Left Main Dissection and Pseudoaneurysm Formation After a Road Traffic Accident

We present here the case of a 46-year-old man, a smoker, who was involved in a motor vehicle accident. He was hit by a car while driving his motorcycle. The emergency medical care team found that the patient had a Glasgow Coma Scale score of 3 and quickly developed a bradyasystolic cardiac arrest. After successful advanced resuscitation, the ECG showed right bundle-branch block and anterolateral ST-segment elevation (Figure 1), so the patient was transported to the intensive care unit. Figure 1. ECG after the cardiac arrest showing right bundle-branch block and anterolateral ST-segment elevation. First, a body computed tomography scan and x-ray were done, demonstrating jaw, rib, femur, and tibia fractures without any points of active bleeding. The right bundle-branch block disappeared but the ST-segment elevation persisted on ECG. In addition, an urgent echocardiogram detected wall motion abnormalities with an anteroseptal akinetic area and a moderately depressed ejection fraction without pericardial effusion (Movies I and II in the online-only Data Supplement). Consequently, an emergency coronary angiogram showed a thin radiolucent line in the distal left main coronary artery (LMCA) that suggested intimal flap (dissection) with Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in the left anterior descending (LAD) artery and left circumflex artery (Figure 2A …