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Seminars in Neurosurgery 2002; 13(3): 265-278
DOI: 10.1055/s-2002-39820
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Carotid Dissection: A Clinical Review

Jonathan E. Martin, Rocco A. Armonda
  • Walter Reed Army Medical Center, Washington, D.C., and National Naval Medical Center, Bethesda, Maryland
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Publication History

Publication Date:
24 June 2003 (online)

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ABSTRACT

Carotid artery dissection (CD) is an unusual pathological entity capable of producing devastating neurological deficits in affected patients. Symptoms include one or more of the clinical triad of headaches, oculosympathetic dysfunction, and retinal or cerebral ischemia. Cerebral angiography remains the gold standard for the diagnosis of carotid dissection. However, magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) are emerging as both sensitive and specific modalities for the diagnosis of carotid artery disease. Management of CD remains controversial; the efficacy of anticoagulation, the current standard of care for initial management of CD, has not been demonstrated in a clinical trial. The authors review management options to include anticoagulation, antiplatelet agents, endovascular stenting, and surgical management of carotid dissection.

KEYWORDS

Carotid artery dissection - diagnosis - management

REFERENCES

  • 1 Verneuil M. Contusions multiples, deire, violent, hemiplegie a droite, signes de compression cerebrale.  Bull Acad Natl Med (Paris). 1872;  1 46-56
    PubMedGoogle Scholar
  • 2 Jentzer A. Dissecting aneurysms of the left internal carotid artery.  Angiology . 1954;  5 232-234
    PubMedGoogle Scholar
  • 3 Bogousslavsky J, Pierre P. Ischemic stroke in patients under age 45.  Neurol Clin . 1992;  10 113-124
    PubMedGoogle Scholar
  • 4 Cogbill T H, Moore E E, Meissner M. et al . The spectrum of blunt injury to the carotid artery: a multicenter perspective.  J Trauma . 1994;  37 473-479
    CrossrefPubMedGoogle Scholar
  • 5 Milhaud D, de Freitas R G, van Melle G, Bogousslavsky J. Occlusion due to carotid artery dissection: a more severe disease than previously suggested.  Arch Neurol . 2002;  59 557-561
    CrossrefPubMedGoogle Scholar
  • 6 Schievink W I, Mokri B, Whisnant J P. Internal carotid artery dissection in a community: Rochester, Minnesota, 1987-1992.  Stroke . 1993;  24 1678-1680
    PubMedGoogle Scholar
  • 7 Mokri B. Spontaneous dissections of internal carotid arteries.  Neurologist . 1997;  3 104-119
    PubMedGoogle Scholar
  • 8 Davis J, Holbrook T, Hoyt D. Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment.  J Trauma . 1990;  30 1514-1517
    CrossrefPubMedGoogle Scholar
  • 9 Biffl W L, Moore E E, Ryu R K. et al . The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome.  Ann Surg . 1998;  228 462-470
    CrossrefPubMedGoogle Scholar
  • 10 Bouthillier A, van Loveren R H, Keller J T. Segments of the internal carotid artery: a new classification.  Neurosurgery . 1996;  38 425-433
    CrossrefPubMedGoogle Scholar
  • 11 Resnick D K, Subach B R, Marion D W. The significance of carotid canal involvement in basilar cranial fracture.  Neurosurgery . 1997;  40 1177-1181
    CrossrefPubMedGoogle Scholar
  • 12 Mokri B, Sundt Jr M T, Houser O W, Piepgras D G. Spontaneous dissection of the cervical internal carotid artery.  Ann Neurol . 1986;  19 126-138
    CrossrefPubMedGoogle Scholar
  • 13 Moarr J J. Traumatic rupture of the cervical carotid arteries: an autopsy and histopathological study of 200 cases.  Forensic Sci Int . 1987;  34 227-244
    CrossrefPubMedGoogle Scholar
  • 14 Schievink W I, Michels V V, Piepgras D G. Neurovascular manifestations of heritable connective tissue disorders: a review.  Stroke . 1994;  25 889-903
    PubMedGoogle Scholar
  • 15 Brandt T, Hausser I, Orberk E. et al . Ultrastructural connective tissue abnormalities in patients with spontaneous cervicocerebral artery dissections.  Ann Neurol . 1998;  44 281-285
