Cervical Internal Carotid Artery Dissection Research Articles

A Sudden Unilateral Visual Field Loss in a Recreational Tennis Player: Cervical Internal Carotid Artery Dissection Associated With Low-Impact Sports

A Sudden Unilateral Visual Field Loss in a Recreational Tennis Player: Cervical Internal Carotid Artery Dissection Associated With Low-Impact Sports

Importance of cerebral angiography in the evaluation of delayed carotid stent thrombosis: a case report

BackgroundWhile noninvasive imaging is typically used during the initial assessment of carotid artery disease, digital subtraction angiography remains the gold standard for evaluating carotid stent thrombosis and stenosis (Krawisz in Cardiol Clin 39:539–549, 2021). This case highlights the importance of digital subtraction angiography for assessing carotid artery stent patency in place of non-invasive imaging.Case presentationWe present a 61-year-old African American male patient with a history of right cervical internal carotid artery dissection that was treated with carotid artery stenting and endovascular thrombectomy, who developed recurrent right hemispheric infarcts related to delayed carotid stent thrombosis. Digital subtraction angiography found multiple filling defects consistent with extensive in-stent thrombosis not clearly observed with magnetic resonance angiography. Etiology was likely secondary to chronic antiplatelet noncompliance. Therefore, the patient was treated medically with a heparin drip, and dual antiplatelet therapy (dAPT) was restarted. At 1-month follow-up the patient did not report new motor or sensory deficits.ConclusionIn the setting of delayed carotid stent thrombosis secondary to antiplatelet noncompliance, digital subtraction angiography may play an essential diagnostic role for early identification and determination of the most appropriate treatment.

Impact of Day 1 carotid patency on outcome in dissection-related tandem occlusions treated with mechanical thrombectomy

The clinical benefit of mechanical thrombectomy(MT) for stroke patients with tandem occlusion is similar to that of isolated intracranial occlusions. However, the management of cervical internal carotid artery(ICA) occlusion during the MT, particularly in the setting of carotid dissection, remains controversial. We aimed to investigate the clinical impact of cervical ICA patency at day 1 on 3-month functional outcome. We collected data from the Endovascular Treatment in Ischemic Stroke, a prospective national registry in 30 French centers performing MT between January 2015 and January 2022. Inclusion criteria were consecutive tandem occlusions related to cervical ICA dissection treated with MT. Tandem occlusions of other etiology, isolated cervical ICA occlusions without intracranial thrombus and patients without day-1 ICA imaging were excluded. Primary endpoint was the 3-month functional outcome. Secondary endpoints included intracranial hemorrhage(ICH), excellent outcome, mortality and early neurological improvement. A sensitivity analysis was performed in patients with intracranial favorable recanalization after MT. During the study period, 137 patients were included of which 89(65%) presented ICA patency at day 1. The odds of favorable outcome did not significantly differ between patients with patent and occluded ICA at day 1(68.7 vs 59.1%;aOR=1.30;95%CI 0.56-3.00,p=0.54). Excellent outcome, early neurological improvement, mortality and ICH were also comparable between groups. Sensitivity analysis showed similar results. ICA patency at day 1 in patients with tandem occlusions related to dissection did not seem to influence functional outcome. Endovascular recanalization of the cervical ICA including stenting might not be systematically required in this setting.

A Case of Internal Carotid Artery Dissection Presenting With Dysgeusia (P12-5.014)

