Head pain in non-traumatic carotid artery dissection: a series of 65 patients

In order to assess the prevalence and characteristics of cephalic pain in internal carotid artery (ICA) dissection, and to compare clinical and angiographic features of patients with painful and non-painful dissections, we observed 65 patients with angiographically diagnosed extracranial ICA dissection from 1972 to 1990. Forty-eight patients (74%) complained of a cephalic pain which was inaugural in 38 (58.5%). It was homolateral to the dissection in 79% of cases and lasted from 1 h to 30 days, with a median of 5 days. Signs of cerebral or retinal ischemia were observed in 79% of patients, often delayed and occurring up to 29 days after the onset of pain. A painful Horner's syndrome was present in 31% of patients, and was the only manifestation of dissection in 16%. The clinical presentation of the dissections and angiographic findings were similar in patients with and without pain except for a past history of migraine which was more frequent in patients with painful dissections. Cephalic pain is frequent and often inaugural in carotid dissection. Its recognition is important for early diagnosis and treatment.     

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.     

B-flow imaging in low cervical internal carotid artery dissection.

OBJECTIVE: Generally, the vascular ultrasonographic examination is the first method in evaluation of internal carotid artery (ICA) dissection. B-flow imaging (BFI), conversely, is a newer method of vascular ultrasonography. The objective of this study was to assess the accuracy and efficacy of BFI for the diagnosis of low cervical ICA dissection. METHODS: Seventeen consecutive patients with 18 angiographically confirmed low cervical ICA dissections and 16 nondissected ICAs were studied with BFI and color Doppler ultrasonography (CDU). The results were compared with those of digital subtraction angiography. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of BFI in diagnosis of low ICA dissection were 94%, 94%, 94%, 94%, and 95%, respectively. Corresponding results for CDU were 83%, 94%, 94%, 83%, and 88%. B-flow imaging more precisely showed the intimal flap and the visualization of flow within the true and false lumens. In dissected carotid arteries, 6 intimal flaps were diagnosed with CDU, and 15 intimal flaps were diagnosed with BFI. The agreement between the observers in determining low cervical ICA dissection by BFI was found to be excellent (kappa = 0.80 for intramural hematoma; kappa = 0.93 for intimal flap). CONCLUSIONS: B-flow imaging seems to be a new reliable vascular ultrasonographic technique for evaluation of low cervical ICA dissection.     

Symptomatic hemicrania continua after internal carotid artery dissection

We report a male patient with a right internal carotid artery (ICA) dissection and a consecutive hemicrania continua (HC) fulfilling the criteria of the International Headache Society. This is the first time that a HC secondary to ICA dissection has been reported.     

Bilateral carotid artery dissection after dental work

Carotid artery dissection has been reported to occur spontaneously and after many types of neck trauma. A case patient is presented who developed a right-sided oculosympathetic palsy and was found to have bilateral carotid artery dissection after she visited her dentist. To the best of our knowledge, this case represents the first report of bilateral carotid dissection following dental work.     

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.     

Giant cell arteritis with rare manifestations of stroke and internal carotid artery dissection: A case study

Giant cell arthritis is a systemic vasculitis. A 51‐year‐old man was presented with sudden onset of right‐side blurred vision, frozen movements, and ptosis in the right eye and left side paresis. The diagnosis of GCA with first manifestations of stroke and carotid dissection may be neglected as an underlying cause.     

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.     

Age determination of vessel wall hematoma in spontaneous cervical artery dissection: A multi-sequence 3T Cardiovascular Magnetic resonance study

Background

Previously proposed classifications for carotid plaque and cerebral parenchymal hemorrhages are used to estimate the age of hematoma according to its signal intensities on T1w and T2w MR images. Using these classifications, we systematically investigated the value of cardiovascular magnetic resonance (CMR) in determining the age of vessel wall hematoma (VWH) in patients with spontaneous cervical artery dissection (sCAD).

Methods

35 consecutive patients (mean age 43.6 ± 9.8 years) with sCAD received a cervical multi-sequence 3T CMR with fat-saturated black-blood T1w-, T2w- and TOF images. Age of sCAD was defined as time between onset of symptoms (stroke, TIA or Horner''s syndrome) and the CMR scan. VWH were categorized into hyperacute, acute, early subacute, late subacute and chronic based on their signal intensities on T1w- and T2w images.

Results

The mean age of sCAD was 2.0, 5.8, 15.7 and 58.7 days in patients with acute, early subacute, late subacute and chronic VWH as classified by CMR (p < 0.001 for trend). Agreement was moderate between VWH types in our study and the previously proposed time scheme of signal evolution for cerebral hemorrhage, Cohen''s kappa 0.43 (p < 0.001). There was a strong agreement of CMR VWH classification compared to the time scheme which was proposed for carotid intraplaque hematomas with Cohen''s kappa of 0.74 (p < 0.001).

Conclusions

Signal intensities of VWH in sCAD vary over time and multi-sequence CMR can help to determine the age of an arterial dissection. Furthermore, findings of this study suggest that the time course of carotid hematomas differs from that of cerebral hematomas.     

