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Late-Onset Dysphagia in a Sumo Wrestler after a Sumo Bout

2013; Lippincott Williams & Wilkins; Volume: 12; Issue: 1 Linguagem: Inglês

10.1249/jsr.0b013e31827dc1c8

1537-8918

Aiko Osawa, Shinichiro Maeshima, Hajime Maruyama, Hidetaka Takeda, Norio Tanahashi,

Restraint-Related Deaths

Introduction Although neck trauma in sporting events may be common, ischemic cerebrovascular disease caused by trauma is extremely rare. Nonetheless, ischemic cerebrovascular disease in younger people accounts for only 3% of cases across all age groups, and among such cases, those caused by trauma are extremely rare (1). Sumo was traditionally a martial art performed in Japan at religious events and festivals. It's been only recently that it has become a competitive combat sport practiced worldwide. Sumo wrestlers are not graded by age, height, or weight. A wrestler loses when he touches the ground outside of the ring or when any part of his body, other than the soles of his feet, touches the ground in the ring. A major characteristic of sumo is the emphasis on constant pushing in the forward direction (i.e., pushing the opposing wrestler backward) and the eschewing of pulling, the stepping out of the way, or other such evasive manoeuvres whenever possible, because sumo is a contest of strength and skill. A sumo bout begins with the tachiai face-off; the wrestlers crouch, look into each other's eyes, place both their fists on the ground, and then stand and launch into each other. Because each bout begins, by definition, with a collision that exerts great impact on the wrestlers' head and neck (7), wrestlers commonly develop neck trauma and disorders (Fig. 1).Figure 1: Sumo tournament. Sumo wrestlers throw themselves against each other during the initial charge.This report concerns the experience of a student who experienced a late-onset dysphagia caused by stroke after he participated in butsukari-geiko or "collision training," which involves colliding repeatedly into the chest of another wrestler and pushing him backward. Butsukari-geiko aims to instill proper stances for colliding and taking the force of the other wrestler away at the point of collision. Case Report An otherwise healthy, 19-year-old man, a sumo wrestler, was admitted to our hospital; he complained of headache, dizziness, and dysphagia. Concerning his sports history, he started practicing sumo when he was an elementary school student, participated in national tournaments when he was a middle and high school student, and was a member of the sumo club at his university. He repeatedly hit his head with his opponents and twisted his neck in practicing tachiai (the initial charge at the beginning of a bout). He experienced syncope and underwent an emergency examination at a nearby medical facility. However, a computed tomography (CT) scan of his head revealed no abnormalities, and therefore, he was not provided medical care; however, monitoring of his condition was recommended. Three days after, he experienced headaches, vomiting, and walking instability. He showed increasing inability to swallow food and experienced numbness in his right arm and leg. Physical examination revealed no visible injuries or scars, no bruit in the neck, and no obvious abnormality, except obesity (height, 174 cm; weight, 150 kg; body mass index (BMI), 49.6). His consciousness was clear and his orientation was normal. He revealed ptosis of his left eye with a miotic pupil and anhydrosis in his left hemifacial area, all of which were compatible with Horner's syndrome. His soft palate was deviated to the right side. Loss of gag reflex was observed on both sides. Deterioration of muscular strength in the limbs was not observed, the deep tendon reflex was normal, and pathological reflex was not found. Slight weakening of the tactile, pain, and temperature sensations was observed on the right side of the face and body. Coordinated movement was tested using the finger-to-nose and knee-heel tests; the results showed poor movement on the left side of the body and difficulty in walking. Magnetic resonance imaging (MRI) performed on admission detected cerebral infarcts in the dorsolateral region of the left medulla oblongata and in the left cerebellum (Fig. 2A). Magnetic resonance angiography (MRA) showed that the distal portion of the left vertebral artery was occluded abruptly (Fig. 2B). Basiparallel anatomic scanning MRI (12) showed no difference between the right and left vertebral arteries. A three-dimensional CT angiography (3D-CTA) performed on the fifth day of hospitalization showed occlusion of the left vertebral artery from the C1 superior margin to the basilar artery junction (Fig. 2C). A CT scan of the vertebral spine revealed no bone fracture. Three weeks later, MRA was performed, but the left vertebral artery was not visible. Even though the patient was obese, he had no other risk factors that may lead to stroke, such as diabetes, hypertension, arrhythmia, or dyslipidemia; therefore, the occlusion was thought to be caused by vertebral artery dissection secondary to forceful neck torsion or neck trauma.Figure 2: A, MRI scans on admission. A diffusion-weighted image of the outside of the back of the left medulla oblongata and from the inside of the left cerebellar hemisphere to the vermis revealed a stroke lesion of high signal intensity. B, MRA scans on admission. MRA revealed an abrupt occlusion; however, visibility of the distal portion of the left vertebral artery was poor. C, A 3D-CTA on the fifth day of hospitalization. 