Carotid dissection

Georgiadis D, Lanczik O, Schwab S, Engelter S, Sztajzel R, Arnold M, Siebler M, Schwarz S, Lyrer P, Baumgartner RW. IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection. Neurology. 2005 64 1612-1614. 

Muller BT, Luther B, Hort W, Neumann-Haefelin T, Aulich A, Sandmann W. Surgical treatment of 50 carotid dissections indications and results. J Vase Surg 2000 31 980-988. 

Cerebrovascular Carotid spasm Compromise of ECA ostium Hyperfusion syndrome Contrast encephalopathy Transient symptomatic cerebral ischemia Global Focal Carotid dissection Carotid perforation Hyperperfusion syndrome Acute stent thrombosis Major ischemic stroke Cerebral hemorrhage... 

Beis JM, Keller C, Morin N et al (2004) Right spatial neglect after left hemisphere stroke qualitative and quantitative study. Neurology 63 1600-1605 Benninger DH, Georgiadis D, Kremer C et al (2004) Mechanism of ischemic infarct in spontaneous carotid dissection. Stroke 35 482-485... 

Mokri B, Sundt TM Jr, Houser OW (1979) Spontaneous internal carotid dissection, hemicrania, and Horner s syndrome. Arch Neurol 36 677-680... 

Fig. 5.22a-d. Time course of post-traumatic carotid dissection. Spin echo Tl-weighted (a,c) and TOF single slices (b,d). The typically bright hematoma and stenosis are well seen 12 days after the trauma (c,d). On day 4, however, (a,b) there is already stenosis on both images, but signal intensity of hematoma is not yet markedly increased... 

Fig. 5.23a-c. Carotid dissection. While the characteristic intramural hematoma is easily recognized as bright on TOF-MRA source images (a) and MIP (b), CE-MRA (c) outlines the long high grade stenosis of the distal extracranial vessel, but not the hematoma itself... 

The presence of cranial neuropathy may result in a misdiagnosis of brainstem stroke. Cranial nerve palsies may result from local pressure from the false internal carotid artery lumen, thromboembolism or hemodynamic compromise to the blood supply of the nerve. Cranial nerve III receives its blood supply from the ophthalmic artery, branches of the internal carotid or the posterior cerebral artery and, consequently, may rarely become ischemic after carotid dissection. 

Sometimes arterial occlusion is demonstrated by angiography in migrainous stroke and the cause is hypothesized to be in-situ thrombosis complicating vasospasm. No provoking factors are known. Other possible causes of stroke in the context of headache must be considered carotid dissection, mitochondrial cytopathy, ruptured vascular malformation, antiphospholipid antibody syndrome and CADASIL (cerebral autosomal dominant arterio-pathy with subcortical infarcts and leukoencephalopathy). Migraine auras without headache may be confused with TIA (Ch. 8). 

Neurological examination is primarily to localize the brain lesion but there may also be clues as to the cause of the stroke a Horner s syndrome ipsilateral to a carotid distribution infarct suggests dissection of the internal carotid artery or sometimes acute atherothrom-botic carotid occlusion. Lower cranial nerve lesions ipsilateral to a hemispheric cerebral infarct can also occur in carotid dissection. 

Fig. 11.4. Diffusion-weighted MRI showing multiple areas of acute infarction in a patient with a right carotid dissection.

Cranial nerve palsies are rare, occurring in less than 7% of cervical artery dissection cases in hospital-based series. The outwardly distended vessel wall may compress nearby structures. In carotid dissection at the base of the skull, compression palsies of cranial nerves IX, X, XI, and XII are sometimes seen due to the dissection or to the formation of a pseudoaneurysm at the site. Carotid dissection can also intermpt the sympathetic... 

Baumgartner RW, Arnold M, Baumgartner 1, Mosso M, Conner F, Studer A, Schroth G, Schuknecht B, Sturzenegger M Carotid dissection with and without ischemic events local symptoms and cerebral artery findings. Neurology 2001 57 pp. 827-832. 

In the emergency situation, we beheve this technique can be successfully employed in selected patients with symptomatic ischemia due to dissection or atherosclerotic disease despite being on maximal medical therapy. We have also seen patients with carotid occlusion and an isolated cerebral hemisphere (poor collateral flow) benefit from EC-IC bypass. Any potential benefit, however, must... 

Findlay JM, Ashforth R, Dean N. Malignant carotid artery dissection. Can J Neurol Sci 2002 29 378-385. 

Dissection of the internal carotid and vertebral arteries is a common cause of stroke, particularly in young patients. Although many occur due to trauma, it is estimated that over half occur spontaneously. The mechanism of stroke following arterial dissection is either by artery-to-artery embolism, by thrombosis in situ, or by dissection-induced lumenal stenosis with secondary cerebral hypoperfusion and low-flow watershed infarction. Occasionally, dissection may lead to the formation of a pseudoaneurysm as a source of thrombus formation. Vertebrobasilar dissections that extend intracranially have a higher risk of rupture leading to subarachnoid hemorrhage (SAH). ° ... 

Lucas C, Moulin T, Deplanque D, Tatu L, Chavot D. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 1998 29 2646-2648. 

Jacobs A, Lanfermann H, Neveling M, Szelies B, Schroder R, Heiss WD. MRI- and MRA-guided therapy of carotid and vertebral artery dissections. J Neurol Sci 1997 147 27-34. 

Engelter S, Lyrer P, Kirsch E, Steck AJ. Long-term follow-up after extracranial internal carotid artery dissection. Eur Neurol 2000 44 199-204. 

Schievink W. The treatment of spontaneous carotid and vertebral artery dissections. Curr Opin Cardiol 2000 15 316-321. 

Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane... 

Malek AM, Higashida RT, Phatouros CC, Lempert TE, Meyers PM, Smith WS, Dowd CP, Halbach VV. Endovascular management of extracranial carotid artery dissection achieved using stent angioplasty. AJNR Am J Neuroradiol 2000 21 ... 

Spontaneous dissection of the internal carotid or the vertebral artery is an important cause of ischemic stroke in young adults (Fig. 1.3). In the late 1970s Fisher et al. (1978) and Mokri et al. (1979) described dissections of carotid and vertebral arteries as detected by modern diagnostic techniques rather than by post-mortem examination. This may occur... 

Mokri B, Silbert PL, Schievink WI et al (1996) Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery. Neurology 46 356-359 Molina CA, Montaner J, Abilleira S et al (2001) Timing of Spontaneous Recanalization and Risk of Hemorrhagic Transformation in Acute Cardioembolic Stroke. Stroke 32 1079-1084 Molina CA, Alvarez-Sabin J, Montaner J et al (2002) Thrombolysis-related hemorrhagic infarction a marker of early reperfusion, reduced infarct size, and improved outcome in patients with proximal middle cerebral artery occlusion. Stroke 33 1551-1556... 

Anomalies of the ICA are infrequent, and aplasia of the ICA is a rarity (Van de Perre et al. 2004). In hypoplasia, the vessel tapers off behind a normal proximal segment and can sometimes be followed up to the circle of Willis. Occasionally differential diagnosis is difficult against an arterial dissection or a very high grade stenosis with a collapsing distal lumen (pseudoocclusion). In cases of doubt, the CT shows the hypoplastic osseous carotid canal (Chen et al. 1998). An aberrant lateral course of ICA... 

Guillon B, Levy C, Bousser MG (1998) Internal carotid artery dissection an update. J Neurol Sci 153 146-158 Hacke W, Brott T, Caplan L et al. (1999) Thrombolysis in acute ischemic stroke controlled trials and clinical experience. Neurology 53 S3-14... 

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