57 year-old male with left amaurosis fugax and left frontal headache. No history of trauma except for a syncopal episode approximately 8 months prior to the onset of symptoms.
PMHx: Mild urinary retention. No history of HTN, CAD, MI or DM
Non-smoker, retired pilot
Normal physical exam and laboratory evaluation.
DIAGNOSTIC EVALUATION: CT scan of the head was normal. MRI with DWI revealed nonspecific foci of increased signal consistent with microvascular ischemic changes without findings of large vessel ischemic changes or edema. Carotid duplex ultrasound demonstrated a very narrowed left internal carotid artery. The patient was referred to Interventional Radiology for carotid angiogram to evaluate for possible carotid artery dissection. Left carotid arteriogram showed a smooth tapered narrowing of the proximal left internal carotid artery near its origin with delayed washout of contrast consistent with left internal carotid artery dissection extending from the bulb to the intracranial internal carotid artery. The aortic arch, right carotid artery and remaining intracranial vessels examined were normal. There was no evidence of atherosclerotic vascular disease. The etiology of this patientâ€™s carotid artery dissection was unclear.
Dx: Spontaneous Carotid Artery Dissection confirmed by carotid arteriography
Dx Confirmed by:
The patient was treated with anticoagulant therapy and will obtain follow-up carotid arteriogram in approximately 3 months.
Spontaneous carotid and vertebral arterial dissections are recognized causes of stroke, especially in young and middle-aged patients without other risk factors for stroke. Cervical arterial dissection has been reported to often occur in healthy individuals without clear antecedent trauma or with only mild mechanical stress such as coughing, sudden head movement, infection or participation in sports. Arterial dissection occurs when there is a separation of the vessel wall. The separation is usually between the intima and media or within the media. Often dissection occurs because of an intimal tear resulting in a false lumen or intramural hematoma. Complications include stroke from emboli or hemodynamic compromise and rupture. If untreated, the false lumen can enlarge to compress the true lumen, rupture, persist or thrombose.
Although the causes of aortic dissections are frequently known (long standing hypertension, trauma, degradation of the media), the pathogenesis of spontaneous cervical arterial dissections is unknown. An underlying connective tissue disorder leading to arterial wall structural instability has been postulated and is supported by the high incidence of dissections in patients with heritable connective tissue disorders.
Diagnosis frequently can be made with Doppler sonography and confirmed with arteriography. Cervical arterial dissections are usually treated with anticoagulation.
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