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The accompanying articles that speculate that Alexander the Great had a traumatic carotid dissection or congenital cervical scoliosis demonstrate the difficulties in retrospective diagnosis as a historical enterprise. The extant primary sources were written centuries after Alexander's death and are ambiguous in their original languages, and even more so in translation. Thus we cannot be certain what illness Alexander actually had. Furthermore, anachronistic diagnosis removes Alexander from the medical context of this time, telling us little of historical significance about him. Such investigations also illustrate the more general limits that the absence of context imposes on the study of ancient history.

Background and Purpose: Generally, the prognosis for cervical artery dissection (CAD) is uncertain. The recanalization rate of CAD can be up to 85% within 3 months. This study evaluates the variables that might affect recanalization and the role of recanalization as a predictor for neurological outcome. Patients and Results: This study prospectively included 38 patients with acute stroke following occlusion due to CAD (18 males, 20 females, median age 50.5 years, range 16–82). Vertebral and carotid dissections were equally distributed (19 carotid dissections). The recanalization rate was influenced by the presence of hypertension (p = 0.001). Outcomes were dependent on infarct location. Patients with lateral medullary infarction returned to functional independence (p = 0.026), while patients with deep hemispheric infarction tended to have a disabling stroke (p = 0.068). The presence of good collaterals seemed to influence functional independence (p = 0.03). Conclusion: There seemed to be no relationship between outcome and the rate of recanalization following CAD. Recanalization appeared to be a spontaneous mechanism, which could have depended on the intrinsic condition of the vessels. Finally, neurological outcome was dependent on lesion localization and the presence of good collaterals.

The authors describe a child presenting with Horner's syndrome after the repeated application of birthing forceps to the head and neck during vaginal delivery. Magnetic resonance imaging and angiography confirmed that the proximal right internal carotid artery (ICA) showed injury caused by dissection. Carotid duplex and transcranial ultrasonography provided supporting evidence of distal right ICA occlusion with the development of intracranial collaterals. The authors interpret these findings to indicate that the child suffered a traumatic dissection of the distal right ICA to mimic "congenital" Horner's syndrome (CHS). In a review of English medical literature published since 1972, the authors found 70 cases of CHS, none of which was attributed to carotid dissection. This case demonstrates that carotid dissection is an underreported cause of CHS.

Carotid dissection is a major complication of blunt head and neck trauma. The authors describe a case report of sudden bleeding of a distal branch of the external left carotid artery caused by a fracture of the mandible. This event occurred a week after the trauma. After a first phase consisting in cardiopulmonary resuscitation and blood loss replacement, the placement of a Guglielmi detachable coil (GDC) was considered the best and safest way to stop the bleeding. Guglielmi detachable coil represents a good technique for emergency treatment of bleeding from distal carotid vessels. Given its high cost, the diagnostic study of vessels near mandible fractures should not be considered as routine in cases of head and neck trauma, but should be considered in the presence of local hemorrhage or suspicious neurologic signs.

INTRODUCTIONA rare but significant cause for stroke is sub-intimal carotid dissection and this mechanism accounts for approximately 2.5% of all strokes.1 Dissection of the carotid artery is often caused by trauma to the face or neck.2 Under 45 years old, it is the second leading cause of stroke.3 Neurological symptoms can be lacking or subtle, therefore the condition may be overlooked but the pathological processed is believed to be attributed to thromboembolism.4 Microemboli in the middle cerebral artery, are known as a risk factor for ischaemic stroke following a transient ischaemic attack (TIA) and can be detected by transcranial Doppler examination (TCD).5 The established treatment regime is antiplatelet therapy, anticoagulation or both along with supportive therapy.6 Current evidence suggests managing microemboli in both crescendo TIA's and post carotid endarterectomy improves outcome.7 We have found the use of Tirofiban, a potent intravenous antiplatelet agent currently licensed for use in acute coronary syndrome, effective in the treatment of microemboli in this manner.7CASE PRESENTATIONWe report a case of symptomatic carotid artery dissection post radical neck dissection, causing TCD detected microemboli and successfully treated with Tirofiban.CONCLUSIONWe believe further study into the use of Tirofiban in the treatment of microemboli after carotid dissection is indicated.

