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Carotid artery dissection

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Carotid artery dissection
Dissection in the carotid artery
SpecialtyVascular surgery, Neurology
SymptomsSudden, severe headache, neck or facial pain, vision changes, Horner's syndrome, stroke-like symptoms
ComplicationsStroke
CausesSpontaneous or traumatic (e.g., minor injuries, neck movement)
Diagnostic methodUltrasound, MRI, MRA, CTA
TreatmentAnticoagulants, antiplatelet agents, Stenting, Angioplasty
FrequencyCommon cause of stroke in younger adults


Carotid artery dissection is a serious condition in which a tear forms in one of the two main carotid arteries in the neck, allowing blood to enter the artery wall and separate its layers (*dissection*). This separation can lead to the formation of a blood clot, narrowing of the artery, and restricted blood flow to the brain, potentially resulting in stroke. Symptoms vary depending on the extent and location of the dissection and may include a sudden, severe headache, neck or facial pain, vision changes, a drooping eyelid (Horner's syndrome), and stroke-like symptoms such as weakness or numbness on one side of the body, difficulty speaking, or loss of coordination.

Carotid artery dissection can occur spontaneously or be triggered by trauma, including minor injuries, certain medical conditions, or activities that involve neck movement. It is a leading cause of stroke in young and middle-aged adults. The condition is typically diagnosed through imaging studies, such as ultrasound, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), or computed tomography angiography (CTA), which help visualize the blood vessels and detect abnormalities.

Management of carotid artery dissection depends on the severity and symptoms. Treatment options often include medications like anticoagulants or antiplatelet agents to prevent blood clot formation and reduce the risk of stroke. In more severe cases, surgical or endovascular interventions, such as stenting or angioplasty, may be required to restore proper blood flow. Early detection and treatment are crucial for improving outcomes, though the prognosis can vary based on the extent of the dissection and the presence of complications.

Description

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Carotid artery dissection (or cervical artery dissection) is the separation of the layers within the wall of the carotid arteries, which supply oxygen-rich blood to the brain.[1] It is a significant cause of stroke in younger adults.[2]

The carotid arteries are major blood vessels in the neck that branch into smaller vessels called the external and internal carotid arteries.[3] In carotid artery dissection, a tear in the arterial wall allows blood to flow between the layers of the artery, leading to potential narrowing, reduced blood flow, or clot formation, which may cause a stroke.[4]

Signs and symptoms

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The signs and symptoms of carotid artery dissection may be divided into ischemic and non-ischemic categories:[5][6]

Non-ischemic signs and symptoms:

Ischemic signs and symptoms:

Causes

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Dissection in ultrasound

Dissection may occur after direct physical trauma, traffic collision, strangulation, or any phenomenon that causes hyperextension of the neck. They can also happen spontaneously.[8][9]

The causes of carotid artery dissection can be broadly categorized into two classes: spontaneous or traumatic.[10]


Dissection may occur after direct physical trauma, traffic collision, strangulation, or any phenomenon that causes hyperextension of the neck. They can also happen spontaneously.[8][11]

Spontaneous

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Once considered uncommon, spontaneous carotid artery dissection is an increasingly recognized cause of stroke that preferentially affects the middle-aged.[12][13]

The incidence of spontaneous carotid artery dissection is low, and incidence rates for internal carotid artery dissection have been reported to be around 2.6 to 2.9 incidents per 100,000.[14] Though the incidence is low, it is the cause of the vast majority of strokes in young people.[15]

Observational studies and case reports published since the early 1980s show that patients with spontaneous internal carotid artery dissection may also have a history of stroke in their family and/or hereditary connective tissue disorders, such as Marfan syndrome, Ehlers-Danlos syndrome, autosomal dominant polycystic kidney disease, pseudoxanthoma elasticum, fibromuscular dysplasia, and osteogenesis imperfecta type I.[16] IgG4-related disease involving the carotid artery has also been observed as a cause.[17]

However, although an association with connective tissue disorders does exist, most people with spontaneous arterial dissections do not have associated connective tissue disorders. Also, the reports on the prevalence of hereditary connective tissue diseases in people with spontaneous dissections are highly variable, ranging from 0% to 0.6% in one study to 5% to 18% in another study.[16]

Internal carotid artery dissection can also be associated with an elongated styloid process (known as Eagle syndrome when the elongated styloid process causes symptoms).[18][19]

Traumatic

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Carotid artery dissection is thought to be more commonly caused by severe violent trauma to the head and/or neck. An estimated 0.67% of patients admitted to the hospital after major motor vehicle accidents were found to have blunt carotid injury, including intimal dissections, pseudoaneurysms, thromboses, or fistulas.[20] Of these, 76% had intimal dissections, pseudoaneurysms, or a combination of the two. Sports-related activities such as surfing[21] and Jiu-Jitsu[22] have been reported as causes of carotid artery dissection.

