Letters to Editor

like our present case, an AVM. Digital subtraction

angiography is important for the evaluation of the type
of collateral circulation before planning any
intervention.

N. K. Shyam Kumar, N. R. S. Surendrababu,

V. Rajshekhar*
Departments of Radiodiagnosis and *Neurological Sciences,
Christian Medical College, Vellore, Tamil Nadu - 632 004, India.
E-mail: nrssbabu@yahoo.com

References

m
o
fr
d ns
a
o tio
l
n
ICA and carotid canal cannot develop. Agenesis and
w lica
hypoplasia can be reliably diagnosed by HRCT of the
o
skull base by noting the absence or narrowing of the
d ub
carotid canal respectively. There are three types of
e P ).
collateral circulations associated with this entity for
e
r
completion of the circle of Willis. The commonest is of f
w om
the fetal type P Com is dilated and supplies the MCAr
o
o
n .c
and A Com supplies the ACA. The second variety isfof
k
e
the adult type, both ACA and MCA are suppliedlby the d
w
o
b
A Com. The third variety-distal ICA - is present
with e
a ECA Mor kn
transcranial anastamoses that develop from
l
i
contralateral ICA or primitive vessels.
a bywith ed
Agenesis of ICA is most commonly v
associated
a d due to.m
cerebral aneurysms at the circle of Willis
s
i teof 25-35%.
hemodynamic alterations with an incidence
wand
s
F
Other associations described are occulomotor
w
o torticollis,
D
trigeminal nerve palsies,
spasmodic
h
(w nerve
P te with facial
hypopituitarism, ear malformations
s syndrome.
palsy, congenital Horners
Infarctions are Spinal epidural air following
i
i
s
h
uncommon, in fact, due to development of adequate
T a
multiple thorax trauma
collateral circulation.
1.

Figure 3: HRCT of skull base showing absence of right carotid canal.

The arrow shows the left carotid canal
[4]

2.

3.

[5]

4.

5.
6.
7.

[4]

[6]

The etiology of AVM is considered to be dysregulated

angiogenesis that occurs in the neuronal proliferation and
histiogenesis phase of the brain development. Fukui et al
earlier described a case in which there was anomalous
origin of the ICA from the CCA, with anomalous course
of ICA and an associated ipsilateral AVM. [7] They
proposed that the AVM would be due to maldevelopment
of the vascular network including the aortic arches on
the same side. In our case the AVM is on the side
contralateral to the agenesis of ICA. To our knowledge
this is the first documented case of this type. We cannot
determine whether the agenesis of ICA and contralateral
AVM occurred in our patient by an associated pathogenic
mechanism or just simply by chance.
In these cases of agenesis of ICA diagnosed by MRA
or HRCT, it is mandatory to search for associated
vascular malformations like aneurysms and very rarely

86
86 CMYK

Midkiff RB, Boykin MW, McFarland DR, Bauman JA. Agenesis of

the internal carotid artery with intercavernous anastomosis. Am J
Neuroradiol 1995;16:1356-9.
Claros P, Bandos R, Gilea I, Claros A Jr, Capdevila A, Garcia
Rodriguez J, et al. Major congenital anomalies of the internal
carotid artery: Agenesis, aplasia and hypoplasia. Int J Pediatr
Otorhinolaryngol 1999;49:69-76.
Dinc H, Gumele HR, Kuzeyli K, Baykal S. Unilateral agenesis of
internal carotid artery with subarachnoid hemorrhage: Report of
two cases. Int J Angiol 1999;8:157-60.
Dinc H, Alioglu Z, Erdol H, Ahmetoglu A. Agenesis of the internal
carotid artery associated with aortic arch anomaly in a patient with
congenital Horners syndrome. Am J Neuroradiol 2002;23:929-31.
Sunada I, Inoue T. Bilateral internal carotid artery agenesis. J
Neurol Neurosurg Psychiatry 1996;61:206-7.
Florio F, Balzano S, Nardella M, Strizzi V, Cammisa M, Bozzini V,
et al. Congenital absence of the internal carotid artery. Cardiovasc
Intervent Radiol 1999;22:74-8.
Fukui S, Katoh H, Nawashiro H, Ooigawa H, Kaji T, Otani N, et al.
Anomalous internal carotid artery associated with ipsilateral
cerebral arteriovenous malformation - case report. Neurol Med
Chir (Tokyo) 2001;41:607-10.

