Vibration trauma serves as a potential yet not recognized in large clinical series risk factor of cervical artery dissection. We present case report of a young male patient who developed internal carotid artery dissection as a result of prolonged drilling

Dominika Budzisz-Turbakiewicz

Jacek Jaworski

Janusz Kocki

Katarzyna Grabowska–Aleksandrowicz

Kinga Kądziołka

Konrad Rejdak

Lidia Kotuła

Tomasz Blicharski

Journal of Education Health and Sport

Jaworski, Jacek

Kotuła, Lidia

Budzisz-Turbakiewicz, Dominika

Kądziołka, Kinga

Grabowska–Aleksandrowicz, Katarzyna

Blicharski, Tomasz

Kocki, Janusz

Rejdak, Konrad

Akademicka Platforma Czasopism

Jaworski Jacek, Kotuła Lidia, Budzisz-Turbakiewicz Dominika, Kądziołka Kinga, Grabowska–Aleksandrowicz Katarzyna,Blicharski  Tomasz,  Kocki  Janusz,  Rejdak Konrad.  Vibration trauma  as  a  causative  factor  of  internal  carotid arterydissection. Journal  of  Education,  Health  and  Sport.  2019;9(4):194-203.  eISNN  2391-8306.  DOIhttp://dx.doi.org/10.5281/zenodo  . 2631035  http://ojs.ukw.edu.pl/index.php/johs/article/view/6793The journal has had 7 points in Ministry of Science and Higher Education parametric evaluation. Part B item 1223 (26/01/2017).1223 Journal of Education, Health and Sport eISSN 2391-8306 7© The Authors 2019;This article is published with open access at Licensee Open Journal Systems of Kazimierz Wielki University in Bydgoszcz, PolandOpen Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use,distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the termsof the Creative Commons Attribution Non commercial license Share alike.(http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, providedthe work is properly cited.The authors declare that there is no conflict of interests regarding the publication of this paper.Received: 15.03.2019. Revised: 25.03.2019. Accepted: 04.04.2019.VIBRATION TRAUMA AS A CAUSATIVE FACTOR OF INTERNAL CAROTIDARTERY DISSECTIONJacek Jaworski, MD, PhD, https://orcid.org/0000-0002-8124-4159Chair and Department of Neurology of the Independent Public Clinical Hospital No. 4 in LublinLidia Kotuła, MD, PhD http://orcid.org/0000-0001-7219-6872Department of Clinical Genetics of Medical University of LublinDominika Budzisz - Turbakiewicz, MD, https://orcid.org/0000-0002-1743-0125Clinic of Orthopedics and Rehabilitation of the Independent Public Clinical HospitalNo. 4 in LublinKinga Kądziołka MD, https://orcid.org/0000-0001-6136-0542  Department of Clinical Genetics of Medical University of LublinKatarzyna Grabowska – Aleksandrowicz, MD, https://orcid.org/0000-0002-7667-7734Chair and Department of Neurology of the Independent Public Clinical Hospital No. 4in LublinTomasz Blicharski, MD, PhD,  https://orcid.org/0000-0001-9747-8817Clinic of Orthopedics and Rehabilitation of the Independent Public Clinical HospitalNo. 4 in LublinJanusz Kocki, MD, PhD, Professor https://orcid.org/0000-0002-9541-6353Department of Clinical Genetics of Medical University of LublinKonrad Rejdak, MD, PhD, Profesor https://orcid.org/0000-0002-7019-6681Chair and Department of Neurology of the Independent Public Clinical Hospital No. 4in Lublin194AbstractVibration trauma serves as a potential yet not recognized in large clinical series risk factor ofcervical artery dissection.  We present case report of a young male patient who developedinternal carotid artery dissection as a result of prolonged drilling.Key words: vibration trauma, dissection of internal carotid arteryIntroductionCervical  artery  dissection  (CAD),  including internal  carotid  artery dissection  and cervicalvertebral artery dissection, is responsible for approximately 2% of all ischemic stroke cases.In the group of young patients aged 18-50 years CAD is, however, one of the main etiologicalfactors of ischemic stroke, accounting for 20% of stroke cases. The annual incidence rate  is  2-4  /  100000.  However,  it  should  be  mentioned  that  the  disorder  may  have  a  minor-symptom course making proper diagnosis difficult (1).CAD pathophysiology is still not fully understood. It is assumed that in addition to geneticpredisposition and biomechanical factors, environmental factors, namely neck injuries, playa key role. In the group of patients with severe, dull carotid artery injury, dissection occursin  1-2% of  cases.  