Introduction: Data related to the treatment of patients with acute ischemic stroke caused by carotid artery dissection is scarce. Methods: We retrospectively reviewed our interventional stroke database Sep 2010 - Jan 2014 to investigate the clinical and radiological characteristics of patients presenting with tandem cervical and intracranial occlusions due to cervical carotid dissection. Results: Out of 504 consecutive patients treated with endovascular therapy for acute ischemic stroke during the study period, 12 (2.5%) patients were observed to have cervical carotid artery dissection as the underlying etiology. Mean age was 56±13 years, 75% were male, 50% received IV t-PA, mean NIHSS was 20±5, 75% had CT ASPECTS≥7, and mean time from last known normal to groin puncture was 6±3 hours. There were 4 MCA M1, 1 MCA M2 and 7 ICA-T occlusions. Extracranial carotid stent was used in 58% and angioplasty in 8% of cases. In 33% of the cases, the carotid dissection was not stented due to the fear of hemorrhagic transformation in cases of IV thrombolysis (presumably increased risk if dual antithrombotics used). IA tPA was used in 41% of cases, while Merci in 16%, Penumbra in 58%, and stentretrivers in 50%. Intracranial TICI 2b-3 reperfusion was achieved in 91% of patients, with PH2 hemorrhage in 8% and mRS at 90 days in 45% of cases. Conclusions: Carotid dissections with associated intracranial occlusions are often refractory to IV tPA and present with a high stroke severity. These lesions are amenable to endovascular therapy resulting in high rates of reperfusion with an acceptable safety profile.

Carotid endarterectomy is a standard vascular surgical procedure performed worldwide and encompasses multiple risks including cerebral hyperperfusion syndrome, stroke, carotid dissection and aneurysmal formation, all of which are well documented in the literature. However, neovascular glaucoma manifesting post carotid endarterectomy, is extremely rare and can have disastrous consequences if left undiagnosed. In this article, we present one such case of neovascular glaucoma manifesting post carotid endarterectomy and review the available literature on this uncommon entity.

This case describes a patient with amaurosis fugax as a result of non-traumatic internal carotid dissection. Typical symptoms of monocular blindness, especially in the setting of headache or neck pain should prompt evaluation for carotid dissection. Initial presentation with transient vision loss, lasting thirty minutes with a normal ophthalmic exam should raise suspicion for transient ischemic attack as well as carotid dissection. Symptoms may progress with resultant cerebral infarction as the dissection progresses. Carotid ultrasound with notable decreased internal carotid artery velocity prompts CT angiography of the neck confirming the carotid dissection. Anti-platelet therapy is the first line treatment, with anticoagulation reserved for cases of recurrent, progressive symptomatic episodes.

This cohort study examines the association between migraine and ischemic stroke due to cervical artery dissection in young patients with ischemic stroke.

Raeder first described Horner's syndrome with ipsilateral head pain due to paratrigeminal organic disease, but most subsequent reports of this syndrome were idiopathic. Our recent case prompted a review of past reports of idiopathic Raeder's syndrome. Because in recent years the features of Raeder's syndrome have been recognized as common manifestations of carotid artery dissection, we divided the cases into those with and those without carotid imaging studies. The classifications and differential diagnoses are discussed. Sixteen cases with carotid imaging studies were not very different from the 28 cases without such studies. Most studies were performed several weeks after onset of symptoms and carotid dissection could not be definitely excluded in any case. In most cases of idiopathic Raeder's syndrome, carotid artery dissection was not considered and in no case was that condition definitively excluded. People with Raeder's syndrome not associated with a paratrigeminal organic lesion probably have a disease of the carotid artery. Because of the different criteria and classifications of Raeder's syndrome it is best to relegate this eponym to history.

Blunt cerebrovascular injuries (BCVI) carry significant morbidity if not diagnosed and treated early. A high index of clinical suspicion is needed to recognize the injury patterns associated with this condition and to order the requisite imaging studies needed to diagnose it accurately. We report of BCVI associated with a congenital cervical spine malformation after blunt trauma. We recommend inclusion of cervical spine malformations to the current Eastern Association for the Surgery of Trauma screening criteria for BCVI and explain our rationale for the same.

