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Table of Contents    
Year : 2017  |  Volume : 65  |  Issue : 1  |  Page : 206-207

“Stroke by a pencil”: A friend turned fiend

Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication12-Jan-2017

Correspondence Address:
Dr. Ashish Aggarwal
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.198224

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How to cite this article:
Aggarwal A, Gupta D, Dhandapani S S. “Stroke by a pencil”: A friend turned fiend. Neurol India 2017;65:206-7

How to cite this URL:
Aggarwal A, Gupta D, Dhandapani S S. “Stroke by a pencil”: A friend turned fiend. Neurol India [serial online] 2017 [cited 2023 Feb 8];65:206-7. Available from: https://www.neurologyindia.com/text.asp?2017/65/1/206/198224


An uncommon mode of trauma in childhood is injury to the soft palate because of the presence of a foreign body inside the oral cavity. A rare consequence can be internal carotid artery (ICA) injury, leading to the development of stroke.

A 7-year-old male child was playing with a pencil in his mouth. He sustained a fall in face-down position, leading to an injury to the left side of the soft palate. The patient had an intraoral bleeding, which subsided on its own after sometime. This was followed 8–9 hours later by headache, multiple episodes of vomiting, and weakness of right side of the body. On examination (approximately 31 hours after trauma), the child was conscious but aphasic, with right hemiparesis grade 2/5. Non-contrast computed tomography (NCCT) of the head (8 hours after trauma) [Figure 1]a revealed a near normal brain parenchyma. A subsequent NCCT head (31 hours after trauma) [Figure 1]b and [Figure 1]c showed a left middle cerebral artery (MCA) territory infarct with mass effect. CT angiography of the neck and cranial vessels [Figure 1]d and [Figure 1]e revealed nonfilling of the left ICA. An urgent left decompressive hemicraniectomy was performed. Postoperative NCCT was satisfactory [Figure 1]f. Following this, heparin was started. Subsequently, the hemiparesis improved to grade 3/5 and the patient was discharged in a conscious state.
Figure 1: (a) Early noncontrast computed tomography (NCCT) of the head showing normal brain parenchyma. (b and c) Delayed NCCT of the head showing a left middle cerebral artery infarct. (d) CT angiography showing the left internal carotid artery (ICA) cut off (shown by arrow). (e) CT angiography showing nonvisualization of the left ICA in the cavernous segment (shown by arrow) (f) NCCT head showing evidence of the hemicraniectomy and correction of the midline shift

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Putting a foreign body in the mouth such as a tooth brush, chopstick, straw, and spoon is an innocuous activity which we perform daily. At times, these very objects become agents of severe oropharyngeal trauma. Different mechanisms of trauma are a fall with a foreign body in the oral cavity, or a fall with mouth open on a fixed foreign body.[1] Injury to the ICA is a rare complication, which was first described by Caldwell in 1936.[2]

The carotid sheath is located posteromedial to the palatine tonsil [Figure 2]. The foreign body compresses the ICA against the C2 vertebra, leading to thrombus formation and its propagation.[3],[4] Clinically, often there is a delay of 1–60 hours between the injury and appearance of neurological symptoms.[5] A potential long-term complication can be the development of pseudoaneurysm of the cervical ICA.[6]
Figure 2: Schematic line diagram of the relevant anatomy of oropharynx showing the probable path of the foreign body

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The diagnosis, especially in cases where there is a lucid interval, is difficult. A high index of suspicion should be maintained especially in the presence of an initial 'herald' bleed. Angiography remains the gold standard method to accurately locate the site and extent of the thrombus.

The therapeutic options are limited. Further clot propagation may be prevented by heparin and anticoagulants; however, their definite role is debatable. Direct carotid endarterectomy has a limited role because of the surgically difficult location near the skull base and the risk of reperfusion injury.[5] Potential therapies include an extracranial-to-intracranial bypass procedure or a carotid stenting, which have been used to treat other causes of acute ICA occlusion also.[7],[8]

Injury to the ICA, due to trauma in the presence of a foreign body in the mouth, can be potentially devastating. The diagnosis at an early stage is difficult because of the presence of a lucid interval. As definite therapeutic options are limited, primary prevention remains the best possible option.

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Conflicts of interest

There are no conflicts of interest.

 » References Top

Hellmann JR, Shott SR, Gootee MJ. Impalement injuries of the palate in children: Review of 131 cases. Int J Pediatr Otorhinolaryngol 1993;26:157-63.  Back to cited text no. 1
Caldwell JA. Post-traumatic thrombosis of the internal carotid artery. Report of 2 cases. Am J Surg 1936;32:522-3.  Back to cited text no. 2
Pitner SE. Carotid thrombosis due to intraoral trauma: An unusual complication of a common childhood accident. N Engl J Med 1966;274:764-7.  Back to cited text no. 3
Randall DA, Kang DR. Current management of penetrating injuries of the soft palate. Otolaryngol Head Neck Surg 2006;135:356-60.  Back to cited text no. 4
Borges G, Bonilha L, Santos SF, Carelli EF, Fernandes YB, Ramina R, et al. Thrombosis of the internal carotid artery secondary to soft palate injury in children and childhood. Report of two cases. Pediatr Neurosurg 2000;32:150-3.  Back to cited text no. 5
Bhaisora KS, Behari S, Godbole C, Phadke RV. Traumatic aneurysms of the intracranial and cervical vessels: A review. Neurol India 2016;64(Suppl):S14-23.  Back to cited text no. 6
Andrews BT. Treatment of acute traumatic internal carotid artery occlusion with extracranial-to-intracranial arterial bypass: Case report. Neurosurgery 1989;25:90-2.  Back to cited text no. 7
Singh RR, Barry MC, Ireland A, Bouchier Hayes D. Current diagnosis and management of blunt internal carotid artery injury. Eur J Vasc Endovasc Surg 2004;27:577-84.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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