3D-CTA showed abrupt occlusion of the left vertebral artery from the C1 superior margin to the basilar artery junction.The patient was diagnosed with an infarction in the left cerebellum and medulla oblongata and was administered antiplatelet medication. The patient's dysphagia was indeed serious because he could not swallow fluids and experienced choking. Videofluorography (VF) conducted 2 wk later showed a delayed swallowing reflex and an inability to relax the cricopharyngeal muscle, with food tending to accumulate at the entrance to the esophagus. No food boluses entered the esophagus, but some entered the trachea without coughing of the patient (silent aspiration). Thus, the patient was found to have difficulty in consumption of food and was provided indirect training. A VF test performed 5 wk after the initial manifestation of symptoms revealed that aspiration of fluids persisted. However, while significant food bolus residues in the throat still were observed, food did seem to be passing through the entrance to the esophagus. Subsequently, he was administered a training regime to encourage the swallowing of whole slices of jelly. In a VF test performed 8 wk after the initial manifestation of the symptoms, the patient still showed some aspiration of fluids, but the amount of residual food in the throat remarkably reduced; consequently, he was maintained on a diet of rice gruel. He was discharged 10 wk after the initial manifestation of symptoms. He was able to walk without assistance, but numbness etc. persisted. He, therefore, had no choice but to resign from the sumo club. A VF test performed 16 wk after the initial manifestation of symptoms showed some fluid retention in the larynx, and therefore, he was administered subsequently a thickener. Discussion In the case presented, the patient had no preexisting risk factors for cerebral vascular disease, such as high blood pressure, hyperlipidemia, and diabetes. He was diagnosed with a traumatic cerebrovascular disorder caused by occlusive dissection of the vertebral artery due to a head injury incurred while engaging in sumo wrestling. Occlusive cerebrovascular disorders caused by closed injuries to the cervical vessel are rare, occurring at a frequency of 0.08% and 3% (3,8). Even among these injuries, those incurred when playing sports are few and rare. Miki et al. (10) reported that of 4,873 patients with sport-related head and neck trauma, only two patients (0.04%) showed symptoms of occlusive cerebrovascular disorder. Conversely, another study showed that vertebral artery dissection accounts for approximately 33% of all sport-related strokes (9). American football, archery, tennis, swimming, volleyball, snowboarding, soccer, and wrestling are all sports where such strokes have occurred (9). The causes of these strokes include severe impact from falling, or strong bending of, or pressure on, the vertebral artery as a result of unnatural twisting of the head and neck, which is thought to damage the intima, resulting in the formation of blood clots and blocking of blood vessels (13). In the case described here, the patient experienced an overextension of the neck during sumo practice, resulting in severe bending and compression of the vertebral artery at the craniocervical junction. This damaged the intima, resulted in the formation of a blood clot, and led to a posterior inferior cerebellar artery stroke. In many cases of traumatic cerebrovascular disorder, signs of neurological disorders do not present themselves immediately after the trauma. Approximately half of all patients show symptoms within 24 h after the injury is incurred (8), but a significant proportion show symptoms more than 24 h (35%) later, and some patients take even longer than a month (11%). This is attributable to the time required for the formation of a blood clot around the damaged part of the vertebral artery wall (8). However, diagnosis is rather difficult, because these cases often involve bone fractures in the head and neck as well as brain trauma (14). In the case presented here, the patient complained of headaches and vomiting at the time of the initial examination but was not admitted to a hospital for treatment because his head CT showed no abnormalities. For the next few days, he did not undergo a treatment program with either bed rest or medicine. A few days later, however, he experienced severe dysphagia, which brought him back to the hospital for evaluation. The onset was thought to be delayed because the dissection of the vertebral artery progressed over many days, thus blocking the artery gradually rather than immediately. This caused an infarction on the outside of the medulla oblongata (i.e., Wallenberg syndrome), which directly affected the cranial nerve nucleus that controls the swallowing function. Therefore, in such cases where a patient complains of headaches after engaging in sports activity where his or her head and neck are bent or twisted severely, it is vital to consider the possibility of vascular dissection to obtain detailed information about the situation leading to the injury. Further, it is important to examine the vasculature by using 3D-CTA and MRA scans. In addition, MRI diffusion-weighted images should be obtained to increase the chances of early detection of any dissection (2,4). Moreover, it is imperative that the physician is completely aware of the pathological characteristics of an advancing dissection. While the mortality rate among wrestlers who tend to have high BMI scores has been reported to be high, sumo is unique, in that a high body weight is needed to succeed in the sport (5). As such, the daily regime of sumo wrestlers involves eating large amounts of food and resting frequently; however, this tends to cause severe obesity and frequently leads to sugar metabolism disorders and hyperlipidemia (6). In addition, wrestlers are susceptible to hardening of the arteries, and many die from strokes and heart diseases. The sumo population is not large, but sumo is as much a contact sport as judo or other forms of wrestling. Nakagawa et al. (11) studied trauma injuries in university sumo wrestlers and reported that at least 30% of wrestlers experienced back, neck, and knee pains. Conclusion We reported a sumo wrestler who experienced dysphagia caused by late-onset stroke after overextension of the neck during sumo practice, which resulted in dissection of the vertebral artery by severe bending and compression at the craniocervical junction. Careful medical management for neurological symptoms after neck damage and the strengthening of neck muscles on a routine basis are very important among wrestlers. We thank the staff of Saitama Medical University International Medical Center and Hanno-Seiwa Rehabilitation Hospital for their help and support in this study. This study was not sponsored because it is a clinical study in our university hospital. All authors report no conflicts of interest.