16,[23][24][25][26] and seven case reports [27][28][29][30][31][32][33] . Most prominent body regions in which love bites are placed in soft tissues such as neck, cheek, lip, breast and nipple, fore arm, upper arm and genital organs (penis, vulva) 14,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] . ...
... I could locate two reviews 21,22) , five original papers 16,[23][24][25][26] and seven case reports [27][28][29][30][31][32][33] . Most prominent body regions in which love bites are placed in soft tissues such as neck, cheek, lip, breast and nipple, fore arm, upper arm and genital organs (penis, vulva) 14,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] . Depending on the intensity of the bites, trauma can be either of minor type (suction type mark, characterized by a small area of petechial bruising in neck or breast region) or a major type (aggressive biting mark, easily identified by teeth imprints on the skin 14,34) . ...
Love bites or Monkey Bites: A Medical Trauma of a Kind
Article
Full-text available
  • Feb 2016
An update on medical trauma caused by love bites, including a few case reports omitted by Al Fallouji (in his 1990 review on traumatic love bites or monkey bites which appeared in the British Journal of Surgery) is presented. Published surveys in sexuality books and reports in medical journals on love bites were studied. Based on original papers, reviews and case reports, I classify four types of love bites, which can result under the following four circumstances: (1) during consensual sex play (between willing partners), (2) a combination act of consensual sex sliding into sex aggression (between willing partners), (3) during aggression by a sex offender (one individual showing aggression against a powerless victim, including clinical vampirism), (4) self-biting of a body part due to aggravating psychiatric condition in an individual. Trauma grades of these four types of love bites are also identified. Though antimicrobial therapy for human bites do exist, many love bite injuries do not receive proper care from health personnel due to factors like victim embarrassment, negotiated quasi-resolution of conflict between the victim and aggressor, as well as fear of legal repercussions.
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... Der findes i litteraturen kun ét tidligere tilfaelde af et embolisk cerebralt infarkt efter påførelse af et sugemaerke på halsen [3]. ...
[Love bite on the neck resulted in an embolic stroke.]
Article
Full-text available
  • Dec 2014
A 35-year-old woman experienced sudden onset of right-sided weakness due to a left middle cerebral artery stroke 12 hours after she had obtained a love bite on the left side of her neck. Duplex ultrasonography showed a near-occlusion of the left internal carotid artery (ICA) and CT angiography revealed a mural thrombus at the same location. This case report shows that love bites on the neck are a rare cause of embolic stroke. The most likely aetiology is embolization of thrombus material from a local intimal lesion of the ICA.
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Etiologies and Mechanisms of Ischemic Stroke Associated with Sexual Intercourse: A Literature Review
Article
  • Oct 2021
Background: Exposure to some special events, also called stroke triggers, can precipitate the onset of ischemic stroke (IS). Previous studies have presented preliminary hypotheses about sexual intercourse as a trigger of IS in predisposed individuals, but the mechanisms of IS associated with sexual intercourse are still not well defined. This literature review summarizes the etiologies and mechanisms of IS associated with sexual intercourse. Further studies on stroke triggers are warranted, and early recognition and appropriate preventive strategies directed against the short-term risks posed by stroke triggers may complement the long-term risk factor reduction approach. Methods: Articles were selected from PubMed (1946-2021) and Web of Science Core Collection (1990-2021) using the following search terms: ischemic stroke, ischaemic stroke, stroke, cerebral infarction, cerebral ischemia, cerebral embolism, embolism, sexual intercourse, sexual activity, intercourse, coitus, coition, and coital. Results: A total of 20 studies, which included 26 patients with IS associated with sexual intercourse, were included. This literature review found that IS associated with sexual intercourse is not rare but has not received enough attention, and paradoxical embolization and postcoital arterial dissection are common etiologies. Other etiologies include drug usage (such as sexual adjuvant drugs and illicit drugs), paroxysmal sympathetic hyperactivity, and reversible cerebral vasoconstriction syndrome. Discussion/conclusion: Sexual intercourse should be considered an important trigger for IS. Clinicians should be aware that IS associated with sexual intercourse is not subjective but may be a warning sign of multiple etiologies and mechanisms.
