Case 8: stab (knife) wound to the face

posted: September 2, 1996

Resident: Ian Angel, MD
Attending: Deepak Awasthi, MD

PRESENTATION: This 50 year man presented to the ER after sustaining a stab wound to his left face following an argument with his wife. On arrival to the ER, the patient was awake and alert. His only neurological deficit was a left peripheral 7th nerve paresis (superior >inferior part of face). His pulse and blood pressure were normal and stable. The knife handle was broken, however, the knife blade could be seen entering the face- anterior to the left tragus:

Note the knife blade without the handle entering the face.

At this point initial x-rays including skull x-rays were performed:

Note the proximity of the knife to the cervical spine in the lateral (left) and AP (right) projections.

Of note- about 13 cm! of the knife blade was within the wound.

What would you do at this point- any additional diagnostic studies or take the patient to the OR and remove the knife?

Please comment: dawast@lsuhsc.edu

A 4 vessel angiogram was done at this point and it revealed a remarkable transection of the left vertebral artery at the C2-3 level. See below:

An oblique (left) and AP (right) projections of the left and right vertebral injections, respectively. No other vascular injury was noted.

What would you do at this point? Endovascular vs. Open occlusion of left vertebral artery?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: Initially, the left vertebral artery was occluded proximal to the transection with coils and then another catheter was guided through the right vertebral artery (VA) into the distal left VA which was also occluded with coils near the transection.

After adequate occlusion, the patient was taken to the OR where initially the left cervical internal carotid artery was secured (in case the knife egde would lacerate the artery upon withdrawal). Now, the knife was removed without complications (no hemorrhage was noted, blood pressure and pulse were stable). Next, the transected ends of the superior division of the extracranial left facial nerve were identified under the parotid gland and repaired in an end-to-end manner with 7-0 prolene sutures.

Postoperatively, the patient did well. No new neurological deficits. Followup angiogram revealed no additional vascular lesions. He was discharged home on postop day #3.

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