A 30-year-old man was involved in a motor vehicle accident. He had rib fractures, a pulmonary contusion, and mild neck pain, but no other injuries. He denied amaurosis fugax, weakness, numbness, paralysis, paresthesias, speech disturbance, or gait disturbance. On the upper cuts of a chest computed tomography (CT), a dissection of his right internal carotid artery (ICA) was seen, and a focal dissection starting just distal to the right carotid bulb and extending through the cervical ICA was confirmed on a subsequent CT angiogram of the neck.
Dissection causes less than 2% of ischemic strokes, but up to 20% of the ischemic strokes in patients less than 50 years old are related to dissection. It is the second leading cause of cervical carotid disease, behind atherosclerosis.1,2, and 3
ETIOLOGY AND PATHOPHYSIOLOGY
Carotid dissection, as in other vascular beds, starts when a tear in one or more layers of the arterial wall occurs, allowing blood to separate the layers and form a thrombosis or a patent false lumen.
In the cervical carotid artery, the dissection often occurs after trauma causing a whiplash-type motion.
Carotid dissections may be spontaneous as well, though often a careful history will reveal a temporally associated trivial trauma such as a cough or neck rotation.
Predisposing factors such as Marfan disease, Ehlers-Danlos type IV syndrome, or fibromuscular dysplasia may be present in these cases, but these connective tissue disorders are implicated in only 5% of spontaneous dissections.4
The location of the dissection is usually at a mobile point of the artery, such as distal to the carotid bulb.
Carotid dissection may also present as an extension of aortic dissection (Figure 26-1).
Carotid artery dissection may be spontaneous, related to trauma, or result as an extension of aortic dissection. (A) Vertebral artery injury (double-sided black arrow), and (B) carotid artery dissection (double-sided white arrow).
Diagnosis is often made incidentally, perhaps by imaging done at the time of multiple trauma.
Carotid dissection can be detected with duplex ultrasound (Figure 26-2), CT angiography, magnetic resonance (MR) angiography, or catheter angiography.
Sagittal view of the common carotid artery on duplex ultrasound grayscale imaging showing a large intimal flap in the lumen of the artery.
When found incidentally, many carotid dissections may be asymptomatic.
If symptomatic, in addition to cerebral ischemia, carotid dissection can present with unusual or pathognomonic symptoms.
Headache and neck pain are the most common nonischemic symptoms.
A Horner ...
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