PMC9239694_01
Preoperative imaging (A: overview of the patient, B-G: computed tomography angiography (CTA)).
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A. The patient's neck was totally penetrated from right to left.
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B. Three-dimensional (3D) reconstruction of brain CTA showing the crossbow bolt totally penetrating the neck from right to left after penetrating the dermis.
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C, D, E. Brain CT showing that the crossbow bolt pierced the right parotid gland, the gap between the right mastoid tip and the mandible (C), the retropharyngeal space, and was in contact with the anterior arch of the atlas (D), and the gap between the left mastoid tip and the mandible (E).
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F, G. 3D reconstruction of brain CTA showing the crossbow bolt in contact with bilateral external and internal carotid arteries and the internal jugular vein (F) and that the crossbow bolt caused left external carotid artery dissection (arrow) (G).
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On presentation, the bolt completely penetrated the patients' neck from right to left (Fig. 1A). Neck contrast-enhanced CT showed the crossbow bolt totally penetrating from right to left sides after entering the dermis (Fig. 1B). The bolt pierced the right parotid gland, the gap between the right mastoid tip and the mandible, the retropharyngeal space, and was in contact with the anterior arch of the atlas, and the gap between the left mastoid tip and the mandible (Fig. 1C-E). Regarding the vascular structures, the bolt was in contact with bilateral external and internal carotid arteries and the internal jugular vein and caused left external carotid artery (ECA) dissection (Fig. 1F and G).
Angiogram of endovascular therapy.
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A. Right common carotid artery angiography (CCAG) showing no arterial bleeding or abnormal arterial changes.
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B. Left CCAG showing dissection of the main trunk of the left external carotid artery (ECA).
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C. Postoperative left CCAG showing complete embolization of the ECA, including the dissection lesion.
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D. We prepared for possible fatal bleeding while withdrawing the crossbow bolt under protection using balloon guiding catheters placed in bilateral common carotid arteries. Crossbow bolt removal was accomplished without bleeding by checking bilateral CCAG images.
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Right common carotid artery angiography (CCAG) showed no arterial bleeding or abnormal arterial change (Fig. 2A). Left CCAG showed dissection of the main trunk of the left ECA (Fig. 2B). Then, we successfully embolized the ECA, including the dissection lesion, using eight coils (Target XL360 soft 4 mm x 120 mm; Stryker Neurovascular) (Fig. 2C). To safely remove the crossbow bolt, we prepared for possible fatal bleeding while withdrawing the bolt under protection using the balloon guiding catheters placed in bilateral common carotid arteries (Fig. 2D).
A. The overview of the crossbow bolt that was removed from the patient.
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The arrowhead of the crossbow bolt was a conical field tip (arrowhead). First, the tail of the crossbow bolt was cut away to obtain a CT imaging (white arrow). The shaft of the crossbow bolt was cut short across the skin to shorten its length through the patient's neck as much as possible before removal (black arrow). Then, residual crossbow bolt (from black arrow to arrowhead) through the neck was pulled out gently from the left side.
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B. Postoperative neck computed tomography angiography (CTA) (left side).
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CTA revealed no abnormal vascular changes and coil mass into left ECA.
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C. Anatomical classification of neck trauma (Zones I-III).
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Zone I is from the clavicle to the cricoid cartilage, which is the thoracic outlet. Zone II is from the cricoid cartilage to the mandibular angle, which includes the internal and external carotid arteries, jugular veins, pharynx, larynx, esophagus, recurrent laryngeal nerve, thyroid, parathyroid, and spinal cord. Zone III is from the mandibular angle to the skull base and is protected by the skull bones. A direct surgical approach was difficult due to these structures. In the present case, the injury occurred in Zone III.
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First, the tail of the crossbow bolt was cut away to obtain a computed tomography (CT) imaging (Fig. 3A). The crossbow bolt was pulled out gently from the left side (Fig. 3A). Postoperative computed tomography angiography (CTA) showed no bleeding or abnormal vascular change and no damage to any crucial organs (Fig. 3B).