Accepted on 21-07-2006

Sir,
A 67-year-old man was brought to the emergency room
because of dyspnea after physical assault. He was awake
and hypotensive. His airway was open and spontaneous
breathing was insufficient. He was intubated and
mechanically ventilated for multiple rib fractures, which
caused an inability in inspiration. He had subcutaneous
emphysema in his face, neck and thorax.
Saline were infused via peripheral and central venous
route. After fluid replacement, his blood pressure had a
normal range.
Chest X-ray revealed the presence of multiple rib
fractures in his left side, generalized subcutaneous
emphysema and bilateral pneumothorax with
pneumomediastinum [Figure 1]. Chest tubes were put
into both sides.
Neurology India | January-March 2007 | Vol 55 | Issue 1

Letters to Editor

m
o
fr
d ns
a
o tio
l
n
Lateral X-ray of cervical spine was normal up to the which provides the venous drainage
a for the individual
columnic
is related to the veins of
level of C5 because of the superimposition of shoulder. vertebrae of the spinal w
o bl to the mechanisms
We could not see C6 and C7 cervical vertebrates. We the neck. Thus,din addition
baseduon these neuroanatomical
decided to evaluate these levels by using axial CT scan. mentioned above,
ewe also
Pthink that). in our case, epidural
CT scan showed left-sided spinal epidural air between characteristics,
e
r
f
spinal air may have
levels C6 and C7 [Figure 2].
wneckmigrated
m from subcutaneous
r
in the
toothe epidural space via the
He died because of severe respiratory tract infection after emphysema
o
o
c
venousf system. n
38 days from admission.
.
k
e
Chest
of pneumothorax) and
In the literature, intraspinal air has been described
l X-ray
d (in theowdiagnosis
b
e
subcutaneous
emphysema is important in the
secondary to basal skull fracture, instrumentation, cervical
n air, because of this CT scan
of intraspinal
epidural abscess or disc degeneration. However,ilasuspicion
M
k
d in the diagnosing of intraspinal air
a should
performed
intraspinal air occurring in association with a chest trauma
y bepatients
v
e
b
in
the
with traumatic pneumothorax and
is extremely rare. Scialdone and Wagle have reported
achest dpneumomediastinum.
m
one case developing intraspinal air following a blunt
.
is te w
trauma.
F suchosas Ahmet
Intraspinal air is often due to iatrogenic causes
w Baydin, Dursun Aygun, Selim M. Nural*,
D
spinal surgery, lumbar puncture or epidural anesthesia.
w
h
Keramettin Aydin**, Cemil Nargis
P airtefollowing (
Scialdone et al reported a case of intraspinal
s rostral
a blunt chest trauma. They thoughtithat
si migration
h
of air may have occurred through the epidural
Tof the mediastinum
a spaceandor
the communicating facial planes
Figure 1: Chest X-ray

Figure 2: CT scan shows left-sided spinal epidural air between levels

C6 and C7

[4]

[1]

[1]

[1]

neck.[1] In our case, spinal epidural air may have

developed by the same accomplished mechanisms.
Several case reports have described the development of
cervical subcutaneous emphysema following lumbar
epidural anesthesia.[2] These findings may point out the
presence of a communication between the subcutaneous
emphysema of the neck and the epidural space of the
spinal cord. Finally, it is probable that because of the
absence of a fascial barrier between the posterior
mediastinum and neck, the air may migrate from these
spaces into the spinal canal through the intervertebral
foramina.[1,3] On the other hand, it is known that air can
migrate into the venous system of the central nervous
system from the environment in open-brain injury. In
the epidural space of the spinal cord, the internal venous,

Neurology India | January-March 2007 | Vol 55 | Issue 1

Ondokuz Mayis University, Faculty of Medicine, Department of

Emergency Medicine, Samsun-Turkey *Ondokuz Mayis
University, Faculty of Medicine, Department of Radiology,
Samsun-Turkey, **Ondokuz Mayis University, Faculty of Medicine, Department of Neurosurgery, Samsun-Turkey.
E-mail: abaydin@omu.edu.tr

References
1.
2.
3.
4.

Scialdone CJ, Wagle W. Intraspinal air: An unusual manifestation

of blunt chest trauma. Clin Imaging 1990;14:59-60.
Bromage PR. Epidural air bubbles and frothy syllogisms. Anaest Analg
1988;67:93-4
Defouilloy C, Galy C, Lobjoie E, Strunski V, Ossart M. Epidural
pneumatosis: A benign complication of benign pneumomediastinum.
Eur Respir J 1995;8:1806-7.
Geldmucher DS, Bowen BC. Spinal cord vascular disease. In:
Bradley WG, Daroff RB, editors. Neurology in clinical practice.
Butterworth and Heinemann: Philadelphia; 2004. p. 1313-22.

Accepted on 18-07-2006

87
CMYK87