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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

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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

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

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

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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.