The probable mechanism of injury for most internal carotid injuries is rapid deceleration, with resultant hyperextension and rotation of the neck, which stretches the internal carotid artery over the upper cervical vertebrae, producing an intimal tear.[20] After such an injury, the patient may remain asymptomatic, have a hemispheric transient ischemic event, or have a stroke.[23]

Artery dissection has also been reported in association with some forms of neck manipulation.[8] There is significant controversy about the level of risk of stroke from neck manipulation. It may be that manipulation can cause dissection,[24] or it may be that the dissection is already present in some people who seek manipulative treatment.[25]

Pathophysiology

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Arterial dissection of the carotid arteries is a condition that arises when a small tear forms in the innermost lining of the arterial wall, known as the tunica intima. This tear allows blood to enter the space between the inner and outer layers of the vessel, leading to either narrowing (stenosis) or complete occlusion. Notably, the stenosis in the early stages of arterial dissection is a dynamic process, and some occlusions can quickly transition back to stenosis. When complete occlusion occurs, it can result in ischemia, a condition characterized by insufficient blood supply to a particular area.[26]

In cases of complete occlusion, symptoms may not always be evident due to the presence of collateral circulation, which helps to adequately perfuse the brain. However, complications can arise when blood clots develop at the site of the tear and subsequently break off, forming emboli. These emboli can then travel through the arteries and reach the brain, where they may block the blood supply. This blockage leads to an ischemic stroke, also known as a cerebral infarction.[27] It is believed that blood clots or emboli originating from the dissection are responsible for causing infarctions in the majority of cases involving strokes in the presence of carotid artery dissection.[28][29]

Cerebral infarction, as a result of carotid artery dissection, can cause irreversible damage to the brain. Studies have demonstrated a significant number of patients with dissections go on to experience full blown strokes, often some time after the original dissection event.[30][31] This emphasizes the serious and potentially life-altering consequences associated with this condition.

Treatment

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The goal of treatment is to prevent the development of an actual stroke or limit the continuation of neurologic deficits should a stroke occur after dissection. Treatments include observation, anti-platelet agents, anticoagulation, stent implantation, carotid endarterectomy, and carotid artery ligation.[10][32]

Epidemiology

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Carotid dissections events can occur at any age. They tend to occur more often in younger individuals under 50. Such events are slightly more common in men than in women.[33] Spontaneous internal carotid artery dissection is a rare event with an incidence rate of approximately 2.6 to 2.9 per 100,000 individuals. However, such events account for ~5% to ~22% of strokes in patients under the age of 45 years.[34]

