Spontaneous Bilateral Internal Carotid Artery Dissection and Migraine: A Potential Diagnostic Delay

A 36-year-old man with a history of migraine without aura, presented with recurrent bouts of severe headache, perception of flashing lights in both visual fields, and transient bilateral neurological deficits. In view of his history, migraine with aura was considered. Ancillary investigations showed bilateral extracranial internal carotid artery dissection. This case illustrates that when attacks of severe headache with scotomata and transient bilateral neurological deficits occur in a patient with a history of migraine, the diagnosis of carotid artery dissection should be considered, especially when the pattern of headache is different or when some clinical characteristics have not been experienced previously.     

Bilateral spontaneous internal carotid artery dissection with both early and very late recanalization: A case report

Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened.     

Benign Raeder's syndrome is probably a manifestation of carotid artery disease

Raeder first described Horner's syndrome with ipsilateral head pain due to paratrigeminal organic disease, but most subsequent reports of this syndrome were idiopathic. Our recent case prompted a review of past reports of idiopathic Raeder's syndrome. Because in recent years the features of Raeder's syndrome have been recognized as common manifestations of carotid artery dissection, we divided the cases into those with and those without carotid imaging studies. The classifications and differential diagnoses are discussed. Sixteen cases with carotid imaging studies were not very different from the 28 cases without such studies. Most studies were performed several weeks after onset of symptoms and carotid dissection could not be definitely excluded in any case. In most cases of idiopathic Raeder's syndrome, carotid artery dissection was not considered and in no case was that condition definitively excluded. People with Raeder's syndrome not associated with a paratrigeminal organic lesion probably have a disease of the carotid artery. Because of the different criteria and classifications of Raeder's syndrome it is best to relegate this eponym to history.     

Giant pseudoaneurysm of the external carotid artery causing stroke: A case report

We report a patient in whom mechanical compression of the internal carotid artery by a giant external carotid artery pseudoaneurysm caused a stroke. This was a case of vascular Eagle syndrome due to the impingement of an elongated styloid process on the external carotid artery with subsequent dissection and formation of a pseudoaneurysm. Carotid ultrasonographic examination allowed distinguishing the pseudoaneurysm from other vascular and solid masses of the neck.     

Acute carotid artery dissection treated with stenting and hematoma aspiration guided by ultrasonography

We report the successful treatment of dissection with stenosis of the carotid artery by stenting and aspiration of hematoma. A male patient, presenting with acute blurred vision and weakness and numbness of the right side of his body, was diagnosed with common carotid artery (CCA) dissection and severe stenosis of the internal carotid artery and CCA by digital subtraction arteriography and color Doppler ultrasonography (CDU). Two stents were separately implanted into the left internal carotid artery and CCA to restore blood flow and seal the opening of the dissection. The hematoma inside the CCA dissection was transcutaneously aspirated under CDU guidance after thrombolysis with tissue plasminogen activator. Three days after the operation, the dissection was still sealed. The patient was discharged 1 week later without any signs or symptoms. Follow‐up examination at 70 days confirmed complete healing of the CCA dissection. Transcutaneous intradissection hematoma aspiration with CDU guidance may be applicable in treating arterial dissection, especially when conservative treatments cannot be expected to improve severe flow disturbances. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 41:509–513, 2013;     

Horner syndrome due to carotid dissection

Background: Internal carotid artery dissection typically presents with a clear history of blunt cranial-cervical trauma. Presenting symptoms include headache, focal cerebral ischemic symptoms, and oculosympathetic paresis (Horner syndrome). It is usually thought that internal carotid dissection is a serious but infrequent cause of Horner syndrome. Objective: A review of the literature reveals that carotid dissection is under-recognized as a cause of Horner syndrome, and outcome is thought to be compromised by diagnostic delay. Case Report: This case report describes a patient who presented to the Emergency Department with a traumatic Horner syndrome caused by internal carotid dissection. Summary: The etiology, clinical manifestations, diagnostic evaluation, and treatment options of carotid dissection are discussed.     

Initial clinical experience with Xpert-Pro peripheral self-expanding stent system for internal carotid artery dissection: Two case reports

Background: The standard treatment for internal carotid artery(ICA) dissection is obscure. Current therapeutic strategies include the use of antiplatelet drugs, anticoagulant drugs, intravenous thrombolysis, and endovascular treatment. Endovascular treatment is important in acute internal carotid artery dissection. This study reports two acute internal carotid artery dissection cases that were treated successfully using the Xpert-Pro peripheral selfexpanding stent system.Case summary: The first ...     

Sumatriptan Can Alleviate Headaches Due to Carotid Artery Dissection

Cluster headaches can be mimicked by a spontaneous carotid artery dissection. We report a 45-year-old man with a spontaneous carotid artery dissection whose unilateral headache responded to sumatriptan. An oral dose of 50 mg of sumatriptan relieved 90% of the pain after 2 hours. A second dose the next day achieved similar results within 4 hours. The diagnosis of dissection was made later by magnetic resonance angiogram and conventional angiography. This case illustrates that a positive response to a triptan can not be used to distinguish the first attack of cluster headache from a carotid artery dissection.     

