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PATIENT STORY

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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.

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EPIDEMIOLOGY

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  • 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

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ETIOLOGY AND PATHOPHYSIOLOGY

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  • 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).

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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).

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DIAGNOSIS

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  • 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.

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FIGURE 26-2

Sagittal view of the common carotid artery on duplex ultrasound grayscale imaging showing a large intimal flap in the lumen of the artery.

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CLINICAL FEATURES

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  • 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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