See also

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References

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  1. ^ "Cervical Artery Dissection: Causes and Symptoms". Cleveland Clinic. Retrieved 2023-11-07.
  2. ^ Mattu, Amal (2007). Emergency Medicine: Avoiding the Pitfalls and Improving the Outcomes. Blackwell / BMJ Books. ISBN 978-1-4051-4166-6.
  3. ^ "Carotid artery: Anatomy, function, disease, and more". Medical News Today. 2020-03-10. Retrieved 2023-11-04.
  4. ^ "Carotid Artery Dissection: Symptoms and Treatment". Cleveland Clinic. Retrieved 2023-11-04.
  5. ^ Kerry, Roger; Taylor, Alan J. (November 2006). "Cervical arterial dysfunction assessment and manual therapy". Manual Therapy. 11 (4): 243–253. doi:10.1016/j.math.2006.09.006. PMID 17074613.
  6. ^ "Cervical Artery Dissection (CeAD) | Treatment & Diagnosis | UH Harrington Heart & Vascular Institute | University Hospitals | Cleveland, Ohio | University Hospitals". www.uhhospitals.org. Retrieved 2023-11-07.
  7. ^ "Cervical artery dissection | Health Information | Bupa UK". www.bupa.co.uk. Retrieved 2023-11-07.
  8. ^ a b c Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ (2012). "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice. 66 (10): 940–947. doi:10.1111/j.1742-1241.2012.03004.x. PMC 3506737. PMID 22994328.
  9. ^ Weintraub, Michael I. (28 April 1993). "Beauty Parlor Stroke Syndrome: Report of Five Cases". JAMA. 269 (16): 2085–2086. doi:10.1001/jama.1993.03500160051022. PMID 8468755.
  10. ^ a b Goodfriend, Steven D.; Tadi, Prasanna; Koury, Ron (2024). "Carotid Artery Dissection". StatPearls. StatPearls Publishing. PMID 28613585.
  11. ^ Weintraub, Michael I. (28 April 1993). "Beauty Parlor Stroke Syndrome: Report of Five Cases". JAMA. 269 (16): 2085–2086. doi:10.1001/jama.1993.03500160051022. PMID 8468755.
  12. ^ Mokri, Bahram (March 1997). "Spontaneous dissections of internal carotid arteries". The Neurologist. 3 (2): 104–119. doi:10.1097/00127893-199703000-00005.
  13. ^ "Carotid Dissection | Mount Sinai − New York". Mount Sinai Health System. Retrieved 2023-11-07.
  14. ^ Lee, Vivien H.; Brown, Robert D.; Mandrekar, Jayawant N.; Mokri, Bahram (28 November 2006). "Incidence and outcome of cervical artery dissection: A population-based study". Neurology. 67 (10): 1809–1812. doi:10.1212/01.wnl.0000244486.30455.71. PMID 17130413.
  15. ^ "Spontaneous coronary artery dissection (SCAD) − Symptoms and causes". Mayo Clinic. Retrieved 2023-11-04.
  16. ^ a b de Bray, Jean-Michel; Baumgartner, Ralf W. (July 2005). "History of Spontaneous Dissection of the Cervical Carotid Artery". Archives of Neurology. 62 (7): 1168–1170. doi:10.1001/archneur.62.7.1168. PMID 16009782.
  17. ^ Barp, Andrea; Fedrigo, Marny; Farina, Filippo Maria; Lepidi, Sandro; Causin, Francesco; Castellani, Chiara; Cester, Giacomo; Thiene, Gaetano; Valente, Marialuisa; Baracchini, Claudio; Angelini, Annalisa (January 2016). "Carotid aneurism with acute dissection: an unusual case of IgG4-related diseases". Cardiovascular Pathology. 25 (1): 59–62. doi:10.1016/j.carpath.2015.08.006. PMID 26453089.
  18. ^ Sveinsson, Olafur; Kostulas, Nikolaos; Herrman, Lars (11 June 2013). "Internal carotid dissection caused by an elongated styloid process (Eagle syndrome)". BMJ Case Reports. 2013: bcr2013009878. doi:10.1136/bcr-2013-009878. PMC 3702984. PMID 23761567.
  19. ^ Ogura, Takenori; Mineharu, Yohei; Todo, Kenichi; Kohara, Nobuo; Sakai, Nobuyuki (2015). "Carotid Artery Dissection Caused by an Elongated Styloid Process: Three Case Reports and Review of the Literature". NMC Case Report Journal. 2 (1): 21–25. doi:10.2176/nmccrj.2014-0179. PMC 5364929. PMID 28663957.
  20. ^ a b Fabian, T. C.; Patton, Joe; Croce, Martin; Minard, Gayle; Kudsk, Kenneth; Pritchard, F. (1996). "Blunt Carotid Injury". Annals of Surgery. 223 (5): 513–552. doi:10.1097/00000658-199605000-00007. PMC 1235173. PMID 8651742.
  21. ^ Pego-Reigosa, R.; López-López, S.; Vázquez-López, M. E.; Armesto-Pérez, V.; Brañas-Fernández, F.; Martínez-Vázquez, F.; Piñeiro-Bolaño, R.; Cortés-Laiño, J. A. (14 June 2005). "Sea wave–induced internal carotid artery dissection". Neurology. 64 (11): 1980. doi:10.1212/01.WNL.0000163855.78628.42. PMID 15955962.