Die Symptomatik eines 52-jahrigen Patienten der Universitats-HNO-Ambulanz begann mit plotzlichen Kopfschmerzen und Halskratzen, es folgten Kribbeln im Mund sowie Probleme beim Kauen, danach ein Abweichen der Zunge nach rechts. Auserdem lag eine positive Nikotinanamnese vor. Der MRT-Befund ergab eine intraluminale Signalsteigerung in der A. carotis interna rechts. Die isolierte Hypoglossusparese ohne Beteiligung anderer Hirnnerven ist selten, wird sie zeitgleich mit neu aufgetretenen Kopfschmerzen beobachtet, so sollte differenzialdiagnostisch in Erwagung gezogen werden, dass eine Dissektion der A. carotis interna vorliegen konnte – wie in dem vorgestellten Fall.

A case of chronic carotid dissection associated with new neurologic symptoms was treated with occipital artery to internal carotid artery bypass. After surgery, the patient remained without neurologic symptoms with a widely patent anastomosis. This novel reconstruction has not previously been reported and provides a suitable alternative for patients with inadequate greater saphenous vein. The mechanism causing this injury and management algorithms are discussed with a review of the literature.

Bungee jumping is a popular recreational activity in which participant experiences transient freefall while connected to a bungee cord. The rapid freefall and the resultant rebound force created by the bungee cord can result in a variety of bodily injuries. We report herein a case of traumatic carotid artery dissection caused by bungee jumping. The symptoms related to carotid artery dissection were successfully treated with anticoagulation. The etiology of carotid dissection related to bungee jumping is discussed. Physicians should be cognizant of this potential injury due to the force created by the freefall and rebound motion associated in this recreational sport.

Scopo del lavoro è quello di descrivere le caratteristiche morfologiche TC ed RM delle patologie espansive benigne nel soggetto adulto, correlando le alterazioni di densità alla TC e segnale alla RM, alle lesioni anatomo-patologiche presenti. Queste lesioni espansive benigne, infatti, rivestono un particolare interesse non solo perchè sono piuttosto rare, ma soprattutto perchè possono mimare patologia di altra natura, specie neoplastica maligna. Viene pertanto proposto uno schema di interpretazione delle immagini sulla base delle nozioni embriologiche e di sviluppo, allo scopo di effettuare una corretta diagnosi differenziale tra le lesioni congenite e quelle acquisite benigne nei confronti di quelle maligne. Sono stati valutati retrospettivamente i quadri morfologici TC e RM, eseguiti negli ultimi due anni ed effettuati secondo protocollo iniziale standardizzato, di 350 pazienti (174 maschi, 126 femmine, di età compresa tra i 16 e i 77 anni), con patologia espansiva del distretto testa-collo, accertata con esame clinico e/o strumentale endoscopico. Nella nostra casistica abbiamo riscontrato anche nell'adulto un discreto numero di soggetti affetti da patologia espansiva benigna nell'ambito delle regioni sopra- e sottoioidea del distretto testa-collo, confermata con la biopsia e/o dopo intervento chirurgico (47 casi). Abbiamo distinto diverse categorie principali di lesioni: Lesioni cistiche congenite: cisti di Tornwaldt (6), del dotto tireoglosso (5), delle tasche branchiali (5); Lesioni cistiche acquisite: laringoceli (2), laringomucopioceli (3); Lesioni Vascolari: malformazioni vascolari venose (3), linfangiomi (4); Lesioni neoplastiche benigne: paragangliomi (4), lipomi (2), tumori ghiandolari misti (3), neurinomi (2); Pseudotumori: vascolari: giugulare ectasica (2) e dissezione della carotide interna (2); ossei: osteofitosi vertebrale somatica ed interapofisaria (4). Non deve essere allora dimenticato che nel soggetto adulto si possano manifestare patologie espansive benigne, anche congenite, a primitiva localizzazione negli spazi fasciali profondi periviscerali, oppure in quelli sede delle principali stazioni linfoghiandolari del distretto testa-collo, il cui aspetto clinico-semeiologico è nella maggioranza dei casi del tutto aspecifico e pertanto pone seri problemi diagnostico-differenziali se non addirittura erronee diagnosi di natura. Viene quindi suggerito un razionale ricorso alla diagnostica per immagini TC e/o RM, tenuto conto che una corretta diagnosi differenziale di queste lesioni con effetto massa non può prescindere da una precisa identificazione dello spazio fasciale primitivo di origine e dall'analisi degli aspetti morfologici caratteristici, uniti a nozioni embriologiche, che possono aiutare ad escludere la natura maligna ed a formulare infine una corretta caratterizzazione etiologica, con ovvie conseguenze sulla prognosi e sulla pianificazione di un'idonea terapia.