    CrossrefPubMedGoogle Scholar
  • 16 Cardon C, Diemont F, Julia P, Chemla E, Fabiani J N. Bilateral carotid dissection and factor V mutation: a second case.  Ann Vasc Surg . 2000;  14 503-506
    CrossrefPubMedGoogle Scholar
  • 17 Schievink W I, Wijdicks E FM, Kuiper J D. Seasonal pattern of spontaneous cervical artery dissection.  J Neurosurg . 1998;  89 101-103
    PubMedGoogle Scholar
  • 18 Grotta J C, Ward R E, Flynn T C, Cullen M L. Spontaneous internal carotid artery dissection associated with fibromuscular dysplasia.  J Cardiovasc Surg . 1982;  23 512-514
    PubMedGoogle Scholar
  • 19 Jeret J S. More complications of spinal manipulation.  Stroke . 2001;  32 1936-1937
    PubMedGoogle Scholar
  • 20 Woll M M, Goff Jr M J, Gillespie D L, Minken S L. Bilateral spontaneous dissection of the internal carotid arteries: a case report.  Vasc Surg . 2001;  35 221-224
    PubMedGoogle Scholar
  • 21 Evers S, Altenmuller E, Ringlestein E B. Cerebrovascular ischemic events in wind-instrument players.  Neurology . 2000;  55 865-867
    PubMedGoogle Scholar
  • 22 Cloft H J, Jensen M E, Kallmes D F, Dion J E. Arterial dissections complicating cerebral angiography and cerebrovascular interventions.  Am J Neuroradiol . 2000;  21 541-545
    PubMedGoogle Scholar
  • 23 Singhal A, Golomb M, Mochida G. et al . Another case of internal carotid artery dissection after mandibular osteotomy.  J Oral Maxillofac Surg . 1998;  56 115-116
    PubMedGoogle Scholar
  • 24 Biffl W L, Moore E E, Offner P J, Brega K E, Franciose R J, Burch J M. Blunt carotid arterial injuries: implications of a new grading scale.  J Trauma . 1999;  47 845-853
    CrossrefPubMedGoogle Scholar
  • 25 Biousse V, D'Anglejan-Chatillon J, Massiou H, Bousser M G. Head pain in nontraumatic carotid artery dissection: a series of 65 patients.  Cephalgia . 1994;  14 33-36
    CrossrefPubMedGoogle Scholar
  • 26 Silbert P L, Mokri B, Schievink W I. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections.  Neurology . 1995;  45 1517-1522
    CrossrefPubMedGoogle Scholar
  • 27 Mokri B, Sundt T M, Houser O W, Piepgras D G. Spontaneous dissection of the cervical internal carotid artery.  Ann Neurol . 1986;  19 126-138
    CrossrefPubMedGoogle Scholar
  • 28 Harris J P, Horlbeck D M, Brew K H. Unique case of pulsatile tinnitus.  Ann Otol Rhinol Laryngol . 2000;  109 1103-1106
    PubMedGoogle Scholar
  • 29 Shahab R, Savy L E, Croft C B, Hung T. Isolated hypoglossal nerve palsy due to internal carotid artery dissection.  J Laryngol Otol . 2001;  115 587-589
    CrossrefPubMedGoogle Scholar
  • 30 Opeskin K. Traumatic carotid artery dissection.  Am J Forensic Med Pathol . 1997;  18 251-257
    CrossrefPubMedGoogle Scholar
  • 31 Resnick D K, Subach B R, Marion D W. The significance of carotid canal involvement in basilar cranial fracture.  Neurosurgery . 1997;  40 1177-1187
    CrossrefPubMedGoogle Scholar
  • 32 Touze E, Randoux B, Meary E, Arquizan C, Meder J F, Mas J L. Aneurysmal forms of cervical artery dissection: associated factors and outcome.  Stroke . 2001;  32 418-423
    PubMedGoogle Scholar
  • 33 Cloft H J, Jensen M E, Kallmes D F, Dion J E. Arterial dissections complicating cerebral angiography and cerebrovascular interventions.  Am J Neuroradiol . 2000;  21 541-545
    PubMedGoogle Scholar
  • 34 Landwehr P, Schulte O, Voshage G. Ultrasound examination of carotid and vertebral arteries.  Eur Radiol . 2001;  11 1521-1534
    CrossrefPubMedGoogle Scholar
  • 35 Eljamel M SM, Humphrey P RD, Shaw M DM. Dissection of the cervical internal carotid artery: the role of Doppler/Duplex studies and conservative management.  J Neurol Neurosurg Psych . 1990;  53 379-383
    PubMedGoogle Scholar
  • 36 Bowen B C, Quencer R M, Margosian P, Pattany P M. MR Angiography of occlusive disease of the arteries in the head and neck: current concepts.  Am J Roentgenol . 1994;  162 9-18
    PubMedGoogle Scholar