Bilateral internal carotid artery dissection from vomiting

Dissection of the internal carotid artery is responsible for approximately 5% of ischemic strokes in adults. The pathophysiology of dissection can be either traumatic or spontaneous. The true incidence of spontaneous dissection is unknown. Once considered very rare, an increased awareness, combined with noninvasive evaluation by ultrasound and magnetic resonance angiography, has demonstrated a more frequent occurrence. Trivial trauma (ie, rather than external blunt or penetrating trauma) such as vomiting has rarely been documented as causing bilateral dissection. It is well recognized by neurologists but often not by other physicians. Prognosis is good, but delay in diagnosis may result in residual neurologic deficits. It should therefore be suspected early, especially in younger patients presenting with transient ischemic attacks or stroke.     

Tissue plasminogen activator via cross-collateralization for tandem internal carotid and middle cerebral artery occlusion

Tandem internal carotid and middle cerebral artery occlusion after carotid dissection predicts poor outcome after systemic thrombolysis. Current treatments include the use of endovascular carotid stenting, which carries with it a high risk of propagating further embolic events and worsening the dissection. New strategies for avoiding the aforementioned side-effects include recanalization using cross-collaterals for delivery of intra-lesional tissue plasminogen activator (tPA). We present two cases that provide further support for this novel approach. Both patients presented with a National Institute of Health Stroke Scale of 20, received intra-arterial tPA via cross-collateralization, and made full recoveries without the need for stenting.     

Carotid artery dissection revealed by an oculosympathetic spasm

Internal carotid dissection can be responsible for stroke and lead to severe neurological and functional complications. Thus, it must be diagnosed and treated with heparin as soon as possible. Horner syndrome is one of the most usual manifestations of internal carotid dissection. We report the case of a patient who presented with a unilateral non-reactive enlargement of the right pupil that did not last longer than 30 s. As a carotid dissection was not recognized from this atypical symptomatology, magnetic resonance angiography was performed only a few days later when Horner syndrome occurred. It disclosed a dissection of the internal carotid artery ipsilateral from its origin. The evolution and the duration of the pupil involvement suggest that the initial episode of mydriasis was caused by an oculosympathetic spasm, a rare form of sympathetic dysfunction that can be observed when the sympathetic nerve or the pericarotid plexus is irritated. It is important to recognize this oculosympathetic spasm because it has equal value as Horner syndrome for the diagnosis of internal carotid dissection.     

Pain as the only manifestation of internal carotid artery dissection

Internal carotid artery dissection is a major cause of ischemic stroke in the young. Pain is the leading symptom and is associated with other focal signs such as Horner's syndrome and painful tinnitus or with signs of cerebral or retinal ischemia. We report two patients with angiographically confirmed extracranial internal carotid artery dissection presenting with cephalic pain as the only manifestation. The first patient had a diffuse headache and a latero-cervical pain lasting for 12 days, reminiscent of carotidynia. The second patient experienced an exploding headache suggestive of subarachnoid hemorrhage, which was ruled out by computed tomography of the head and cerebrospinal fluid study. These patients demonstrate that recognition of carotid artery dissection as a cause of carotidynia and headache suggestive of subarachnoid hemorrhage may permit an earlier diagnosis and possibly the prevention of a stroke through the use of anticoagulation.     

Noninvasive Imaging of Carotid Arteries in Stroke

Objective. Comprehension of the pathophysiologic characteristics of atherosclerosis has focused its attention on the study of dynamic and metabolic processes involving the vessel wall as possible causes of stroke. When compared with conventional radiologic techniques, sonography has the main advantage of being a real‐time imaging modality. We report 2 acute stroke cases in which carotid sonography showed some dynamic features that could not be identified with computed tomography (CT) and magnetic resonance angiography (MRA). Methods. Carotid sonography with high‐resolution probes (9–14 MHz) was compared with CT and MRA findings showing carotid axis occlusion in 2 patients with acute stroke. Results. In case 1, the internal carotid artery occlusion observed on CT and MRA was interpreted as a dissection on a clinical basis, but sonography showed a mobile embolus originating from the heart in the internal carotid artery. In case 2, the occlusion of the whole carotid axis observed on CT and MRA was instead related to a heart‐originating embolus floating in the common carotid artery. Conclusions. The evaluation of dynamic aspects of atherosclerosis is fundamental to understanding the pathophysiologic characteristics of stroke. Sonography is fundamental in carotid artery imaging for its possibility of showing dynamic processes that could be misdiagnosed with “static” imaging. The correct identification of the pathophysiologic characteristics of stroke in these cases could have led to different diagnostic and therapeutic algorithms.     

