Carotid Artery Dissection in Older Adults

Fri, 6/12/09 - 9:19am
0 Comments
3990 reads

Citation:

Pages 32 - 35

Authors:

Shraddha Prakash, MD, Qingping Yao, MD, PhD, and Meika A. Fang, MD

Spontaneous extracranial internal carotid artery dissection (ICAD) causes a broad spectrum of symptoms, ranging from minor headache to permanent ischemia of the brain or retina. Although ICAD is one of the most common causes of ischemic stroke in young and middle-aged adults, it can occur in older adults and pose a diagnostic challenge due to its local signs and symptoms such as headache, neck pain, Horner syndrome, tinnitus, and cranial nerve palsy, which mimic other conditions. This article provides a comprehensive overview of the possible causes, clinical features, diagnostic modalities, and treatments, as well as differential diagnoses of ICAD.

Case Vignette

A 62-year-old male was admitted to the hospital with a 3-week history of severe, persistent right-sided headache and blurred vision. He was initially diagnosed with sinusitis and treated with three courses of antibiotics without much improvement. There was moderate relief of his headache with the addition of 5 days of daily prednisone 60 mg for presumptive sinusitis; however, it quickly recurred after discontinuation of the drug. On admission, the patient reported dull right-sided headache associated with nausea and vomiting, right-sided scalp tingling, visual loss, and right temporal pain. He also complained of neck pain with extreme flexion. He denied jaw claudication, myalgia, muscle weakness, arthralgia, or morning stiffness. The remainder of the review of systems was negative. His past medical history was significant for allergic rhinitis, hypothyroidism, hyperlipidemia, essential tremor, posttraumatic stress disorder, and testicular cancer treated with orchiectomy and radiation therapy. The patient reported that he fell on ice 2 months prior to admission and sustained ecchyomosis of his right cheek. At presentation, his medications included prednisone, indomethacin, levothyroxine, simvastatin, fluoxetine, primidone, trimethoprim/sulfamethoxazole, and mometasone nasal spray.

On physical examination, the patient’s vital signs were normal except for a temperature of 100.94 degrees F (38.3 degrees C), and he appeared in mild distress due to pain. There was marked tenderness over the angle of the right jaw, temporal region, maxillary sinus, and sternocleidomastoid muscle. There was no erythema, swelling, or beading of the temporal arteries, and no carotid bruits were heard. He had full range of motion of the temporomandibular joints. A fundoscopic examination of dilated pupils showed no evidence of hemorrhage, cotton-wool spots, or disc ischemia. No peripheral synovitis was noted. The neurologic examination was significant for right ocular ptosis and miosis, with the rest of the cranial nerves intact.

Admission laboratory values were significant for platelets of 102 x103/µL. Westergren erythrocyte sedimentation rate (ESR) was 25 mm/h (0-20 mm/h) and C-reactive protein was 9.77 mg/dL (< 0.744 mg/dL). Computed tomography of the head was unremarkable except for bilateral moderate mucosal thickening with opacification of the ethmoid and maxillary sinuses.

The patient was restarted on high-dose prednisone 80 mg daily because of the concern that giant cell arteritis (GCA) could be a potential cause of his headaches and blurred vision. He had significant improvement in his symptoms the following day, and the next day underwent right temporal artery biopsy, which showed mild arteriosclerosis but no evidence of GCA. Magnetic resonance imaging and angiography (MRI/MRA) of the brain/neck was obtained, which showed dissection of the right internal carotid artery (ICA) with subacute thrombus extending from the right extracranial ICA bulb to the skull base with involvement of the proximal ICA petrous segment. The axial T1-weight MRI revealed a crescent sign, an elliptical bright signal within the arterial wall from blood (Figure).

References:

1. Stapf C, Elkind MS, Mohr JP. Carotid artery dissection. Annu Rev Med 2000;51:329-347.

2. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001;344(12):898-906.

3. Thanvi B, Munshi SK, Dawson SL, Robinson TG. Carotid and vertebral artery dissection. Postgrad Med J 2005;81:383-388.

4. Khimenko LP, Esham HR, Ahmed W. Spontaneous internal carotid artery dissection. South Med J 2000;93(10):1011-1016.

5. Baumgartner RW, Bogousslavsky J. Clinical manifestations of carotid dissection. Front Neurol Neurosci 2005;20:70-76.

6. Baumgartner RW, Arnold M, Baumgartner I, et al. Carotid dissection with and without ischemic events: Local symptoms and cerebral artery findings. Neurology 2001;57:827-832.

7. Lucas C, Moulin T, Deplanque D, et al. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 1998;29:2646-2648.

8. Koennecke HC, Trocio SH Jr, Mast H, Mohr JP. Microemboli on transcranial Doppler in patients with spontaneous carotid artery dissection. J Neuroimaging 1997;7:217-220.