Tandem internal carotid and middle cerebral artery occlusion after carotid dissection predicts poor outcome after systemic thrombolysis. Current treatments include the use of endovascular carotid stenting, which carries with it a high risk of propagating further embolic events and worsening the dissection. New strategies for avoiding the aforementioned side-effects include recanalization using cross-collaterals for delivery of intra-lesional tissue plasminogen activator (tPA). We present two cases that provide further support for this novel approach. Both patients presented with a National Institute of Health Stroke Scale of 20, received intra-arterial tPA via cross-collateralization, and made full recoveries without the need for stenting.

Spontaneous internal carotid artery dissection (sICAD) occurs annually in 2.5 to 3 per 100,000 presenting with signs of ischemic events in the majority of cases. In contrast, lower cranial nerve palsy due to peripheral nerve affection is seldom the presenting clinical sign. In symptomatic cases (>90%), sICAD is most commonly accompanied by local pain. We report a case of a 49-year old woman with a left sICAD presenting with isolated ipsilateral hypoglossal palsy as the sole clinical sign. Compared to other cases, local pain was absent and other cranial nerves were not affected. Further, sICAD could not be detected in repeated Doppler-/Duplex-sonography, but magnetic resonance imaging and MR-angiography only.

Drs. Child and Cascino are correct that their report of seizure-associated carotid artery dissection has …

Isolated behavioural disturbances can mimic psychiatric diseases and delay diagnosis of acute brain disease. We reported the case of a patient with carotid dissection manifesting only with apathetic syndrome that was initially considered as a possible postpartum depression, causing a threatening diagnostic delay.

A 37-year-old woman experienced a generalized tonic-clonic seizure. Subsequent to the seizure, the patient observed left-sided face and neck pain. A left Horner syndrome was noted on examination. An MRI and magnetic resonance angiogram revealed a left skull base carotid artery dissection without infarction (figure, A and B). Previous MRI had shown normal carotid flow voids. The patient was treated conservatively and magnetic resonance angiogram 1 month later revealed recanalization (figure, C).

Clinical presentation of carotid artery dissection (CAD) is variable, including acute or subacute headache, cervical pain, or focal neurologic deficit that occurs spontaneously, after a high-speed neck manipulation, or trauma. Isolated lower cranial nerve palsy in carotid dissection is uncommon.

In the vascular type of Ehlers-Danlos syndrome there is a defect in the synthesis of collagen type III, important constituent of the blood vessel wall, which may cause arterial rupture and dissection. We report a 15-year-old girl with a history of Ehlers-Danlos syndrome, who suffered an ischemic stroke secondary to dissection of the right internal carotid artery. She was managed conservatively with antiplatelet agents with a good clinical response.

BACKGROUND AND OBJECTIVE: Retinal artery occlusion from carotid dissection is rare and classically considered a post-traumatic phenomenon occurring in young patients and associated with additional symptoms of dissection such as neck pain, headache, or focal neurological deficits. PATIENTS AND METHODS: The authors report three cases of retinal artery occlusion due to carotid artery dissection and briefly review the literature. RESULTS: Antecedent trauma or neck injury was reported in only 42% (five of 12) of previously reported cases and in none of the three cases presented here. All three patients in this series initially denied symptoms such as headache or neck pain; however, one patient’s wife later recalled her husband experiencing minor neck soreness several days prior to visual loss. In 17% (two of 12) of previously reported cases, no additional symptoms of carotid dissection were reported. CONCLUSION: These cases highlight the importance of considering carotid dissection in young patients with retinal artery occlusion, even in the absence of a report of recent trauma or associated symptoms such as pain. [ Ophthalmic Surg Lasers Imaging Retina. 2013;44:555–650.]

