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To the Editor: While most cases of sudden death among athletes have been linked to a diverse group of cardiovascular diseases,¹ we have also reported sports-related sudden deaths triggered by innocent-appearing blows to the chest.² Here we expand the clinical profile of sudden death among athletes to include blunt blows to the neck during competitive ice hockey.

Methods
We assessed our prospective autopsy-based national registry of sudden cardiovascular deaths in young athletes, 1992 to 2002, composed of cases initially identified from a variety of sources including news media reports (and then subsequently tracked).

Results
Of the 370 trained athletes who died suddenly of defined cardiovascular-related causes,¹ 6 cases were selected for the present study group. Ages were 9 to 30 years (median, 17); all were male.

During competitive ice hockey, blunt and nonpenetrating blows were delivered to the exposed right (n = 4) or left lateral or posterolateral neck area (n = 2), just under the mandible between the helmet and neck guard. Fatal blows were inflicted by the puck in 5 (a slap-shot in 4 and a deflected shot in one); 4 events occurred during play on the ice while one individual was sitting on the team bench. The other athlete was struck by a fist during an altercation. Each collapsed immediately and resuscitative efforts were unsuccessful.

At autopsy, death was attributed to dissection and rupture of the vertebral (n = 4) or internal carotid (n = 1) artery (precise location was unresolved in 1), leading to massive subarachnoid hemorrhage with rapid accumulation of blood within basilar cistern, Sylvian fissures and ventricles, and brainstem herniation (Figure 1). In no individual was a cerebral aneurysm identified.

View larger version (144K): [in this window] [in a new window] Figure. Proposed Anatomical Basis by Which a High-Velocity Blow to One Side of the Neck by a Hockey Puck May Produce Vertebral Artery (or Internal Carotid Artery) Rupture A, Anatomy of the vertebral artery as the vessel courses through the bony canal of the foramina transversarium. B, Enlarged area of detail. C, View from above at the level of C1. In both B and C, arrowheads indicate the 3 anatomical points at which the vertebral artery is rigidly anchored as it traverses the transverse process of the first cervical vertebra through the foramen transversarium, the posterior atlanto-occipital membrane, and the dura mater. A blow to the neck by a hockey puck may produce arterial rupture where the vertebral artery penetrates the posterior atlanto-occipital membrane or the dura mater.

Comment
The scenario of virtually instantaneous death during ice hockey competition in which high-velocity blows to the neck (inflicted by pucks or fist) caused rupture of a major artery has been unappreciated. The precise mechanism by which death occurred is uncertain. Although it is possible that a blow to the neck may directly cause arterial rupture, it is also possible that it can result from reflex hyperextension and rotation of the head (triggered by an unexpected blow). The vertebral artery courses through the foramina transversarium, firmly fixed anatomically at 3 points, and vulnerable to dissection in these areas. Rapid head motion could cause arterial rupture at the rigid anchor points, instantaneously producing massive hemorrhage into the subarachnoid space, increased intracranial pressure, brainstem herniation, and termination of cardiorespiratory function (Figure 1). Indeed, nonfatal vertebral artery dissections have been reported with hyperextension of the neck in other sports, including football, wrestling, gymnastics, and boxing.^3-5

Our novel cases, in which blows to the neck by hockey pucks produced subarachnoid hemorrhage, underscore the broad spectrum of causes and mechanisms that may be responsible for sudden death on the athletic field. Awareness of such risks to young athletes is crucial for developing an informed public and formulating protective measures to enhance the safety of sports activities.

Funding/Support: This study was sponsored in part by a grant from the National Operating Committee on Standards for Athletic Equipment (NOCSAE), Providence, RI.

Barry J. Maron, MD
Minneapolis Heart Institute Foundation
Minneapolis, Minn

Liviu C. Poliac, MD
Department of Anesthesiology
University of Miami Medical Center
Miami, Fla

Alan B. Ashare, MD
St Elizabeth's Medical Center
Boston, Mass

Walter A. Hall, MD
Department of Neurosurgery
University of Minnesota School of Medicine
Minneapolis

1. Maron BJ. Cardiovascular risks to young persons on the athletic field. Ann Intern Med. 1998;129:379-386. FREE FULL TEXT 2. Maron BJ, Poliac L, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med. 1995;333:337-342. FREE FULL TEXT 3. Marks RL, Freed MM. Nonpenetrating injuries of the neck and cerebrovascular accident. Arch Neurol. 1973;28:412-414. ISI | PUBMED 4. Rogers L, Sweeney PJ. Stroke: a neurologic complication of wrestling: a brainstem stroke in a 17-year-old athlete. Am J Sports Med. 1979;7:352-354. FREE FULL TEXT 5. Plant JR, Butt JC. Laceration of vertebral artery: an historic boxing death. Am J Forensic Med Pathol. 1993;14:61-64. ISI | PUBMED

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;290:599-601.