Bottle neck sign of the proximal portion of the internal carotid artery in moyamoya disease.

OBJECTIVE: We investigated morphologic features of the extracranial internal carotid artery (ICA) by carotid ultrasonography in patients with moyamoya disease. METHODS: We performed conventional carotid ultrasonography and transoral carotid ultrasonography on 19 ICAs in 10 patients with moyamoya disease (moyamoya group) and 28 ICAs in 14 control subjects (control group). We evaluated whether the diameter was greatly reduced at the proximal portion of the ICA above the bulbus, like a champagne bottle neck, to be less than half that of the common carotid artery and whether the diameter of the ICA was smaller than that of the external carotid artery (diameter reversal) on conventional carotid ultrasonography. We then measured the internal diameter of the extracranial distal ICA by transoral carotid ultrasonography. We compared the incidence of a "bottle neck" appearance, diameter reversal, and the ICA diameter between the 2 groups. RESULTS: The bottle neck and diameter reversal were shown in 14 (74%) and 16 (84%) of the 19 ICAs in the moyamoya group, respectively (chi2 test, P<.0001). However, neither of them was shown in the control group. The diameter of the distal ICA in the moyamoya group was significantly smaller than that in the control group (mean+/-SD, 2.4+/-0.60 versus 4.1+/-0.52 mm; unpaired t test, P<.0001). CONCLUSIONS: These results suggest that rapid internal diameter reduction at the proximal portion of the ICA, characterized by a bottle neck appearance or diameter reversal, is an important morphologic feature of moyamoya disease.     

Review article: Non-penetrating neck artery dissection in young adults: Not to be missed!

Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front-line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi-disciplinary team management of this condition. In general, guideline-based recommendation for the management of neck artery dissection involving an intimal flap is by anti-platelet therapy while treatment of neck artery dissection that results in a pseudo-aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.     

Flapping of the dissected intima in a case of traumatic carotid artery dissection in a jackhammer worker

We present the sonographic finding of flapping of the dissected intima inside the carotid artery in a 48‐year‐old man who suffered an acute stroke after vigorous use of a jackhammer. The dissected intima was seen to flap inside the lumen regularly and in synchrony with the vessel's pulse. There was no distal segmental stenosis. The extracranial blood flow velocities were within normal limits and transcranial Doppler examination did not reveal any velocity alteration. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound 2009     

Cluster headache and internal carotid artery dissection: two cases and review of the literature

We describe 2 patients with cluster headache attacks associated with a dissection of the ipsilateral internal carotid artery at the extra-intracranial passage. These cases highlight the need for extensive neuroradiological investigation in cluster headache patients when atypical features are present. We also performed a PubMed search to review the current literature data about this association.     

Traumatic dissection of the internal carotid artery: simultaneous infarct of optic nerve and brain

Traumatic intracranial internal carotid artery dissection is a rare but significant cause of stroke in patients in their forties, leading to high morbidity and mortality. Simultaneous ischemic stroke and optic nerve infarction can occur. Clinical suspicion of dissection is determining in the acute management.     

The “double carotid artery” sign: A rare case of spontaneous carotid dissection

Carotid artery dissection, which accounts for up to 20% of strokes in young patients, usually extends distally and leads to acute stenosis, occlusion and aneurysmal changes with increased risk for thromboembolic events, especially in young people.     

Headache as the initial manifestation of acute aortic dissection type A

The most common initial symptom of aortic dissection is chest pain. Other initial symptoms include pain in the neck, throat, abdomen and lower back, syncope, paresis, and dyspnoea. Headache as the initial symptom of aortic dissection has not been described previously. A 61-year-old woman with a history of migraine and arterial hypertension developed continuous bifrontal headache. Two hours later, right-sided thoracic pain and a diastolic murmur were suggestive of aortic dissection that was confirmed by echocardiography and subsequent surgery. The dissection commenced in the ascending aorta and involved all cervical arteries until the base of the skull. Headache as the initial manifestation of aortic dissection was assumed due to either vessel distension or pericarotid plexus ischemia. Aortic dissection has to he considered as a rare differential diagnosis of frontal headache, especially in patients who develop aortic regurgitation or chest pain for the first time.     

高频超声检测颈动脉早期诊断颅内颈内动脉系统远端阻塞性病变

目的：利用高频超声检测颈动脉早期诊断颅内颈内动脉系统远端阻塞性病变。方法：对三组（正常组、无脑梗死颈动脉粥样硬化组、脑梗死颈动脉粥样硬化组）共120例患者行超声检查颈动脉，观察动脉硬化情况，记录血流值。对三组同侧颈内动脉与颈总动脉血流收缩期血流速度比值（ICA／CCA）进行统计学F检验。结果：正常组、无脑梗死颈动脉粥样硬化组与脑梗死颈动脉粥样硬化组的IcA／CCA比值有统计学显著差异（P〈0．05），正常组与无脑梗死颈动脉粥样硬化组的ICA／CCA比值无统计学显著差异（P〉0．05）。结论：同侧颈内动脉与颈总动脉血流收缩期血流速度比值（ICA／CCA）有助于早期诊断颅内颈内动脉系统远端阻塞性病变。