Spontaneous dissection of the internal carotid artery is a leading cause of stroke and TIA, particularly in young patients. The antithrombotic treatment with or without an interventional procedure is a unanimously accepted indication for the prevention of the ischemic events in these patients. Whether anticoagulants or antiplatelets as antithrombotics are a better option is a matter of debate. The authors, based on clinical and pathophysiological data in the published studies and their own experience argue in favour of antiplatelets in most cases, without excluding the need of anticoagulants in some cases, due to the lack of objective proofs for the superiority of anticoagulants in this pathology and at the same time, a better safety profile of antiplatelets. To have a clear-cut answer to this debate, a large comparative randomized clinical trial between the two types of treatment is desirable.

A 58 year old man was involved in a high impact road traffic incident and was admitted for observation. Asymptomatic for the first 24 hours, he collapsed with symptoms and signs consistent with a cerebrovascular accident. Computed tomography angiogram (CTA) and Magnetic resonance angiogram (MRA) demonstrated bilateral internal carotid artery dissections and a left middle cerebral artery infarct. It was not considered appropriate to attempt stenting or other revascularistation. The patient was treated with heparin prior to starting warfarin. He made a partial recovery and was discharged to a rehabilitation facility. This case is a reminder of carotid dissection as an uncommon but serious complication of high speed motor vehicle accident, which may be silent initially. Literature Review suggests risk stratification before relevant radiological screening at risk patients. Significant advances in CTA have made it the diagnostic tool of choice, but ultrasound is an important screening tool.

Background Small clinical series have reported the safety of intravenous thrombolysis in ischemic stroke related to extracranial internal carotid dissection. However, no studies specifically analyzing the effects on stroke outcome are available. Aims Our goal was to evaluate whether patients with ischemic stroke related to extracranial internal carotid dissection obtain any benefit from intravenous thrombolysis. Methods Multicenter, prospective and observational study conducted in four university hospitals from the Madrid Stroke Network. Consecutive ischemic stroke patients who received intravenous thrombolysis were included, as well as patients with extracranial internal carotid dissection regardless of intravenous thrombolysis treatment. Stroke severity (NIHSS) and three-month outcome (modified Rankin Scale) were compared between the following groups: ( 1 ) intravenous thrombolysis-treated patients with ischemic stroke related to extracranial internal carotid dissection vs. other causes of stroke; ( 2 ) intravenous thrombolysis-treated extracranial internal carotid dissection patients vs. nonintravenous thrombolysis treated. Outcome was rated at three-months using the modified Rankin Scale. A good outcome was defined as a modified Rankin Scale score ≤2. Results A total of 625 intravenous thrombolysis-treated patients were included; 16 (2·56%) had extracranial internal carotid dissection. Besides, 27 patients with extracranial internal carotid dissection and ischemic stroke who did not receive intravenous thrombolysis were also included. As compared with other etiologies, patients with extracranial internal carotid dissection were younger, had similar stroke severity and showed less improvement in their NIHSS score at Day 7 (1·38; (95% CI −3·77 to 6·54) vs. 6·81; (95% CI −5·99 to 7·63) P=0·004), but without differences in good outcomes at three-months (43·8% vs. 58·2%; NS). Extracranial internal carotid dissection intravenous thrombolysis-treated patients had more severe strokes at admission than those who were nonintravenous thrombolysis treated (median NIHSS: 15 vs. 7; P=0·031). Intravenous thrombolysis was safe in extracranial internal carotid dissection with no symptomatic hemorrhagic events; however, without differences in good outcome compared with the natural course of extracranial internal carotid dissection (nonintravenous thrombolysis treated) after adjustment for stroke severity (46·7% vs. 64·3%; NS). Conclusions As compared with other etiologies, stroke due to extracranial internal carotid dissection seems to obtain similar benefits from intravenous thrombolysis in outcome at three-months. Although intravenous thrombolysis is safe in stroke attributable to extracranial internal carotid dissection, no differences in outcome were found when comparing intravenous thrombolysis treated with nonintravenous thrombolysis-treated patients, even after adjustment for stroke severity.

