Blunt traumatic injury of innominate artery is uncommon and has been reported only in 132 cases. In the literature there has been a solitary case report of a stroke resulting from an innominate artery injury. We present a case of traumatic injury of the innominate artery resulting in an ischemic stroke.

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2. Case Report
Blunt traumatic injury of the innominate artery
resulting in a stroke e A rare presentation
Dhavapalani Alagappan*, N.R. Ganesh
Apollo Hospitals, Chennai, India
a r t i c l e i n f o
Article history:
Received 16 April 2014
Accepted 2 May 2014
Available online xxx
Keywords:
Blunt arterial injury
Innominate artery injury
Pseudo aneurysm
a b s t r a c t
Introduction: Blunt traumatic injury of innominate artery is uncommon and has been re-
ported only in 132 cases. In the literature there has been a solitary case report of a stroke
resulting from an innominate artery injury. We present a case of traumatic injury of the
innominate artery resulting in an ischemic stroke.
Case presentation: A 20-year-old gentleman ejected from a two wheeler and run over by a
truck presented to us with multiple bleeding facial wounds and severe crush injury of his
upper torso. Bedside chest X-ray revealed a widened mediastinum and multiple rib frac-
tures with pneumothoraces bilaterally which were drained with intercostal tubes. An hour
into his stay in the ED he developed left hemiparesis. CT brain showed infarcts in right
temporo-parietal and occipital regions. CT angiogram of neck vessels revealed an avulsion
injury at the origin of the right innominate artery with pseudoaneurysm formation.
Discussion: The innominate artery is the 2nd most common site of great vessel injury after
the ascending aorta. 71% die before reaching the hospital. Patients who present to the ED
are often stable with associated major injuries including rib fractures, pneumothorax and
closed head injuries. The diagnosis is aided by a thorough clinical examination or a chest
X-ray revealing a widened mediastinum as seen in our patient.
Lessons learnt: Severe upper torso injuries involving the clavicle and upper ribs with pulse
deficits or unexplained neurology should always raise a strong suspicion of major vascular
injuries warranting further evaluation.
Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Blunt traumatic injury of innominate artery is uncommon and
has been reported only in 132 cases.1
In the literature there
has been a solitary case report of a stroke resulting from an
innominate artery injury.2
We present a case of traumatic
injury of the innominate artery resulting in an ischemic
stroke.
2. Case presentation
A 20-year-old gentleman ejected from a two wheeler and ran
over by a truck presented to us with multiple bleeding facial
wounds and severe crush injury of his upper torso. However
he did not have any hemodynamic compromise. Bedside
chest X-ray revealed a widened mediastinum and multiple rib
fractures with pneumothoraces bilaterally which were
* Corresponding author.
E-mail addresses: dhavapalani@hotmail.com, drdhavapalani_a@apollohospitals.com (D. Alagappan).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3
Please cite this article in press as: Alagappan D, Ganesh NR, Blunt traumatic injury of the innominate artery resulting in a stroke
e A rare presentation, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.004
http://dx.doi.org/10.1016/j.apme.2014.05.004
0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. drained with intercostal tubes. An hour into his stay in the ED
he developed left sided hemiparesis. Subsequently he was
intubated for airway protection. CT brain showed infarcts in
right temporo-parietal and occipital regions. CT angiogram of
neck vessels revealed an avulsion injury at the origin of the
right innominate artery with pseudoaneurysm formation. He
was immediately shifted to theater for exploration where he
was found to have intimal transection of innominate artery
with a large intraluminal clot completely obstructing the
lumen with no ante grade flow. The vessel was divided and
repaired successfully. Post-operative recovery was uneventful
and he was discharged on the tenth post operative day with
minimal residual neurological deficit.
Chest X-ray showing widened upper mediastinum fracture
of 1st, 2nd, 3rd and 4th ribs on right side, subcutaneous
emphysema on right side, with bilateral chest drains in situ.
CT scan of brain plain showing a hypo dense lesion sug-
gestive of infarct in right temporo-parietal, occipital and high
parietal region.
CT angiogram reconstructed image showing e avulsion
injury at the origin of the right innominate artery with
pseudo aneurysm formation. Innominate artery is not
visualized. Right common carotid artery shows reduced flow.
3. Discussion
The innominate artery is the 2nd most common site of great
vessel injury, the most common being the aortic isthmus
distal to the left subclavian artery.3
It is usually an avulsion or
transection injury found at the origin of the vessel from the
aortic arch and can be caused by deceleration or crush injuries
secondary to a motor vehicle crash or fall from a great height.
However, penetrating injuries more frequently cause innom-
inate artery disruptions. The postulated mechanism of injury
is an anteroposterior compression of the mediastinum be-
tween the sternum and the vertebrae that displaces the heart
posteriorly and to the left. This increases the curvature of the
arch and causes tension on the outlet vessels. 71% die before
reaching the hospital. Patients who present to the ED are often
stable with associated major injuries including rib fractures
(46%), pneumothorax (36%) and closed head injuries.4
The diagnosis is aided by a thorough clinical examination
(bruit, supraclavicular hematoma, pulse deficit, blood pres-
sure discrepancy between arms or a shoulder-belt sign) or a
chest X-ray revealing a widened mediastinum.5
Bleeding and
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e32
Please cite this article in press as: Alagappan D, Ganesh NR, Blunt traumatic injury of the innominate artery resulting in a stroke
e A rare presentation, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.004

4. hemorrhagic shock may not be evident in blunt innominate
artery injury as the hematoma is usually contained in the
upper mediastinum
4. Lessons learnt
Severe upper torso injuries involving the clavicle and upper
ribs with pulse deficits or unexplained neurology should al-
ways raise a strong suspicion of major vascular injuries war-
ranting further evaluation.
Conflicts of interest
All authors have none to declare.
r e f e r e n c e s
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2006;43:396e398.
4. Stover S, Holtzman RB, Lottenberg L, Bass TL. Blunt
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a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 3
Please cite this article in press as: Alagappan D, Ganesh NR, Blunt traumatic injury of the innominate artery resulting in a stroke
e A rare presentation, Apollo Medicine (2014), http://dx.doi.org/10.1016/j.apme.2014.05.004

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