  • 37 Levy C, Laissy J P, Raveau V. et al . Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography.  Radiology . 1994;  190 97-103
    PubMedGoogle Scholar
  • 38 Phan T, Huston J, Bernstein M A, Riederer S J, Brown R D. Contrast-enhanced magnetic resonance angiography of the cervical vessels: experience with 422 patients.  Stroke . 2001;  32 2282-2286
    PubMedGoogle Scholar
  • 39 Petro G R, Witwer G A, Cacayorin E D. et al . Spontaneous dissction of the cervical internal carotid artery: correlation of arteriography, CT, and pathology.  Am J Neuroradiol . 1986;  7 1053-1058
    PubMedGoogle Scholar
  • 40 LeClerc X, Godefroy O, Salhi A, Lucas C, Leys D, Pruvo J P. Helical CT for the diagnosis of extracranial internal carotid artery dissection.  Stroke . 1996;  27 461-466
    CrossrefPubMedGoogle Scholar
  • 41 Dal Pozzo G, Mascalchi M, Fonda C, Cadelo M, Ronchi O, Inzitari D. Lower cranial nerve palsy due to dissection of the internal carotid artery: CT and MR imaging.  J Comput Assist Tomogr . 1989;  13 989-995
    PubMedGoogle Scholar
  • 42 Wintermark M, Reichhart M, Cuisenaire O. et al . Comparison of admission perfusion computed tomography and qualitative diffusion- and perfusion-weighted magnetic resonance imaging in acute stroke patients.  Stroke . 2002;  33 2025-2031
    CrossrefPubMedGoogle Scholar
  • 43 LeClerc X, Godefroy O, Salhi A, Lucas C, Leys D, Pruvo J P. Helical CT for the diagnosis of extracranial internal carotid artery dissection.  Stroke . 1996;  27 461-466
    CrossrefPubMedGoogle Scholar
  • 44 Egelhof T, Jansen O, Winter R, Sartor K. CT angiography in dissections of the internal carotid artery: value of a new examination technique in comparison with DSA and Doppler ultrasound [in German].  Radiologe . 1996;  36 850-854
    CrossrefPubMedGoogle Scholar
  • 45 Biffl W L, Moore E E, Ryu R K. et al . The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome.  Ann Surg . 1998;  228 462-470
    CrossrefPubMedGoogle Scholar
  • 46 Biffl W L, Moore E E, Offner P J, Brega K E, Franciose R J, Burch J M. Blunt carotid arterial injuries: implications of a new grading scale.  J Trauma . 1999;  47 845-852
    CrossrefPubMedGoogle Scholar
  • 47 Lucas C, Moulin T, Deplanque D, Tatu L, Chavot D. Stroke patterns of internal carotid artery dissections in 40 patients.  Stroke . 1998;  29 2646-2648
    PubMedGoogle Scholar
  • 48 Molina C A, Alvarez-Sabin J, Schonewille W. et al . Cerebral microembolism in acute spontaneous internal carotid artery dissection.  Neurology . 2000;  55 1738-1740
    CrossrefPubMedGoogle Scholar
  • 49 Stroke Prevention in Atrial Fibrillation Collaborators. Stroke prevention in atrial fibrillation study.  Final results. Circulation . 1991;  84 527-539
    PubMedGoogle Scholar
  • 50 Algra A, de Schryver L E, van Gijn J, Kappelle L J, Koudstaal P J. Oral anticoagulants versus antiplatelet therapy for preventing further vascular events after transient ischaemic attack or minor stroke of presumed arterial origin.  Cochrane Database Syst Rev . 2001;  4 CD001342
    PubMedGoogle Scholar
  • 51 International Stroke Trial Collaborative Group. The international stroke trial (IST): a randomized trial of aspirin, subcutaneous heparin, both, or neither among 19,435 patients with acute ischaemic stroke.  Lancet . 1997;  349 1569-1581
    CrossrefPubMedGoogle Scholar
  • 52 Richardson J D, Simpson C, Miller F B. Management of carotid artery injury.  Surgery . 1988;  104 673-680
    PubMedGoogle Scholar
  • 53 Fisher C M, Ojemann R G, Roberson G H. Spontaneous dissection of cervico-cerebral arteries.  Can J Neurol Sci . 1978;  5 9-19
    PubMedGoogle Scholar
  • 54 Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection.  Cochrane Database Syst Rev . 2000;  4 CD000255
    PubMedGoogle Scholar
  • 55 Fabian T C, Patton J H, Croce M A, Minard G, Kudsk K A, Pritchard F E. Blunt carotid injury: importance of early diagnosis and anticoagulant therapy.  Ann Surg . 1996;  223 513-525
    CrossrefPubMedGoogle Scholar
