Right procedure, wrong organ, an unusual case report of aortic trauma in a multiple injured patient

Multiply-injured patients are always a diagnostic and therapeutic clinical challenge. Only a very careful study and interpretation of the trauma history and conditions, the clinical presentation and examination and the appropriate radiological investigation will identify all the related injuries [1]. Such interpretation will offer the key to the correct diagnosis and will also dictate the priorities in the treatment strategy.

Acute traumatic injury of the thoracic aorta is a relatively common injury of deceleration accidents, usually high-speed motor vehicle accidents [3] that still remains highly lethal [1, 4]. As a consequence of major car crashes, thoracic aortic ruptures occur in 10 to 30% of multiply injured patients [5]. They represent the second most common cause of death after trauma, following only the head injuries [6]. Only 15% of these patients reach the hospital alive and their management is further complicated by other lesions in the skeletal and visceral organs with significant difficulties in their diagnosis [7]. Frequently, these patients have also multiple other severe injuries [1, 8, 9] which may draw the main attention of the involved physicians in an Accident and Emergency unit, causing a delay in the diagnosis and treatment of post-traumatic aortic dissections. Early diagnosis of dissection is difficult as it mainly relies on high index of suspicion based on the mechanism of the injury. Furthermore, clinical signs are not sensitive or specific and chest X-rays may not identify the problem in a high number of multiply injured patients [10]. Before hospital admission, the primary cause of death is hemorrhage, and only a small percentage of patients who actually receive medical attention survive [11, 12]. The most important factor to successful hospital management of these victims is early diagnosis by using multislice CT and appropriate urgent treatment that may lead up to 80% of survival [8, 13]. In our case, the situation was even more complicated. The cause of the road accident and subsequent patient injury was an episode of subarachnoid hemorrhage due to the rupture of a cerebral aneurysm. As the brain CT was misdiagnosed, a supposed brain injury attracted the main attention and the co-existent aortic dissection was undetected. When the correct diagnosis of aneurismal subarachnoid hemorrhage was made, the interest was even more concentrated on the possible brain lesion, which also required an urgent treatment. It is well known that a ruptured intracranial aneurysm has a high risk of re-bleeding; this risk is higher immediately after the first event (30% during the first three weeks) carrying also an extremely high mortality rate (50%) [14]. The aorta is the largest arterial vessel of the body and injuries that may lead to its rupture (i.e. aortic dissection) are potentially life threatening [1, 12, 8, 13, 15]. Aortic dissections are usually classified - for treatment purposes - as those involving the ascending aorta (i.e. type A dissections), which are usually managed surgically [6] and type B traumatic dissections which are usually managed with endoluminal aortic stents [9, 16]. Traumatic aortic rupture commonly follows an anterio-posterior thoracic injury, with 60% occurring just distal to the origin of the left subclavian artery (as in our case) and less frequently (25%) at the ascending aorta [15]. Treatment options in these high risk injuries include either open surgical or endovascular repair [3]. Endovascular treatment of thoracic aortic diseases, even in the acute phase, may represent an alternative valid option with a low mortality rate and an excellent outcome [8, 9, 13, 17]. This has been also proved in our case. Following the repair of the aortic dissection, it was then safe to secure the intracranial aneurysm by endovascular treatment with platinum coils. Two main pitfalls can be noted in the management of this patient. Both of them have to do with misinterpretation of the patient history, clinical examination and radiological investigation. The first was the misdiagnosis of posttraumatic instead of aneurismal subarachnoid hemorrhage, which was the actual cause of the accident. This was due to the inability of the patient to describe the event due to retrograde posttraumatic amnesia as well as due to the inexperience of the admitting physician to identify the hinds of the brain CT scan indicating the aneurismal origin of the subarachnoid hemorrhage. The second was the underestimation of the chest injury, regarding either the clinical signs or the chest X-rays. It is reported that 65% of chest trauma in multiple injured patients may be overlooked in plain chest X-rays [18]. Similarly in our case, retrospective review of the patient's chest X-rays identified widened superior mediastinum as well as descending aorta, both findings highly suspicious of an aortic dissection, especially in relation to the clinical finding of chest bruise [19].

The present case report underlines the major importance of the correct interpretation of all the available information and data (trauma history, physical examination, radiological investigation) regarding multiple-injured patients. A systemic process to this particular type of patients is extremely valuable. Early diagnosis of an aortic dissection in a multiply injured patient is often difficult but also particularly important for the final outcome. The early identification of all the possible injuries and their thorough clinical and radiological investigation are of paramount importance for an effective treatment approach and a favorable clinical outcome.

Written informed consent was obtained from the relatives for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.