Internal carotid artery dissection and stroke after SCUBA diving: a case report and review of the literature

Abstract

Serious neurological complications after diving have increased in the last years because of its increased popularity [1,2,5,7]. Dangerous neurological complications such as ischemic stroke reflecting an acute central nervous system pathology are frequently associated with a dysbaric air embolism or decompression sickness (Caisson's disease), but may also include rarer causes [8]. Due to unspecific clinical presentation, the differential diagnosis of diving-related neurological symptoms may be difficult. A dissection of cervical arteries in young to middle-aged scuba divers has rarely been described. We describe a patient with internal carotid artery dissection after scuba diving, who presented at the emergency department with subacute embolic strokes. In addition, we also summarize the published reports to date of cervical artery dissections associated with scuba diving. Case reportA 51-year-old right-handed man presented with a history of neurological symptoms after having performed a scuba dive in a lake a week earlier. The dive was guided by and performed with a professional diving instructor. The whole dive including pre-and post-diving preparation took 2 h. The uneventful time under water was as follows: 15 min at 5 m, 15 min at 20 m and 15 min at 5 m with a total underwater time of 45 min. The weight of the diving gear did not exceed the usual weight range for recreational diving. There was no trauma during the dive or unusual movements or minor trauma afterwards. He was a certified recreational diver with moderate experience. Three hours after surfacing he noted slurred speech and difficulties finding words for 15 min. After 2 days he noted difficulties with tongue movement and problems with swallowing and expressing words. After that, his food intake was restricted to liquids. He also suffered from an aching throat and leftsided dull temporal-occipital headaches. After 4 days he turned to his GP who initiated further vascular evaluation.On presentation at the Neurological Emergency Unit he showed an incomplete Horner's syndrome with miosis and ptosis on the left eye and dysarthria. He also presented a tongue deviation to the left and a deviation of the uvula. The rest of the neurological examination was normal with no clinical evidence of long-tract disturbances, extrapyramidal or brain-stem dysfunction. No sensory abnormalities, motor deficits or cognitive deficits were observed. The general physical examination revealed normal findings.No relevant past medical or family history could be found. He had smoked 20 cigarettes per day until 1990.The ultrasound of the extra-and intracerebral cerebral vessels showed a resistance profile in the distal extracranial part of the left internal carotid artery. The flow in the left middle cerebral artery was decreased in comparison to the right side, but was collaterally fed via the anterior and posterior communicating arteries and the left (retrograde) ophthalmic artery.

Growing Evidence about the Relationship between Vessel Dissection and Scuba Diving

“…With the present work, we want to add another report to the list, in order to promote an in-depth analysis of the problem and, possibly, to define the associated risk factors that can be avoided by scuba divers to prevent this major complication. In the small database offered by the literature, we noticed that in most patients, a dissection of the carotid artery was reported, compared with vertebral vessels, consistent with the general frequency of these lesions [2, 3, 4, 5, 6, 7, 8, 9, 10]. …”

“…In recent years, an interesting correlation was noticed between scuba diving and the dissection of the major arteries of the neck, promoting the identification of this sport as a possible risk factor [2, 3, 4, 5, 6, 7, 8, 9, 10]. …”

Isolated PICA Dissection: An Unusual Complication of Scuba Diving

“…It is clearly known that the occurrence of an arterial dissection does not depend on the diving parameters such as duration, maximum depth, and the speed of surfacing [6][7][8][9]. Latency of neurological symptoms after surfacing does not allow to differentiate between decompression sickness and dissection of cervical arteries [10].…”

Life-threatening neurovascular injuries associated with recreational use of “banana” boats

“…Traumatic dissection has been reported to occur after both minor and significant trauma; it has been reported in association with various sports, including a few reports linked with watersports such as wakeboarding, springboard diving, and scuba diving. [7][8][9][10][11] Various mechanisms of injury have been described, including direct, blunt, or penetrating trauma, abrupt neck movements, Valsalva maneuvers, and rapid ascent from deep immersion, among others. [12][13][14] We assume that there was a multifactorial mechanism involved in the patients presented in this report, involving abrupt and extreme neck movements and repeated Valsalva maneuvers.…”