  • 56 Milhaud D, de Freitas R G, van Melle G, Bogousslavsky J. Occlusion due to carotid artery dissection: a more severe disease than previously suggested.  Arch Neurol . 2002;  59 557-561
    CrossrefPubMedGoogle Scholar
  • 57 Biffl W L, Moore E E, Ryu R K. et al . The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome.  Ann Surg . 1998;  228 462-470
    CrossrefPubMedGoogle Scholar
  • 58 Sturzenegger M, Mattle H P, Rivoir A, Baumgartner R W. Ultrasound findings in carotid artery dissection: analysis of 43 patients.  Neurology . 1995;  45 691-698
    CrossrefPubMedGoogle Scholar
  • 59 Yamaura A, Ono J, Hirai S. Clinical picture of intracranial nontraumatic dissecting aneurysms.  Neuropathology . 2000;  20 85-90
    PubMedGoogle Scholar
  • 60 Coull B M, Williams L S, Goldstein L B. et al . Anticoagulants and antiplatelet agents in acute ischemic stroke: report of the joint stroke Guideline Committee of the American Academy of Neurology and the American Stroke Association.  Neurology . 2002;  59 13-23
    CrossrefPubMedGoogle Scholar
  • 61 Fabian T C, Patton J H, Croce M A, Minard G, Kudsk K A, Pritchard F E. Blunt carotid injury: importance of early diagnosis and anticoagulant therapy.  Ann Surg . 1996;  223 513-525
    CrossrefPubMedGoogle Scholar
  • 62 Mokri B, Sundt T M, Houser O W, Piepgras D G. Spontaneous dissection of the cervical internal carotid artery.  Ann Neurol . 1986;  19 126-138
    CrossrefPubMedGoogle Scholar
  • 63 Kraus R R, Bergstein J M, DeBord J R. Diagnosis, treatment, and outcome of blunt carotid arterial injuries.  Am J Surg . 1999;  178 190-193
    CrossrefPubMedGoogle Scholar
  • 64 Parikh A A, Luchette F A, Valente J F. Blunt carotid injuries.  J Am Coll Surg . 1997;  185 80-86
    CrossrefPubMedGoogle Scholar
  • 65 International Stroke Trial Collaborative Group. The international stroke trial: a randomized trial of aspirin, subcutaneous heparin, both, or neither among 19,435 patients with acute ischaemic stroke.  Lancet . 1997;  349 1569-1581
    CrossrefPubMedGoogle Scholar
  • 66 Wahl W L, Brandt M, Thompson G, Taheri P A, Greenfield L J. Antiplatelet therapy: an alternative to heparin for blunt carotid injury.  J Trauma . 2002;  52 896-901
    CrossrefPubMedGoogle Scholar
  • 67 Marks M P, Dake M D, Steinber G K, Norbash A M, Lane B. Stent placement for arterial and venous cerebrovascular disease: preliminary experience.  Radiology . 1994;  191 441-446
    PubMedGoogle Scholar
  • 68 Liu A Y, Paulsen R D, Marcellus M L, Steinberg G K, Marks M P. Long-term outcomes after carotid stent placement treatment of carotid artery dissection.  Neurosurgery . 1999;  45 1368-1373
    CrossrefPubMedGoogle Scholar
  • 69 Bejjani G K, Monsein L H, Laird J R, Satler L F, Starnes B W, Aulisi E F. Treatment of symptomatic cervical carotid dissections with endovascualr stents.  Neurosurgery . 1999;  755-760
    CrossrefPubMedGoogle Scholar
  • 70 Muller B T, Luther B, Hort W, Neumann-Haefelin T, Aulich A, Sandmann W. Surgical treatment of 50 carotid dissections: indications and results.  J Vasc Surg . 2000;  31 980-988
    CrossrefPubMedGoogle Scholar
  • 71 Fry R E, Wry W J. Extracranial carotid artery injuries.  Surgery . 1980;  88 581-587
    PubMedGoogle Scholar
  • 72 The IC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischmic stroke: results of an international randomized trial.  N Engl J Med . 1985;  313 1191-1200
    CrossrefPubMedGoogle Scholar
  • 73 Adams H P, Powers W J, Grubb R L, Clarke W R, Woolson R F. Preview of a new trial of extracranial-to-intracranial arterial anastomosis: the carotid occlusion surgery study.  Neurosurg Clin N America . 2001;  36 613-624
    PubMedGoogle Scholar
  • 74 Ueno M, Nishizawa S, Toyoda H. et al . Assessment of cerebal hemodynamics before and after revascularization in patients with occlusive cerebrovascular disease by means of quantitative IMP-SPECT with double injection protocol.  Ann Nucl Med . 2001;  15 209-215
    PubMedGoogle Scholar
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