You are here

Article Text

Article menu
Download PDFPDF
Images
Cardiac coup and contrecoup following a suicide attempt
  1. Andre Briosa e Gala1,
  2. Anthony Dimarco1,
  3. Sobana Battinson2,
  4. Ausami Abbas2,
  5. John Rawlins1,
  6. Michael Mahmoudi1
  1. 1 Departmemt of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  2. 2 Department of Cardiothoracic Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  1. Correspondence to Dr Andre Briosa e Gala, Departmemt of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; andre.gala{at}ouh.nhs.uk

http://dx.doi.org/10.1136/postgradmedj-2019-137308

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    A 48-year-old man was admitted as a Level 1 trauma after attempting suicide by jumping 28 m into a river. He was haemodynamically stable with unremarkable physical examination except for bilateral periorbital bruising. Trauma-protocol CT demonstrated an isolated T5 vertebral fracture.

    Despite being pain free, serial ECGs showed dynamic anterior ST-elevation. Review of the trauma CT identified a subtle perfusion defect in the left anterior descending artery (LAD) territory in keeping with a recent infarct, but motion artefact made assessment of the aortic root challenging. In view these findings, he underwent an urgent ECG-gated CT coronary angiogram (CTCA) which demonstrated a planar pattern of intimal injuries involving the aortic root (traumatic aortic injury type I), anterior and posterior wall of the left atrium. This pattern was highly suggestive of coup (aorta) and contrecoup (left atrium) injuries caused by the sudden deceleration on water impact (figure 1). It confirmed a flush occlusion of the LAD as the cause of the myocardial infarction (figure 2). Inappropriate invasive angiography was avoided which could have had catastrophic consequences.

    Figure 1
    Figure 1

    ECG-gated CT images intimal injuries within the both the aortic root with layering of thrombus and left atrium (interrupted black arrows) in a coup and contrecoup distribution and an occluded left anterior descending artery (white arrow).

    Figure 2
    Figure 2

    Curved reformatted ECG-gated CT image showing a thrombus above the ostium of the left main stem (black interrupted arrows) and occluded left anterior descending artery secondary to further intimal injury (white arrows).

    Following a comprehensive multidisciplinary team discussion, he was treated conservatively. Repeat CTCA performed 24 hours later demonstrated stable appearances. After 7 days of observation, he was transferred to a mental health facility. Cardiology follow-up to reassess cardiac function with echocardiography and CTCA was organised at 4 months but he failed to attend.

    Traumatic aortic injury (TAI) is the second most common cause of death in blunt trauma.1 Unlike aortic rupture (TAI type 4) and pseudoaneurysm (TAI type 3) which require surgical intervention, intimal injuries (TAI type 1) are often stable and managed conservatively.2 CT aortogram is the gold-standard imaging modality in suspected aortic trauma; however, ECG-gated protocols are essential to reduce motion artefact and allow for accurate assessment as subtle changes may be missed.3 4

    References

    1. ↵
      2. Cullen EL ,
      3. Lantz EJ ,
      4. Johnson CM , et al
      . Traumatic aortic injury: CT findings, mimics, and therapeutic options. Cardiovasc Diagn Ther 2014;4:238–44.doi:10.3978/j.issn.2223-3652.2014.06.02
      OpenUrl
    2. ↵
      2. Erbel R ,
      3. Aboyans V ,
      4. Boileau C , et al
      . 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873–926.doi:10.1093/eurheartj/ehu281
      OpenUrlCrossRefPubMedWeb of Science
    3. ↵
      2. Hiratzka LF ,
      3. Bakris GL ,
      4. Beckman JA , et al
      . 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/american Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266–369.doi:10.1161/CIR.0b013e3181d4739e
      OpenUrlFREE Full Text
    4. ↵
      2. Raptis CA ,
      3. Hammer MM ,
      4. Raman KG , et al
      . Acute traumatic aortic injury: practical considerations for the diagnostic radiologist. J Thorac Imaging 2015;30:202–13.doi:10.1097/RTI.0000000000000149
      OpenUrl

    Footnotes

    • Contributors ABeG and AD wrote the manuscript. SB and AA performed and reported the cross-sectional imaging. AA, JR and MM reviewed and edited the manuscript. All authors approved the manuscript prior to submission.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Obtained.

    • Provenance and peer review Not commissioned; internally peer reviewed.