<h3>Objective:</h3> NA <h3>Background:</h3> A 42-year-old man presented to the emergency room (ER) with headache and neck pain associated with dysgeusia for three days. The headache was described as sudden, moderate, with throbbing pain, located in the left frontal region, and radiating to the left temporomandibular joint. The pain was not aggravated by chewing or position. He denied mechanical trauma to the neck including deep tissue massage or chiropractic manipulation. He had also incidentally noticed that orange juice tasted bitter. He denied a change in voice or difficulty swallowing. The exam was notable for left-sided ptosis and altered taste to the posterior 1/3^rd tongue to sugar water. CT angiography showed irregularity of the distal left internal carotid artery (ICA) from the C1 segment into the proximal petrosal segment associated with a 3 mm pseudo-aneurysm, concerning for dissection. <h3>Design/Methods:</h3> NA <h3>Results:</h3> The mean annual incidence of spontaneous ICA dissection is 2.9 per 100,000. The classic triad of symptoms is ipsilateral head or neck pain, partial Horner syndrome, and cerebral or retinal ischemic symptoms. Cranial nerve (CN) palsies may occur in more than 10% of patients with extracranial ICA dissections, most commonly involving CN XII, followed by V, VII, IX and X. We discuss a patient with isolated dysgeusia in the posterior 1/3^rd of the tongue with left-sided Horner syndrome in the setting of distal ICA dissection. Clinical presentation is consistent with an isolated glossopharyngeal nerve palsy and Horner syndrome. At the distal cervical level, the glossopharyngeal nerve and sympathetic tract run closely to the ICA and are susceptible to compression by the pseudoaneurysm. There exist only a few reports on loss of taste sensation caused by dissection of ICA. <h3>Conclusions:</h3> This case highlights that posterior ipsilateral dysgeusia can be a manifestation of cervical internal carotid artery dissection and should prompt appropriate evaluation and neuroimaging. <b>Disclosure:</b> Dr. Joseph has nothing to disclose. Dr. Ariza Hutchinson has nothing to disclose. Dr. Shnawa has nothing to disclose. Dr. Sehgal has nothing to disclose.

Blunt Traumatic Cerebrovascular Injury and Stroke: The Need for a High Index of Suspicion when Initial Vascular Imaging is Negative - A Single Center Case Series. (P14-5.019)

<h3>Objective:</h3> NA <h3>Background:</h3> Acute ischemic stroke (AIS) from traumatic cerebrovascular injury (TCVI) leads to approximately 4800 US strokes annually; often as sequelae of cervical arterial dissection. CT angiography (CTA) is typically used for screening, but this modality has limitations of low sensitivity, particularly for low-grade dissections. Our case series illustrates the importance of high index of suspicion in trauma patients to pursue further vessel imaging when there is unexplained AIS. <h3>Design/Methods:</h3> Case series. <h3>Results:</h3> Our series consists of 2 patients admitted to Trauma ICU following motor vehicle collisions. The 1st patient was a 22-year-old woman with left precentral gyrus infarction on diffusion-weighted MRI. Initial CTA showed dissection of cervical right internal carotid artery (ICA) which did not explain her infarction. Echocardiogram was also unrevealing so digital subtraction angiography was pursued, which revealed dissection of the left supraclinoid ICA not seen on CTA. The 2nd patient was a 15-year-old man with bilateral frontal infarctions on diffusion-weighted MRI. His initial CTA showed dissection of cervical left ICA. There was no explanation for his right frontal infarction on further workup so CTA was repeated after 4 days, which showed additional dissection involving the right cervical ICA not seen initially. Etiology of AIS in both cases was unexplained initially but repeat or alternate imaging helped unveil previously undetected ipsilateral dissections. <h3>Conclusions:</h3> Undetected traumatic dissection can result in devastating neurologic sequelae including further strokes and worsening dissection. It can also lead to unnecessary workup such as thrombophilia testing in younger patients. These patients are often hidden from the view of neurologists as they are typically managed by trauma surgeons and literature regarding TCVI is predominantly in surgical journals. We hope to increase awareness and emphasize the importance of a high index of suspicion to pursue further vessel imaging in unexplained stroke so that appropriate treatment can be initiated rapidly. <b>Disclosure:</b> Dr. Asif has nothing to disclose. Dr. Habib has nothing to disclose. Dr. Samkutty has nothing to disclose.

Teaching NeuroImages: An uncommon cause of carotid artery dissection

Cervical internal carotid artery dissection (CAD), a leading cause of ischemic stroke in young adults, has been rarely associated with Fabry disease (FD).1,2 A 49-year-old man with left acute middle cerebral artery occlusion due to underlying spontaneous CAD received IV thrombolysis and mechanical thrombectomy, achieving complete reperfusion (figure 1).