Raeder's Paratrigeminal Syndrome Due to Spontaneous Dissection of the Cervical and Petrous Internal Carotid Artery

The combination of pain, ipsilateral oculosympathetic defect (ptosis and miosis), and ipsilateraltrigeminal dysfunction constitutes Raeder's syndrome. We describe a patient with an acute presentation of Raeder's syndrome due to spontaneous internal carotid artery dissection. True trigeminal dysfunction due to carotid dissection is rare, and the potential mechanisms for its involvement are reviewed in this paper. Finally, we remind clinicians to consider dissection in the differential diagnosis of Raeder's syndrome because of its potential for ischemic cerebral neurologic sequelae and suggest early cranial and neck imaging in the evaluation of such patients.     

Effects of sildenafil on major arterial blood flow using duplex sonography

PURPOSE: Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance. Oral use of sildenafil citrate is effective in the treatment of ED. Although the effects of sildenafil citrate have been investigated in several systems, its effect on aortic, superior mesenteric (SMA), and carotid artery blood flow is still unclear. The aim of this study is to investigate the early phase effects of sildenafil citrate on aortic, SMA, and carotid artery blood flow using color duplex sonography (CDS). METHODS: Thirty-four patients with ED (aged 19-71) were included in this study. Peak systolic velocity, end diastolic velocity, and resistance index (RI) in aorta, SMA, and bilateral common and internal carotid arteries were measured at baseline and 45-75 minutes after the administration of sildenafil citrate using CDS. RESULTS: Statistically significant changes were observed in only 3 of 18 parameters: an increase in post drug values of bilateral internal carotid artery peak systolic velocity (Vmax) compared to baseline values and a significant decrease in the RI value of the left main carotid artery after drug administration compared to baseline values. CONCLUSIONS: Sildenafil citrate had no significant effect on aortic and SMA circulation and only caused mild changes in the carotid artery circulation. Although these alterations may be considered clinically insignificant, further studies assessing long-term effects of sildenafil are warranted.     

恶性肿瘤侵犯高位颈动脉切除与重建术

目的：介绍一种晚期舌癌术后复发侵犯高位颈动脉的外科治疗方法。方法：先行暴露颅外骨组织、用圆结磨去１ｃｍ岩骨段（Ｃ５）。用Ｓｈｕｎｔ管行颈总一颈内动脉分流，肿瘤组织行扩大切除（肿瘤连同颈动脉切除），同时行大隐静脉移植重建颈动。最后用胸大肌带蒂肌皮瓣修复口内外组织缺损。结果：术后２周ＴＣＤ检查大脑前，中动脉的血流速度与术前相近，术后４周颈动脉Ｂ超显示血流通畅，术后随访未出现神经并发症。结论：该手术可行     

颈内动脉颅外段巨大动脉瘤的外科处理：附1例报告

报告一例颈内动脉颅外段巨大的动脉瘤外科处理的经验，介绍颈联合径路鼻咽，口咽侧壁得到良好的暴露，本例行单纯切除，术后无神经系统后遗症，对颈内动脉颅外段动脉瘤的病因，临床表现及外科处理方法进行了讨论。     

Carotid stent deformation: Sonographic findings and CT correlation

Carotid artery dissection is a rare but potentially serious complication of endovascular procedures in the carotid arteries. Stent deformation or incomplete expansion may occur following endovascular repair of an iatrogenic carotid artery dissection and may mimic stent fracture. We report an unusual case of deformation of a common carotid artery open cell design stent following endovascular repair of an iatrogenic dissection, which resulted in persistent blood flow between the stent and the wall of the common carotid artery. Sonographic features are described and correlation with intravascular ultrasound and CT is provided. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42 :313–317, 2014     

颈动脉支架成形术对颈动脉重度狭窄患者生活质量及认知功能的影响

目的观察颈内动脉支架成形术（CAS）对颈动脉重度狭窄患者生活质量及认知功能的影响。方法选取近两年在本院接受治疗的64例重度颈动脉狭窄患者,均行CAS治疗,术前及术后3、12个月对患者进行简易精神状态量表（MMSE）、日常生活能力量表（ADL）、词语流畅性测验（RVR）、数字广度（DS）、视觉保持测验（VRT）和生活质量量表（WHOQDL）评分。结果手术成功率高达100％,且术后无栓塞、颈内动脉血栓等并发症发生。患者术后颈动脉狭窄率降低,且颈动脉血流显著改善。治疗后3、12个月,患者的MMSE、VR及DS评分均明显升高,而ADL评分显著降低,其中治疗后12个月的升高及降低程度明显大于治疗后3个月。治疗后3个月,患者Ⅵ汀正确评分及WHOQOL评分显著增加,而Ⅵ汀错误评分明显降低。结论CAS能明显改善颈动脉重度狭窄患者的认知功能及生活质量,值得临床推广应用。