It's not every day the term "vascular injury" pops up on the injury report in any sport, and its uniqueness is enough to raise concern flags among fans.
That was certainly the case when New York Rangers' goaltender Henrik Lundqvist was reported to have suffered just such an injury after taking a puck to the throat Jan. 31 in a game against the Carolina Hurricanes.
Lundqvist addressed the media Sunday to talk about the injury and what lies ahead and was about as forthcoming as it gets in providing the perspective of an injured player. He described his injury as a "sprained blood vessel," and though this is not a term routinely used in medicine, it conveys the relative severity of the injury in terms most sports fans can understand.
We often hear of sprains in the context of joint injuries; ankle sprains are perhaps one of the most common ailments in sports. Although a sprain -- indicating, by definition, damage to a ligament -- has a broad range of presentations, the word "tear" is often reserved for the most severe injuries, when there is complete disruption of the tissue.
In other words, though a minor sprain can involve some "tearing" of tissue, the use of the word is often associated with the worst-case scenario.
In the case of Lunqvist, he clearly did not have a blood vessel torn apart, which would have been immediately life-threatening (and would probably only be seen in the case of a slicing injury, such as with a skate blade). Rather, he suffered a direct blow to the neck that resulted in trauma to the soft tissue in the area -- soft tissue that included a blood vessel that sustained damage in the process.
Although the Rangers have not offered more specifics than that the injury involved a blood vessel, the most likely scenario involves the carotid artery, given the location of the artery in the anterior (front) of the neck and its relative vulnerability to blunt trauma.
The carotid is easily accessed on either side of the front of the neck and is a common site for measuring one's pulse. In an unfortunate set of circumstances, Lundqvist's mask and attached chin shield were accidentally lifted by teammate Ryan McDonagh's stick, which exposed the right side of his throat as Lundqvist appeared to turn his head left at the precise moment the puck arrived. In the process, the carotid artery was similarly exposed.
Lundqvist said his neck was stiff in the hours and days following the injury, a likely byproduct of trauma to the many muscles in the area that support and control the head and neck.
Vascular injury is typically referred to in medicine as a dissection, which indicates the layers of the vessel wall have separated.
The area of the wall where the dissection occurs is thinner and therefore more susceptible to enlargement of the blood vessel and clot formation.
Think of it like a crack in a garden hose: The hose still functions, but the area of the crack is weakened, hence the risk of more serious potential damage.
Dr. Jason Lee, director of endovascular surgery and associate professor of vascular surgery at Stanford University, treats vascular injuries in elite athletes and noted the biggest risk following an arterial dissection in the neck region is the risk of stroke.
"There is the possibility a clot can form over the healing area of a blood vessel," Lee said. "If a fragment of the clot breaks and dislodges, it can travel to the brain and result in a stroke."
Lee is not treating Lundqvist and has not seen any imaging associated with his case, but Lee said the good news is the majority of these injuries heal on their own, without the need for surgical replacement of the artery.
According to Lee, most patients with a carotid dissection are placed on an anticoagulant (blood thinner) regimen for six to eight weeks, which typically involves the drug Coumadin. Worth noting is Lundqvist said Sunday that he would only be taking aspirin while he remains on the sideline. Aspirin does have some anticoagulant properties, albeit less potent than that of Coumadin.
Generally speaking, athletes on anticoagulants are not permitted to participate in contact sports due to increased risk of bleeding; however, Lee said an aspirin regimen is relatively safe and might be deemed acceptable for contact.
New York Rangers
Beyond preventing clot formation, there is still the matter of the blood vessel healing, something Lee said typically requires two to three months. This would explain Lundqvist's statement that he hopes to return for a push near the end of the season and the playoffs. The last day of the season is April 11.
Lundqvist's reevaluation in the next few weeks will presumably be an opportunity to assess his healing progress to date. In the interim, Lundqvist's activity will be controlled. As he mentioned, he will gradually resume light cardiovascular exercise and potentially light skating over the next few weeks.
Things that involve extreme motions of the neck and any contact or other potential exposure to reinjury of the vascular structure will be off-limits until there is evidence of satisfactory healing.
There's a reason this type of injury is unfamiliar. Not only is a traumatic carotid dissection exceptionally rare in athletes, but it's also unusual in the general population. Most such injuries are caused by violent motor vehicle accidents, often from the restraint of a seat belt against a head and neck moving with great forward momentum.
"We see about 25 motor vehicle accident patients a day at Stanford," Lee said, "and only about one a month has a carotid injury."
He did point out, however, that these injuries are not typically obvious through specific symptoms; they are found incidentally, after imaging. Imaging is generally undertaken only if there is a relevant history of trauma or evidence of significant injury to the area, such as bruising to the neck.
"There may be cases of this happening silently in athletes who suffer trauma to the neck or throat, and it heals on its own, so we never learn of it," he said.
Of course, the risk of not identifying the injury is what gives cause for concern. One study published in the American Journal of Emergency Medicine in 1998 seems to support that notion. The study identified two patients who subsequently developed neurological symptoms after being struck by a softball in the anterolateral neck (front and outer side), which led the authors to conclude carotid artery dissection following blunt trauma to that region might be underrecognized.
Still, it is not an entity seen with any regularity in sports, which makes it difficult to provide comparisons to Lundqvist's situation.
Fortunately for Lundqvist and the Rangers, the injury was properly identified. Now comes the recovery, primarily involving rest and healing. The hope is it will be no more than a few months before a return to competition, but the possibility exists that it could take longer.
While the extent of healing time can vary among individuals, the good news is once the blood vessel has healed, there is no evidence of increased risk going forward. The only risk is returning too soon, something Lundqvist seems to have processed along with the serious potential consequences.
"I feel great ... but you don't want to push this injury," Lundqvist said at the media conference. "You can't take a risk on this."