Treatment of cervical internal carotid artery dissection resulting in intracranial large vessel occlusion treated by mechanical thrombectomy

【目的】急性頭蓋内主幹動脈閉塞に対して，機械的血栓回収療法を施行した頚部内頚動脈解離の解離部位に対する治療選択を，後方視的に検討した．【方法】2015年4月～2022年3月に，当院で機械的血栓回収療法を行った290症例を対象に調査した．診断は臨床症状や画像所見などを総合的に判断し，後方視的に初発症状・神経所見・画像・治療法・転帰を収集した．【結果】頚部内頚動脈解離例は5例で，平均年齢47歳，55歳以下では21%（4/19例）を占め，頭頚部痛発症は2例のみであった．頚部内頚動脈解離に対しては，3例で経皮的血管拡張術を先行させ，うち1例で母血管閉塞，1例で1カ月後に頚部ステント留置術施行，保存加療2例を含め，いずれも治療後に症状の改善を得た．【結語】頚部内頚動脈解離は，若年重症脳卒中の原因疾患として多く，疼痛の訴えがなくても鑑別に挙げる必要があり，個々の症例に応じた治療介入が必要と考えられた．

Primary stent implantation for bilateral spontaneous cervical ICA dissections with hypoperfusion after 72 h from onset: a case report

BackgroundSpontaneous cervical internal carotid artery dissection (cICAD) is a common cause of stroke in young adults. Endovascular therapy is an indispensable treatment for cICAD in some cases, but it faces great challenges.Case presentationA bilateral spontaneous cICADs with hypoperfusion-related AIS after 72 h from the onset was presented herein. The patient responded well to primary Solitaire stent detachment at the critical flow-limiting site.ConclusionsPrimary stent implantation at the critical flow-limiting site rather than covering the entire dissection may be a therapeutic option in spontaneous cICAD complicated with cerebral hypoperfusion. The Solitaire stent may be a good choice at the acute and subacute stages of cICAD.

A case of ruptured dissecting vertebral artery aneurysm with cerebral infarction due to cervical internal carotid artery dissection

A case of ruptured dissecting vertebral artery aneurysm with cerebral infarction due to cervical internal carotid artery dissection

A Case of Endovascular Surgery on an Intracranial Large Vessel Occlusion due to Cervical Internal Carotid Artery Dissection with an Arterial Tortuosity and Thrombus

A Case of Endovascular Surgery on an Intracranial Large Vessel Occlusion due to Cervical Internal Carotid Artery Dissection with an Arterial Tortuosity and Thrombus

Thrombolysis Improves Reperfusion and the Clinical Outcome in Tandem Occlusion Stroke Related to Cervical Dissection: TITAN and ETIS Pooled Analysis.

Background and PurposeDespite the widespread adoption of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke (LVOS) in the anterior circulation, the optimal strategy for the treatment tandem occlusion related to cervical internal carotid artery (ICA) dissection is still debated. This individual patient pooled analysis investigated the safety and efficacy of prior intravenous thrombolysis (IVT) in anterior circulation tandem occlusion related to cervical ICA dissection treated with MT. MethodsWe performed a retrospective analysis of two merged prospective multicenter international real-world observational registries: Endovascular Treatment in Ischemic Stroke (ETIS) and Thrombectomy In TANdem occlusions (TITAN) registries. Data from MT performed in the treatment of tandem LVOS related to cervical ICA dissection between January 2012 and December 2019 at 24 comprehensive stroke centers were analyzed. The primary endpoint was a favorable outcome defined as 90-day modified Rankin Scale (mRS) score of 0–2. ResultsThe study included 144 patients with tandem occlusion LVOS due to cervical ICA dissection, of whom 94 (65.3%) received IVT before MT. Prior IVT was significantly associated with a better clinical outcome considering the mRS shift analysis (common odds ratio, 2.59; 95% confidence interval [CI], 1.35 to 4.93; P=0.004 for a 1-point improvement) and excellent outcome (90-day mRS 0–1) (adjusted odds ratio [aOR], 4.23; 95% CI, 1.60 to 11.18). IVT was also associated with a higher rate of intracranial successful reperfusion (83.0% vs. 64.0%; aOR, 2.70; 95% CI, 1.21 to 6.03) and a lower rate of symptomatic intracranial hemorrhage (4.3% vs. 14.8%; aOR, 0.21; 95% CI, 0.05 to 0.80). ConclusionsPrior IVT before MT for the treatment of tandem occlusion related to cervical ICA dissection was safe and associated with an improved 90-day functional outcome.