9. Molina CA, Alvarez-Sabin J, Schoneville W, et al. Cerebral microembolism in acute spontaneous internal carotid artery dissection. Neurology 2000;55:1738-1740.

10. Cohen JE, Leker RR, Gotkine M, et al. Emergent stenting to treat patients with carotid artery dissection: Clinically and radiologically directed therapeutic decision making. Stroke 2003;34:e254-257. Published Online: November 6, 2003.

11. Flis CM, Jäger HR, Sidhu PS. Carotid and vertebral artery dissections: Clinical aspects, imaging features and endovascular treatment. Eur Radiol 2007;17:820-834. Published Online: July 27, 2006.

12. Adkins AL, Zelenock GB, Bendick PJ, Shanley CJ. Duplex ultrasound recognition of spontaneous carotid dissection: a case report and review of the literature. Vasc Endovascular Surg 2004;38:455-460.

13. Sturzenegger M, Mattle HP, Rivoir A, Baumgartner RW. Ultrasound findings in carotid artery dissection: Analysis of 43 patients. Neurology 1995;45:691-698.

14. Aggarwal S, Kucharczyk W, Keller MA. Asymptomatic postendarterectomy dissection of the internal carotid artery detected incidentally on MRI. Neuroradiol 1993;35:586-587.

15. Arnold M, Baumgartner RW, Stapf C, et al. Ultrasound diagnosis of spontaneous carotid dissection with isolated Horner syndrom. Stroke 2008;39:82-86. Published Online: November 15, 2007.

16. Lanczik O, Szabo K, Hennerici M, Gass A. Multiparametric MRI and ultrasound findings in patients with internal carotid artery dissection. Neurology 2005;65:469-471.

17. Houser OW, Mokri B, Sundt TM Jr, et al. Spontaneous cervical cephalic arterial dissection and its residuum: Angiographic spectrum. AJNR Am J Neuroradiol 1984;5:27-34.

18. Kasner SE, Hankins LL, Bratina P, Morgenstern LB. Magnetic resonance angiography demonstrates vascular healing of carotid and vertebral artery dissections. Stroke 1997;28:1993-1997.

19. Menon R, Kerry S, Norris JW, Markus HS. Treatment of cervical artery dissection: A systemic review and meta-analysis. J Neurol Neurosurg Psychiatry 2008;79(10):1122-1127.

20. Edgell RC, Abou-Chebl A, Yadav JS. Endovascular management of spontaneous carotid artery dissection. J Vasc Surg 2005;42:854-860.

21. Fava M, Meneses L, Loyola S, et al. Carotid artery dissection: Endovascular treatment. Report of 12 patients. Catheter Cardiovasc Interv 2008;71:694-700.

22. Mirza Z, Hayward P, Hulbert D Spontaneous carotid artery dissection presenting as migraine-a diagnosis not to be missed. J Accid Emerg Med 1998;15(3):187-199.

23. Rigamonti A, Iurlora S, Reganati P, at al. Cluster headache and internal carotid artery dissection: Two cases and review of the literature. Headache 2008;48:467-470. Published Online: January 11, 2008.

24. Verghese J, Kachroo A, Sparr SA. Herpes zoster ophthalmicus mimicking carotid artery dissection: A case report. Headache 1997;37(10):663-664.

25. Roz TM, Schiffman LE, Schlossberg S. Spontaneous dissection of the internal carotid artery manifesting as pain in an endodontically treated molar. J Am Dent Assoc 2005;136(11):1556-1559.

26. Sidhu PS, Chauduri KR, Khaw KT. Moyamoya disease mimicking a spontaneous internal carotid artery dissection on Doppler ultrasound. Eur Radiol 2000;10:149-153.

27. Tehrani R, Ostrowski RA, Hariman R, Jay WM. Giant cell arteritis. Semin Ophthalmol 2008;23:99-110.

28. Eberhardt RT, Dhadly M. Giant cell arteritis: Diagnosis, management, and cardiovascular implications. Cardiol Rev 2007;15:55-61.

29. Shah AV, Paul-Oddoye AB, Madill SA, et al. Horner’s syndrome associated with giant cell arteritis. Eye 2007;21:130-131. Published Online: June 23, 2006.

30. Martínez-Taboada VM, Blanco R, Armona J, et al. Giant cell arteritis with an erythrocyte sedimentation rate lower than 50. Clin Rheumatol 2000;19:73-75.

31. Salvarani C, Hunder GG. Giant cell arteritis with low erythrocyte sedimentation rate: Frequency of occurrence in a population-based study. Arthritis Rheum 2001;45:140-145.

32. Hunder GG, Bloch DA, Michel BA, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum 1990;33:1122-1128.