Vascular: Carotid Artery Dissection

Carotid Artery Dissection

Basics

  • Intimal Disruption Allows Blood Extravasation Between the Layers of the Wall
  • Causes:
    • Spontaneous
    • Trauma
    • Iatrogenic
  • Most Common Site: 2-3 cm Past Bifurcation (More Distal Than Atherosclerotic Lesions)

Presentation

  • Classic Triad:
    • Ipsilateral Headache & Neck Pain
    • Ipsilateral Partial Horner’s Syndrome (Oculosympathetic Palsy)
      • Miosis & Ptosis Only, No Anhidrosis
    • Cerebral or Retinal Ischemia
  • Complications:
    • Acute Stenosis
    • Sudden Occlusion
    • Aneurysm & Thromboembolism

Diagnosis

  • Typical Tests: US, CTA or MRA
  • Gold Standard: Four-Vessel Selective Cerebral Angiography
    • Occlusions Tapered & “Flame-Shaped”

Carotid Dissection on Angio, “Flame-Shaped” 1

Treatment

  • Primary Tx: Heparin
    • Follow with Coumadin for 3-6 Months
  • Surgical/Endovascular Interventions:
    • General Indications:
      • Fluctuating or Deteriorating Neurologic Symptoms
      • Compromised Cerebral Blood Flow
      • Anticoagulant Contraindications
      • Symptomatic or Expanding Aneurysm
    • Possible Interventions:
      • Patch Angioplasty
      • Interposition Saphenous Vein Graft
      • Carotid Ligation
      • Endovascular Stent Placement
      • Endovascular Coiling
      • Endovascular Embolization
    • Best Treatment Modality is Not Yet Defined

References

  1. Gooneratne IK, Gamage R, Gunarathne KS. Internal carotid artery dissection: an unusual cause of occipital infarction. Ann Indian Acad Neurol. 2010 Apr;13(2):148-9. (License: CC BY-2.0)