Bilateral carotid artery dissection due to Eagle syndrome in a patient with vascular Ehlers-Danlos syndrome: a case report

BackgroundPatients with vascular Ehlers-Danlos syndrome (EDS) occasionally suffer from arterial dissection. Eagle syndrome, which is caused by an elongated styloid process and also causes arterial dissection, is difficult to diagnose and could sometimes be overlooked. Little is known of the coexistence of these two diseases, and treatment strategy is not established. Here, we present a case of bilateral internal carotid artery (ICA) dissection due to Eagle syndrome in a patient with vascular EDS.Case presentationA 30-year-old man was admitted to our hospital because of sudden onset of mild sensory disturbance in his left limbs. He had a history of Ehlers-Danlos syndrome (EDS) and also had left cervical internal carotid artery (ICA) dissection 3 years before. Diffusion-weighted imaging showed acute cerebral infarcts in the right hemisphere. Cervical computed tomography angiography (CTA) revealed the right ICA narrowing at the cervical portion in addition to the previous left cervical ICA dissection. Cervical magnetic resonance imaging (MRI) revealed double-lumen and intramural hematoma at the narrowing portion of the right cervical ICA, which indicates arterial dissection. CT also revealed bilateral elongated styloid processes which are close to each side of cervical ICA. We diagnosed him as bilateral ICA dissection due to bilateral Eagle syndrome. Considering vascular complications due to vascular EDS, we performed closer follow-up with transoral carotid ultrasonography (TOCU). In 4 months, his right ICA dissection gradually improved without stroke recurrence or deterioration of dissection.ConclusionsSince patients with vascular EDS easily develop arterial dissection, Eagle syndrome may be overlooked. Clinicians should consider Eagle syndrome in the case of vascular EDS with extracranial ICA dissection and close follow-up should be prioritized in cases of Eagle syndrome with vascular EDS.

Emergency carotid artery revascularization using Casper-RX stent: A single-center experience.

Casper-RX (MicroVention, Aliso Viejo, California, USA) is a dual-layer closed cell stent recently introduced as a carotid artery revascularization device. Although its effectiveness and safety has been proved in elective cases, there are contradictive results regarding its patency in emergency settings. The purpose of the study is to present our single-center experience with the Casper-RX stent in the emergency interventions. Consecutive patients who underwent emergency carotid artery stenting using Casper-RX system with or without additional intracranial thrombectomy between August 2016 and June 2019 at our institution were included. Primary end point was the short-term patency of the carotid stents evaluated before hospital discharge by use of Doppler ultrasonography. Twenty-nine procedures performed on 28 patients were included in the study. All stents were patent on final angiograms. Acute stent occlusion was observed only in one case (3.4%) with a spontaneous cervical internal carotid artery dissection the day after the procedure. In 26 (89.6%) cases, an additional intracranial thrombectomy was performed with a successful recanalization rate of 96.1%. Seven adverse events occurred peri-/post-procedural: two cases (6.9%) with iatrogenic dissection of distal cervical internal carotid artery during intracranial thrombectomy, two parenchymal hematoma type 2 (6.8%), and three patients (10.3%) developed massive infarction. This study supports the safety and efficacy of the Casper-RX stent in emergency endovascular carotid artery revascularization procedures.

Two cases of pulsatile tinnitus: Key points for the clinician

IntroductionPulsatile tinnitus is a sound generated by an acoustic source from within the body, which is perceived by the auditory system of the patient. Cases summaryWe report two puzzling cases of pulsatile tinnitus with normal ENT examinations: the first was due to a cervical internal carotid artery dissection, and the second to the compression of the foramina of Monro by a craniopharyngioma, leading to hydrocephalus. DiscussionWe review the systematic management and emphasize the decisive role of the ENT clinician regarding this pulsatile tinnitus complaint, because of the potentially severe complications of its underlying pathology.

The 25th anniversary of the retrograde suction decompression technique (Dallas technique) for the surgical management of paraclinoid aneurysms: historical background, systematic review, and pooled analysis of the literature.