Internal carotid dissection most commonly presents as headache, focal neurological deficits or stroke. Rarely it can manifest itself by causing a palsy of the lower cranial nerves (IX, X, XI, XII). The reported incidence of isolated cranial nerve palsies is rare. We report a case of an internal carotid artery dissection manifesting as isolated XII (hypoglossal) cranial nerve palsy.

Background Though thyroid growths are considered to be a frequent cause of Horner's syndrome, concurrent headache attacks are not commonly seen. Case A 63-year-old woman presented with severe, daily occurring, unilateral headache attacks with ipsilateral Horner's syndrome. Magnetic resonance imaging arteriography showed a multinodular goiter displacing the left common carotid artery. Conclusion This case exemplifies the combination of headache attacks and Horner's syndrome due to mechanical pressure of an enlarged thyroid, mimicking the symptoms both of carotid dissection as well as trigeminal autonomic cephalgias like paroxysmal hemicrania.

Intracranial dissections have been associated with baroreceptor reflex failure. When this occurs labile hypertension may be observed with its own complications, including but not limited to the clinico-radiographic entity, posterior reversible encephalopathy syndrome (PRES). Case report and literature review. We describe a case of carotid dissection resulting in PRES. We believe failure of the baroreceptor reflex due to carotid dissection resulted in hypertension and subsequent posterior reversible encephalopathy syndrome.

International audience; PURPOSE: The early diagnosis of traumatic internal carotid artery dissection (TICAD) is essential for initiating appropriate treatment and improving outcome. We searched for criteria from transcranial Doppler (TCD) measurements on admission that could be associated with subsequent TICAD diagnosis in patients with traumatic brain injury (TBI). METHODS: We conducted a retrospective 1:4 matched (age, mean arterial blood pressure) cohort study of 11 TBI patients with TICAD and absent or mild brain lesions on initial CT scan, 22 TBI controls with comparable brain CT scan lesions (controls 1), and 22 TBI controls with more severe brain CT scan lesions (controls 2) on admission. TCD measurements were obtained on admission from both middle cerebral arteries (MCA). All patients had subsequent CT angiography to diagnose TICAD. RESULTS: A >25% asymmetry in the systolic blood flow velocity between the two MCA was found in 9/11 patients with TICAD versus 0/22 in controls 1 and 5/22 in controls 2 (p < 0.01). The combination of this asymmetry with an ipsilateral pulsatility index < or =0.80 was found in 9/11 patients with TICAD versus none in the two groups of controls (p < 0.01). CONCLUSIONS: Our results suggest that significant asymmetry in the systolic blood flow velocity between the MCAs and a reduced ipsilateral pulsatility index could be criteria from TCD measurements associated with the occurrence of TICAD in head-injured patients. If prospectively validated, these findings could be incorporated in screening protocols for TICAD in patients with TBI.

SummaryBlunt carotid injury associated with cervical spine fractures is a rare entity but potentially lethal. An initial, clinically silent period can be misleading. Prompt diagnosis and treatment are mandatory to avoid neurological damages and death. We present the case of a 36-year-old man diagnosed with an isolated cervical spine fracture, where an associated carotid artery lesion was initially overlooked and diagnosis was made after development of a neurological deterioration secondary to a posterior reversible encephalopathy syndrome (PRES). We discuss a simple algorithm that can be used to make the diagnosis, even during the clinically asymptomatic period of this injury.

Carotid trauma is always very serious. Post-traumatic carotid dissection is rather rare and can be diagnosed late. Authors present a case report of post-traumatic bilateral carotid dissection and its spontaneous recovery. Symptoms, diagnosis, and treatment are discussed.