  22. ^ Demartini, Zeferino; Rodrigues Freire, Maxweyd; Lages, Roberto Oliver; Francisco, Alexandre Novicki; Nanni, Felipe; Maranha Gatto, Luana A.; Koppe, Gelson Luis (2017). "Internal Carotid Artery Dissection in Brazilian Jiu-Jitsu". Journal of Cerebrovascular and Endovascular Neurosurgery. 19 (2): 111–116. doi:10.7461/jcen.2017.19.2.111. PMC 5678212. PMID 29152471.
  23. ^ Matsuura, John H.; Rosenthal, David; Jerius, Hilde; Clark, Michael D.; Owens, David S. (November 1997). "Traumatic Carotid Artery Dissection and Pseudoaneurysm Treated with Endovascular Coils and Stent". Journal of Endovascular Therapy. 4 (4): 339–343. doi:10.1177/152660289700400403. PMID 9418195.
  24. ^ Ernst, E. (2010). "Vascular accidents after neck manipulation: cause or coincidence?". International Journal of Clinical Practice. 64 (6): 673–7. doi:10.1111/j.1742-1241.2009.02237.x. PMID 20518945. S2CID 38571730.
  25. ^ Guzman J, Haldeman S, Carroll LJ, et al. (February 2009). "Clinical practice implications of the bone and joint decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations". Journal of Manipulative and Physiological Therapeutics. 32 (2 Suppl): S227–243. doi:10.1016/j.jmpt.2008.11.023. PMID 19251069. In persons younger than 45 years, there is an association between chiropractic care and vertebro-basilar artery (VBA) stroke; there is a similar association between family physician care and VBA stroke. This suggests that there is no increased risk of VBA stroke after chiropractic care, and that these associations are likely due to patients with headache and neck pain from vertebral artery dissection seeking care while in the prodromal stage of a VBA stroke. Unfortunately, there is no practical or proven method to screen patients with neck pain and headache for vertebral artery dissection. However, VBA strokes are extremely rare, especially in younger persons.
  26. ^ Bax, Monique; Romanov, Valentin; Junday, Keerat; Giannoulatou, Eleni; Martinac, Boris; Kovacic, Jason C.; Liu, Renjing; Iismaa, Siiri E.; Graham, Robert M. (6 December 2022). "Arterial dissections: Common features and new perspectives". Frontiers in Cardiovascular Medicine. 9. doi:10.3389/fcvm.2022.1055862. PMC 9763901. PMID 36561772.
  27. ^ Keser, Zafer; Chiang, Chia-Chun; Benson, John C; Pezzini, Alessandro; Lanzino, Giuseppe (September 2022). "Cervical Artery Dissections: Etiopathogenesis and Management". Vascular Health and Risk Management. 18: 685–700. doi:10.2147/VHRM.S362844. PMC 9447449. PMID 36082197.
  28. ^ Redekop, Gary John (May 2008). "Extracranial Carotid and Vertebral Artery Dissection: A Review". Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques. 35 (2): 146–152. doi:10.1017/s0317167100008556. PMID 18574926.
  29. ^ Jung, Simon; Wiest, Roland; Gralla, Jan; McKinley, Richard; Mattle, Heinrich; Liebeskind, David (11 December 2017). "Relevance of the cerebral collateral circulation in ischaemic stroke: time is brain, but collaterals set the pace". Swiss Medical Weekly. 147: w14538. doi:10.4414/smw.2017.14538. PMID 29231236.
  30. ^ Martin, P J; Humphrey, P R D (July 1998). "Disabling stroke arising five months after internal carotid artery dissection". Journal of Neurology, Neurosurgery & Psychiatry. 65 (1): 136–137. doi:10.1136/jnnp.65.1.136. PMC 2170177. PMID 9667581.
  31. ^ "Articles". Cedars-Sinai. Archived from the original on 2021-09-12. Retrieved 2023-11-07.
  32. ^ Torborg, Liza (2019-07-02). "Mayo Clinic Q and A: Treating a carotid artery tear". Mayo Clinic News Network. Retrieved 2023-11-04.
  33. ^ "Carotid Dissection". www.hopkinsmedicine.org. 2022-12-28. Retrieved 2023-11-04.
  34. ^ Zheng, Chong; Zhou, Hongwei; Zhao, Kexin; Kong, Derui; Ji, Tiefeng (February 2023). "Internal carotid artery dissection with different interventions and outcomes: two case reports". Journal of International Medical Research. 51 (2). doi:10.1177/03000605231154379. PMC 9926001. PMID 36772988.
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