Paraclinoid internal carotid artery (ICA) aneurysms frequently require temporary occlusion to facilitate safe clipping. Brisk retrograde flow through the ophthalmic artery and cavernous ICA branches make simple trapping inadequate to soften the aneurysm. The retrograde suction decompression (RSD), or Dallas RSD, technique was described in 1990 in an attempt to overcome some of those treatment limitations. A frequent criticism of the RSD technique is an allegedly high risk of cervical ICA dissection. An endovascular modification was introduced in 1991 (endovascular RSD) but no studies have compared the 2 RSD variations. The authors performed a systematic review of MEDLINE/PubMed and Web of Science and identified all studies from 1990-2016 in which either Dallas RSD or endovascular RSD was used for treatment of paraclinoid aneurysms. A pooled analysis of the data was completed to identify important demographic and treatment-specific variables. The primary outcome measure was defined as successful aneurysm obliteration. Secondary outcome variables were divided into overall and RSD-specific morbidity and mortality rates. Twenty-six RSD studies met the inclusion criteria (525 patients, 78.9% female). The mean patient age was 53.5 years. Most aneurysms were unruptured (56.6%) and giant (49%). The most common presentations were subarachnoid hemorrhage (43.6%) and vision changes (25.3%). The aneurysm obliteration rate was 95%. The mean temporary occlusion time was 12.7 minutes. Transient or permanent morbidity was seen in 19.9% of the patients. The RSD-specific complication rate was low (1.3%). The overall mortality rate was 4.2%, with 2 deaths (0.4%) attributable to the RSD technique itself. Good or fair outcome were reported in 90.7% of the patients.Aneurysm obliteration rates were similar in the 2 subgroups (Dallas RSD 94.3%, endovascular RSD 96.3%, p = 0.33). Despite a higher frequency of complex (giant or ruptured) aneurysms, Dallas RSD was associated with lower RSD-related morbidity (0.6% vs 2.9%, p = 0.03), compared with the endovascular RSD subgroup. There was a trend toward higher mortality in the endovascular RSD subgroup (6.4% vs 3.1%, p = 0.08). The proportion of patients with poor neurological outcome at last follow-up was significantly higher in the endovascular RSD group (15.4% vs 7.2%, p < 0.01). The treatment of paraclinoid ICA aneurysms using the RSD technique is associated with high aneurysm obliteration rates, good long-term neurological outcome, and low RSD-related morbidity and mortality. Review of the RSD literature showed no evidence of a higher complication rate associated with the Dallas technique compared with similar endovascular methods. On a subgroup analysis of Dallas RSD and endovascular RSD, both groups achieved similar obliteration rates, but a lower RSD-related morbidity was seen in the Dallas technique subgroup. Twenty-five years after its initial publication, RSD remains a useful neurosurgical technique for the management of large and giant paraclinoid aneurysms.

Correction to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Correction to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

A case of bilateral cervical internal carotid artery dissection following herpes zoster of the trigeminal nerve

A 62 year-old man, who was taking prednisolone for nephrotic syndrome, was diagnosed with herpes zoster of the trigeminal nerve and treated with oral valacyclovir. One month later, he reported pain from the right side of the head and vomiting. MRI revealed an acute infarction in the right frontal lobe and dissection of the internal carotid artery of the right cervix. Trauma or other potential triggers were not observed. In consideration of the preceding condition of varicella zoster virus infection, acyclovir was administered in addition to unfractionated heparin, but an intramural hematoma emerged in the left internal carotid artery. Furthermore, evidence showing progression of these lesions was found. On the fifth day, prednisolone was increased to 1 mg/kg/day, and progression of vascular lesions was not observed. This case may prove valuable because it suggests a relationship between cervical artery dissection and herpes zoster.

Anatomical characteristics of the styloid process in internal carotid artery dissection: Case-control study.

