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A 27-year-old male was transferred to the Emergency Department after blunt chest trauma caused by motor cycle accident. Initial electrocardiogram showed a right bundle branch block (RBBB). On physical examination, the patient had non-severe facial injuries and anterior chest wall pain.

Transthoracic echocardiography demonstrated mild anterior hypokinesia with preserved global ejection fraction. Laboratory findings included T-troponins 0.51 ng/mL and CK-MB 31 ng/mL. Analgesia was started and the patient was monitored.

Twenty-four hours later, a transthoracic echocardiography demonstrated extensive anterior akinesia and myocardial damage markers peaked at T-troponins 3.18 and CK-MB 104. ECG showed RBBB resolution and T-wave inversion V1–V4. The patient was asymptomatic. Angiography revealed a single mid-left anterior descending artery lesion with hazy limits and TIMI 3 flow (Panel A). An intravascular ultrasound (IVUS) study showed a subintimal crescent-shape hypoechoic image, suggestive of intimal dissection with subintimal haematoma compressing the vessel lumen (Panel B). Optical coherence tomography (OCT) confirmed this findings with no intimal disruption (Panel C). A conservative management was planned with heparin and abciximab waiting for haematoma resolution to avoid stent deployment. For 1 week the patient remained asymptomatic, but a new angiography proved no resolution of haematoma. Thus, a direct stent was deployed with complete angiographic resolution (Panel D). IVUS confirmed correct stent apposition and haematoma exclusion (Panel E). OCT verified these findings with a final luminal diameter over 4 mm (Panel F). The patient made a good clinical recovery and was discharged 24 h later.

Topic:
Issue Section:
CLINICAL VIGNETTES
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