More  often,  the  nature  of  the  injury  is  so  mild  that  the  dissection  isclassified as spontaneous (2). The mechanism of injury usually consists of a hyperextension,rotation, lateral neck flexion or an increase in pressure inside the chest. Systematic reviews ofliterature mention various types of neck injuries: sports activity with strong neck rotation,manual treatments on the cervical spine, fall with head injury, road collision with the bending-deflection injury of the spine, lifting heavy objects, several hours of work with a supported195head or prolonged delivery (1, 2). Despite the potential importance of vibration trauma, theydo not constitute a significant percentage of the described CAD case series.A case reportA 25-year-old patient, without any vascular risk factors, admitted to the Neurology Clinic ofthe Independent Public Clinical Hospital No. 4 in Lublin to diagnose the cause of obstructionof the right internal carotid artery. The obstruction was diagnosed in other hospital wards.Prior to the disease, the patient was working on the construction site and was drilling usinga hammer drill.  Due to the inconvenient  position,  the patient  rested the drill  on the neck(being right-handed he helped himself with the right side of the neck). After the end of work,the next day patient felt a strong, sudden headache in the right frontotemporal region, alsolocated behind the right eyeball. It was accompanied by the transient right-site vision loss andright-site  Horner  syndrome.  Doppler  ultrasound examination  of  the carotid  artery  showedobstruction of the right internal carotid artery (Fig. 1), in the absence of atherosclerotic lesionsin the examined vessels and normal blood flow in the left internal carotid artery (Fig. 2). Thetranscranial ultrasound examination showed a delay in the peak systolic velocity in the rightmedial  cerebral  artery  (dullness  of  the  flow)  with  the  inclusion  of  collateral  circulationthrough  the  anterior  communicating  artery  left-to-right,  through  the  right  posteriorcommunicating  artery  connecting  the  right  posterior  cerebral  artery  to  the  right  internalcarotid artery and through the ophthalmic artery (connections to the branches of the externalright carotid artery). The MRI study of the head and neck in T1-dependent sequences withsuppression of the fat signal (FATSAT) showed the presence of intramural hematoma withinthe right internal carotid artery, extending from the bifurcation of the right common carotidartery (Fig. 3). The patient remained in a good general condition and no signs of focal damage196to  the  central  nervous  system  were  observed.  Warfarin  was  used  in  the  treatment,  theyrecommend maintaining the INR index in the range of 2-3.DiscussionThe described case draws attention to the importance of vibration trauma as potential CADcauses.  In  many  professions,  employees  are  currently  exposed  to  oscillatory  movements(vibrations) that did not occur before the era of industrialization. Vibrations transmitted fromhand  tools  (hand-transmitted  vibration)  and  whole  body  vibrations  (e.g.  from  car  seatmovements)  can  cause  malaise,  injury,  and  illness.  The  syndrome  of  disease  symptomsis referred to as the "vibration syndrome", which mainly includes disorders of the circulatorysystem, the peripheral nervous system, and the skeletal system. It has been known since thebeginning of the 20th century when the paroxysmal paleness of the fingers of miners (3, 4)was  noted.  The  consequence  of  vibration  trauma  is  underlined  by  the  development  ofEuropean safety standards for exposed workers (5). Nevertheless, it  should be emphasizedthat in the described case the vibration trauma was not cumulative, but it resulted from thedirect transmission of vibrations to the area of the internal carotid artery during drilling.In CAD, strokes  reach as  much as  70% of  cases,  while  transient  neurological  symptomsdevelop in another 13% of patients (1). The primary mechanism of stroke in CAD is arterial-arterial embolism (damage to the vascular wall results in thrombus formation which, whendetached,  moves with the bloodstream, closing the peripheral vessels) or less often in themechanism of cerebral perfusion decline in sluggish collateral circulation. Almost all patientswith internal carotid artery dissection are affected by the stroke in the vascularisation area ofthe central cerebral artery  (6). CAD is one of the main causes of stroke in young patients,whereas in the elderly population it is exceptionally present. This is most likely due to the197progressive hardening of the vascular wall and the presence of atherosclerotic lesions amongolder patients.Diagnosis of carotid dissection is currently based on magnetic resonance imaging (MR) inT1-dependent spin echo (SE) sequences with fat signal saturation (FATSAT), which can beused  to  visualize  the  presence  of  an  intramural  hematoma.  