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Delayed presentation of carotid intimal tear following blunt craniocervical trauma
Article
  • May 1974
  • SURGERY
Blunt craniocervical trauma may produce carotid artery stenosis and occlusion with delayed and unusual clinical manifestations. This condition is illustrated by two patients with traumatic intimal tears, presenting with transient neurologic deficit or asymptomatic bruits several months or years after injury. Such injuries usually follow cranial trauma which stretches the carotid artery by sudden extension and counter-rotation of the head or by direct blunt trauma to the carotid bifurcation. The hallmark of such blunt carotid artery injury is the delayed onset of symptoms, which usually result from an intimal flap and subsequent embolic phenomena. While the symptoms are generally those of carotid insufficiency, a diagnosis of cervical carotid trauma is seldom made clinically because the entity is easily confused with intracranial injury. Aggressive angiographic evaluation and recent improvements in the safety of carotid artery surgery should improve the otherwise poor prognosis for those patients correctly diagnosed in whom operation is properly timed and performed.
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Extracranial Internal Carotid Artery Dissections
Article
  • May 1982
  • ARCH SURG-CHICAGO
Noniatrogenic traumatic extracranial internal carotid artery dissections were encountered in six patients (five men and one woman) 31 to 62 years old. All but one had overt cerebral ischemia manifest by paresis (three), sensory deficits (three), aphasia (three), or amaurosis fugax (two), One patient had an asymptomatic carotid artery bruit. Cerebral arteriography established the diagnosis in all cases. Internal carotid artery impingement between the mandible and transverse processes of the second and third cervical vertebrae, or undue stretching over these vertebral structures, were the most likely primary mechanisms of injury. Secondary complications, a result of distal thromboembolism, were evident in two patients. Direct cerebral revascularization, staged internal carotid artery constriction and ligation, as well as intensive nonoperative therapy were valid therapeutic options. There were no deaths. Treatment relieved transient ischemic symptoms or arrested progression of established neurologic deficits in each case. In select patients, early surgical intervention may lessen attending neurologic sequelae.
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Blunt Carotid Artery Trauma Report of Two Cases and Review of the Literature
Article
  • Apr 1980
Blunt carotid artery trauma is uncommon but has been associated with severe, permanent neurologic deficits in 42% and mortality in 30% of 96 patients previously reported in the English literature. Since neurologic symptoms characteristically develop only after a latent interval and since physical evidence of significant cervical trauma often is absent, diagnosis of nonpenetrating carotid injuries with the use of arteriography usually is delayed until the appearance of obvious, frequently irreversible neurologic complications. Carotid injuries should be suspected in patients who develop monoplegia or hemiplegia following blunt craniocervical trauma, particularly if computerized tomography excludes the presence of intracranial hemorrhage. The cumulative results of a collected series of 96 patients suggest that early surgical correction of blunt carotid injuries is appropriate for patients with transient episodes of cerebral ischemia, strokes in evolution, or mild completed neurologic deficits.
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Nonpenetrating trauma to the carotid artery: Seven cases and a literature review
Article
  • Mar 1994
  • J TRAUMA
Nonpenetrating carotid trauma is uncommon and frequently missed on initial examination. The cases of seven patients seen over a period of 21 years are presented and 100 cases from the most recent literature are reviewed. Causes and mechanisms of injury, clinical presentation, investigations, management, and outcome are discussed. Causes of injury were three motor vehicle collisions, two falls, one sports injury, and one blow to the face. Clinical presentation was early in four and delayed in three. The earliest symptoms and signs were a change in mental status, headache, unprovoked fall, focal weakness, neglect, and dysphasia. Doppler studies may be useful in screening, but a definitive diagnosis is made with the help of angiography. Two patients were treated surgically; one died, one with delayed symptoms from a pseudoaneurysm recovered completely. Five patients were given anticoagulants; all survived with permanent deficits related to their pretreatment neurologic status. The outcome in 100 recent cases from the literature has improved compared with previous reports. The overall mortality was 12%. The outcome in our seven cases supports recent trends toward a strategy of early anticoagulation and selective surgical treatment.
