I N PATIENTS who have concomitant injuries of the head and neck the physician's attention is directed to the cranium when neurologic symptoms are present. This is particularly true when the trauma to the neck is of a blunt nonpenetrating type, and the neurologic manifestations simulating severe craniocerebral injury are not recognized as arising from thrombosis of the internal carotid artery. We wish to report 2 such cases recently encountered which demonstrate the challenge that this type of lesion presents to the physician in diagnosis and treatment. While only an occasional case of thrombosis of the carotid artery secondary to nonpenetrating injuries of the neck has been reported in the literature, the presence of embolism or thrombosis associated with penetrating wounds of the neck or cheek has been more frequently recognized, 2' 3' 4' 11' 16' 17' 18' e1,24,27,28,34 especially in war wounds of the last century22 In addition, 13 since cerebral angiography has been used more widely in the diagnosis of neurological abnormality, certain patients with no apparent trauma are found to have a spontaneous carotid artery thrombosis. Verneuil (187~) 88 was probably the first to report a case of thrombosis following a nonpenetrating injury of the neck:
EAKING intradural aneurysms usually produce extensive subarachnoid hemorrhage. In rare instances the bleeding may occur into the subdural space and the clinical manifestations may be those of an acute subdural hematoma. Five such cases of subdural hematoma associated with bleeding intracranial aneurysm have been encountered within our experience with these lesions. They present additional problems in diagnosis and treatment not common to the usual ancurysm with subarachnoid hemorrhage. CASE REPORTS Case 1. N. P. was a 38-year-old, left-handed female who slipped on the linoleum on Mar. 17, 194~, striking her right cheek and elbow on the floor. She was confused and drowsy for ~4 hours. X-rays of the skull showed no abnormality. A month later right frontal headache and vomiting developed and she became semicomatose, at which time she was referred to University Hospital. Upon admission B.P. was 140/94; pulse rate 80, and respirations 15. She was drowsy, uncooperative and tended to perseverate. There was early bilateral papilledema. The right pupil was larger than the left. There was a mild right central facial palsy and a right hemiparesis. An extensor plantar response was present on the right. Under local anesthesia a small bone flap was turned in the left parietal-parasagittal region. Bloody fluid and clot under increased pressure were evacuated from the subdural space. The bone flap was re-elevated 48 hours later when the patient again became comatose and totally hemiplegic. More bone was removed and a needle was inserted into the left superior temporal gyrus. Bloody fluid under increased pressure was encountered. Angiography performed after the patient had improved showed a small aneurysm on the most proximal portion of the middle cerebral artery and elevation of the Sylvian vessels (Fig. 1). No further treatment was instituted; she gradually improved. She has had no further difficulty for 9 years except for four grand mal seizures and occasional headache centered behind the left eye. Optic atrophy O.S. and astereognosis of the right hand persist. Case 2. F.M. was a 45-year-old male under psychiatric treatment for chronic alcoholism and psychosis. On Aug. ~3, 1945, he was struck on the occiput by a disturbed patient. He fell to the floor, arose and a few minutes later fainted and once
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