Suppression  of  the  fat  signalis  necessary  to  differentiate  the  hyper-intensive  methemoglobin  signal  of  the  intramuralhematoma  from  the  surrounding  adipose  tissue  (7).  In  addition,  MR  angiography  andultrasound  allow  assessing  the  effect  of  dissection  on  hemodynamics  of  the  cerebralcirculation.  A  special  role  of  transcranial  Doppler  ultrasonography  is  the  assessment  ofcollateral circulation efficiency.CAD treatment  in the acute phase consists of the use of unfractionated or low molecularweight  heparin  followed  by  anticoagulant  treatment  (warfarin,  acenocoumarol)  for  3-6months. The prognosis is successful because in most cases the vessel recanalizes within onemonth. After a year of observation, about 60% of patients have complete recanalization, 22%have a vascular obstruction, while the remaining group has different degrees of stenosis (8).Among the postulated factors affecting the possibility of internal carotid artery dissection arenow also local conditions including the length of the styloid process and its distance from theinternal carotid artery, as well as the distance between the hyoid bone and the internal carotidartery  (9,  10).  In  the  case  of  vibration  trauma,  the  proximity  of  the  bone elements  maycontribute to the injury of the vascular wall, leading to dissection.ConclusionsVibratory trauma is  a  potential  cause of carotid  artery dissection.  The preventive  activityunderstood as compliance with work safety rules with devices generating strong vibrations, is198of  particular  importance.  In  addition,  a  key  element  in  the  elimination  of  complications(mainly stroke) is the rapid diagnosis and implementation of proper treatment.Correspondence data:Jacek Jaworski, Lidia Kotuła, Zakład Genetyki Klinicznej UM w Lublinie, 20-080 Lublin, ul. Radziwiłłowska 11, lidka3@op.pl, mobile +48506431401Bibliography:1. Dziewas R., Konrad C., Dräger B., Evers S., Besselmann M., Lüdemann P. i wsp.Cervical  artery  dissection  –  clinical  features,  risk  factors,  therapy  and  outcome  in  126patients. J Neurol 2003; 250 : 1179–1184. Http://DOI 10.1007/s00415-003-0174-5.2. Engelter S. T., Grond-Ginsbach C., Metso T. M.,  A. J. Metso, Kloss M., Debette S.Cervical artery dissection. Trauma and other potential mechanical trigger events.  Neurology2013;80:1950–19573. Zabłocka-Słowińska K., Limburska J., Prescha A., Pieczyńska J., Tomczyk J, GrajetaH. Ocena podaży energii i składników pożywienia w całodziennych racjach pokarmowychosób narażonych na miejscowe drgania mechaniczne. Medycyna Pracy 2011;62:583–5904. Malinowska-Borowska J., Socholik V., Harazin B. Stan zdrowia pracowników leśnychnarażonych na hałas i  wibracje  miejscowe wytwarzane przez piły  łańcuchowe.  MedycynaPracy 2012; 63:19–291995. Griffin M. J. Minimum health and safety requirements for workers exposed to hand-transmitted  vibration  and  whole-body vibration  in  the  European  Union;  a  review.  OccupEnviron Med 2004;61:387–397. http://DOI: 10.1136/oem.2002.0063046. Benninger D. H., Georgiadis D., Kremer C., Studer A., Nedeltchev K., BaumgartnerR.W..  Mechanism  of  Ischemic  Infarct  in  Spontaneous  Carotid  Dissection.  Stroke 2004;35:482-485. Http:// DOI: 10.1161/01.STR.0000109766.27393.527. Cuvinciuc V.,  Viallon M., Momjian-Mayor I., Sztajzel R., Pereira V. M., Lovblad K-O. i wsp. 3D fat-saturated T1 SPACE sequence for the diagnosis of cervical artery dissection.Neuroradiology 2013; 55:595–602. Http://DOI 10.1007/s00234-013-1141-18. Kaźmierski R. Niemiażdżycowe choroby tętnic. W: Kaźmierski R [red]. Podręcznikdiagnostyki ultrasonograficznej w neurologii. Wydawnictwo Czelej, Lublin 2011, ss.107-1229. Renard D., Azakri S., Arquizan C., Swinnen B., Labauge P.,  Thijs V. Styloid andHyoid  Bone  Proximity  Is  a  Risk  Factor  for  Cervical  Carotid  Artery  Dissection.  Stroke2013;44:2475-247910. Muthusami P., Kesavadas C., Sylaja P. N., Thomas B., Harsha K. J., Kapilamoorthy T.R.  Implicating the long styloid process in cervical carotid artery dissection. Neuroradiology2013; 55:861–867. Http://DOI 10.1007/s00234-013-1186-1200Figure 1Doppler Duplex USG test result: Occlusion of the right internal carotid artery.201Figure 2Doppler Duplex USG test result: correct flow and morphology of the right internal carotidartery.202Figure 3Intramural hematoma of of the right internal carotid artery on MR (the FATSAT option).203

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Vibration trauma as a causative factor of internal carotid artery dissection

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Vibration trauma as a causative factor of internal carotid artery dissection

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