Introduction Pathophysiology of cervical artery dissection is complex and poorly understood. In addition to well-known causative and predisposing factors, including major trauma and monogenic connective tissue disorders, morphological characteristics of the styloid process have been recently recognized as a possible risk factor for cervical internal carotid artery dissection. Aims To study the association of the anatomical characteristics of styloid process with internal carotid artery dissection. Methods Retrospective, multicenter, case-control study of patients with internal carotid artery dissection and age- and sex-matched controls. Consecutive patients with internal carotid artery dissection and controls with ischemic stroke or transient ischemic attack of any etiology excluding internal carotid artery dissection, who had performed computed tomography angiography, diagnosed between January 2010 and September 2016. Two independent observers measured styloid process length and styloid process distance to internal carotid artery. Results Sixty-two patients with internal carotid artery dissection and 70 controls were included. Interobserver agreement was good for styloid process length and styloid process-internal carotid artery distance (interclass correlation coefficient = 0.89 and 0.76, respectively). Styloid process ipsilateral to dissection was longer than left and right styloid process in controls (35.8 ± 14.4 mm versus 30.4 ± 8.9 mm and 30.3 ± 8.2 mm, p = 0.011 and p = 0.008, respectively). Styloid process-internal carotid artery distance ipsilateral to dissection was shorter than left and right distance in controls (6.3 ± 1.9 mm versus 7.2 ± 2.1 mm and 7.0 ± 2.3 mm, p = 0.003 and p = 0.026, respectively). Internal carotid artery dissection was associated with styloid process length (odds ratio = 1.04 mm-1, 95% confidence interval = 1.01-1.08, p = 0.015) and styloid process-internal carotid artery distance (OR = 0.77 mm-1, 95% confidence interval = 0.64-0.92, p = 0.004). Conclusion Longer styloid process and shorter distance between styloid process and cervical internal carotid artery are associated with cervical internal carotid artery dissection.

Aetiologies of internal carotid artery pseudo-occlusions in acute stroke patients: what neurointerventionalists can expect.

In cases of acute stroke, differentiation between an occluded and a patent internal carotid artery (ICA) is crucial for diagnosis and management. Although CT angiography (CTA) can be highly accurate in defining high-grade stenosis and ICA occlusions, misleading ICA occlusion patterns are not rare in patients with acute stroke. We investigated the underlying causes of ICA pseudo-occlusions with CTA with respect to digital subtraction angiography. 11 out of 72 patients had pseudo-occlusion on CTA. Of these, there were three cases of tandem occlusions accompanying high-grade ICA stenosis, five cases of Distal ICA bifurcation occlusion as a result of atrial fibrillation, two cases of cervical ICA dissection and one acute thrombosis of the stent. Consideration of the aforementioned aetiologies by interventionists is warranted, as it may change the planning of endovascular intervention and treatment of acute stroke.

Association between carotid artery tortuosity and carotid dissection: a case-control study.

Carotid artery dissections have long been associated with compromise of the structural integrity of the arterial wall from heritable connective-tissue disorders, hypertension, and trauma. However, an association between spontaneous internal carotid artery dissection and tortuous or redundant carotid anatomy has not been fully explored. Patients with CTA confirmed spontaneous cervical internal carotid artery dissections were compared to a group of age and sex matched controls who also received CTA of the neck. Patients with trauma or aortic dissections were excluded. Five radiologists reviewed the CTA images to evaluate internal carotid artery tortuosity (reported as loops, kinks or coils), retrojugular and retropharyngeal courses of the internal carotid artery, presence of fibromuscular dysplasia and presence of atherosclerotic disease. Baseline data collected included demographic characteristics (sex, age, smoking history) and cardiovascular comorbidities. A total of 83 cervical internal carotid artery dissection and their age and sex matched controls were included in this study. 46% of patients were female in each group and mean age was 49.2±10.6 years. The presence of any carotid tortuosity was 53% (N.=44) and 34% (N.=28) in the per-patient analysis of dissection and control groups, respectively (P=0.02). Loops were reported in 22% (N.=18) of dissection patients and 8% (N.=7) of controls (P=0.03). Retrojugular course of the internal carotid artery were seen in 23% (N.=38) of dissection patients and 9% (N.=15) of controls (P=0.0009) in the per-vessel analysis. Our study suggests that there is an association between the presence of tortuous carotid artery anatomy and spontaneous carotid artery dissection. This finding emphasizes the importance of the presence of tortuous arteries on CTA imaging to increase the index of suspicion for a potential dissection.