Spontaneous dissection of the carotid artery was once considered uncommon, but nowadays neuroimaging progress has lead to an increased recognition of the pathology. It is an important cause of stroke in young patients, representing 10 to 25% of the cases1,2. Most patients affected are in the fifth decade of life2,3. It is not definitely established whether the cardiovascular risk factors are important in spontaneous carotid dissection; however, tobacco use, migraine and respiratory tract infections have been shown to be relevant [...]

Internal carotid artery (ICA) dissection with tandem internal carotid and middle cerebral artery occlusion may carry a poor prognosis even if intravenous recombinant-tissular plasminogen activator is administered. A better outcome may be expected with the combination of intravenous thrombolysis and endovascular methods (stenting and thromboaspiration). This procedure was performed in 3 patients who had concurrent ICA dissection and intracerebral occlusion. Endovascular treatment was feasible and safe. All our patients had a good clinical outcome. This potential effective approach may need further validation.

Background Traumatic extracranial carotid artery injuries are rare in children. Treatment options include surgery, anticoagulation therapy and endovascular treatment. There have been only limited reports in the literature documenting endovascular carotid stent placement in the pediatric population. In these reports, stent deployment was utilized in the setting of pseudoaneurysm formation. Case report Here we report a case of endovascular carotid stenting for traumatic carotid dissection in a 15 year-old boy. An uncovered bare self-expanding stent was used to treat progressive high-grade stenosis in the early post-injury period. Conclusion At 6 months post-procedure, complete healing of the carotid artery was demonstrated on follow-up angiogram.

e Abstract—Background: Carotid dissection (CD) is often overlooked as a concern in strangulation and choking cases. When the diagnosis is considered, the question remains what is the best means of evaluation, and which imaging study should be obtained. Objective: To evaluate the literature for evaluation of choking- and strangulation-related injuries and their association with CD. Discussion: This article will review the literature on blunt carotid injuries, with particular attention to subjects with choking and strangulation mechanisms of injury, and will include important physical findings, when and which radiographic evaluations are indicated, and treatment. Conclusion: Although rare, CD can occur after strangulation and choking. When suspected, evaluation should include imaging studies including computed tomography angiography. © 2011 Elsevier Inc.

To the Editor: We read with great interest the recent article by Dulay et al.1 The authors present a 49-year-old woman with a history of vasovagal syncope who lost consciousness because of a sinus arrest while she was being treated with intravenous tissue plasminogen activator for a stroke in the right middle cerebral artery territory involving the insular cortex. The stroke was due to a spontaneous dissection of the cervical …

We thank Dr Sarikaya and colleagues for their response to our image and case report on carotid dissection and profound bradycardia, and we welcome diversity of interpretation of the underlying mechanism of the observations.1 The profound progressive bradycardia observed was reminiscent of reflex bradycardia seen most often in vasovagal syncope and carotid sinus sensitivity. The patient’s history of vasovagal syncope in combination with local injury to the carotid bulb region …

We show magnetic resonance imaging, computed tomography-angiography, and ultrasound images of internal carotid artery dissection in a patient with acute ischemic stroke. Arterial changes occurring during the first few days were detected by serial ultrasound examinations. Neurologic and functional outcome are provided and therapeutic options discussed.

This case illustrates the importance of prompt investigation and management in a patient with localising physical signs. The significance of having the gene for Alports syndrome is unknown, but is of interest as this may have bearing on the aetiology of this patient’s diagnosis.

The clinical, duplex, and angiographic findings in six patients with seven spontaneous extracranial carotid artery dissections are reported. Four dissections resulted in internal carotid artery occlusion. These patients complained of ipsilateral headache followed by contralateral hemiplegia. The other three dissections involved the common carotid artery and resulted in dual (one true and one false) lumens. Two of these dissections were asymptomatic. All dissections were treated nonoperatively with anticoagulant therapy. Neurologic deficits improved or disappeared in all symptomatic patients. On follow-up studies, one of the four internal carotid occlusions completely resolved with normalization of the duplex examination. All three dual lumen dissections remained patent on serial studies. Diagnostic duplex characteristics, both conclusive and supportive, of carotid dissections are described. Duplex scanning is shown to be accurate in diagnosing and ideally suited for serially following spontaneous carotid dissections.