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Blunt Carotid Injury
Article
  • May 1996
The incidence, associated injury pattern, diagnostic factors, risk for adverse outcome, and efficacy of anticoagulant therapy in the setting of blunt and carotid injury (BCI) were evaluated. Blunt carotid injury is considered uncommon. The authors believe that it is underdiagnosed. Outcome is thought to be compromised by diagnostic delay. If delay in diagnosis is important, it is implied that therapy is effective. Although anticoagulation is the most frequently used therapy, efficacy has not been proven. Patients with BCI were identified from the registry of a level I trauma center during an 11-year period (ending September 1995). Neurologic examinations and outcomes, brain computed tomography (CT) results, angiographic findings, risk factors, and heparin therapy were evaluated. Sixty-seven patients with 87 BCIs were treated. Thirty-four percent were diagnosed by incompatible neurologic and CT findings, 43% by new onset of neurologic deficits, and 23% by physical examination (neck injury, Horner's syndrome). There were 54 intimal dissections, 11 pseudoaneurysms, 17 thromboses, 4 carotid cavernous fistulas, and 1 transected internal carotid artery. Thirty-nine patients had follow-up angiograms. Mortality rate was 31%. Of 46 survivors, 63% had good neurologic outcomes, 17% moderate, and 20% bad. Logistic regression analysis demonstrated heparin therapy to be associated independently with survival (p < 0.02) and improvement in neurologic outcome (p < 0.01). Blunt carotid injury is more common than appreciated, seen in 0.67% of patients admitted after motor vehicle accidents. Therapy with heparin is highly efficacious, significantly reducing neurologic morbidity and mortality. Heparin therapy, when instituted before onset of symptoms, ameliorates neurologic deterioration. Liberal screening, leading to earlier diagnosis, would improve outcome.
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Blunt Carotid Artery Injuries
Article
  • Aug 1997
Blunt carotid artery trauma remains a rare but potentially devastating injury. Early detection and treatment remain the goals of management. Our objective was to identify patients sustaining blunt carotid injuries at a regional trauma center and report on the incidence, demographics, diagnostic workup, management, and outcome. A retrospective chart review was performed of patients sustaining blunt carotid artery injury between 1990 and 1996. Twenty patients were identified during the 7-year period. All patients suffered blunt trauma, with motor vehicle accidents being the most common mechanism, and the internal carotid the most frequently injured vessel. Associated injuries were present in all patients, with head (65%) or chest (65%) injuries being the most common. The combination of head and chest trauma (45%) was found to be associated with a 14-fold increase in the likelihood of carotid injury. Cerebral angiography was diagnostic in all patients and the majority were treated nonoperatively with anticoagulation. Twenty percent of patients were discharged with a normal neurologic exam, while 45% left with a significant neurologic deficit. Overall mortality was 5%. Blunt carotid injuries are rare but are associated with significant morbidity and mortality. The combination of craniofacial and chest wounds should raise the index of suspicion for blunt carotid injury. Anticoagulation was associated with the least morbidity.
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Blunt carotid artery injury
Article
  • Jan 2003
Blunt carotid artery injury is an uncommon injury with a potentially devastating outcome. Although treatment is often unhelpful for an established neurologic deficit, there is frequently a delay between the episode of trauma and the onset of neurology. This delay provides a window of opportunity where early detection and intervention may significantly improve outcome and prevent lifelong morbidity in a generally young trauma patient population. This paper will review the literature regarding incidence, outcome, treatment options and optimal methods of diagnosis for this lesion. The following synopsis of a case seen at Royal Perth Hospital Emergency Department illustrates several of the classical features of blunt carotid injury, including delayed presentation and pattern of associated injuries. The patient, a 19-year-old female, presented following a single vehicle motor crash. On arrival she had a Glasgow Coma Scale (GCS) of 14 with no focal neurologic deficit. Multiple injuries were identified, including a large scalp laceration, a compound fracture of the mandible, pneumothorax, sternal fracture, subcapsular haematoma of the liver, and a knee laceration. Initial computed tomography (CT) scan of the head was normal. Twenty hours after the motor vehicle accident the patient's conscious state deteriorated to GCS 9. Repeat CT head demonstrated changes consistent with a left middle cerebral artery infarct. Cerebral angiography revealed traumatic dissection of the left internal carotid artery with complete occlusion of the lumen just distal to its origin. After 13 days in the intensive care unit and 2.5 months in the rehabilitation unit, she was discharged with a persistent severe receptive and expressive aphasia, as well as a dense right hemiparesis. She is now living at home with community supports.
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Blunt Carotid Artery Injury: importance of early diagnosis and anticoagulant therapy
  • 513-25
  • Tc Fabian
  • Jh Patton
  • Croce
  • Ma
Fabian TC, Patton JH, Croce MA, et al. Blunt Carotid Artery Injury: importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996:223:513–25.