Search

Symptomatic carotid dissection following repair of a proximal aortic arch dissection has been successfully diagnosed by noninvasive ultrasonic duplex scanning. Angiographic confirmation, follow-up examinations by duplex scanner, and conservative management with heparin anticoagulation and tight blood pressure control are discussed. The differing etiologies and potential neurologic complications following aortic root dissection vs. spontaneous cervical carotid dissection are considered with a review of the current literature. Although diagnosis can be achieved through arteriography, the combined modalities of duplex scanning allow evaluation of both anatomic and hemodynamic factors. Conservative therapy may prove the most appropriate mode of management in these neurologically unstable patients. (J VASC SURG 1984;1:700-3.)

A rare case of malignant fibrous histiocytoma of the cervical carotid artery is presented. Erosion of the vessel wall by this neoplasm resulted in dissection and pseudoaneurysm formation. The etiology and diagnosis of and the therapeutic alternatives for this unique disorder are discussed briefly. (Neurosurgery 21:571-574, 1987)

A 44-year-old woman developed a left cerebral infarction secondary to internal carotid artery dissection 6 days after childbirth. A cesarean section had been carried out after 14 hours of strenuous unsuccessful labor. Although in the past some authors have implicated oral contraceptives as a cause for carotid dissection, carotid dissection associated with childbirth has not been previously described.

✓ A case of spontaneous carotid artery dissection is presented. In the case described, superficial temporal artery-middle cerebral artery anastomosis was performed because of impending stroke. Surgical revascularization is indicated in a case that shows such a rapid evolution of stroke that spontaneous resolution of the dissection cannot be awaited.

• We describe five patients with angiographic features of dissecting aneurysm of the cervical portion of the internal carotid artery who were seen initially with unilateral headaches and ipsilateral oculosympathetic paresis. This combination of symptoms is a rather common mode of manifestation of this entity.

Technical factors and surgical techniques in carotid endarterectomy remain a controversial subject. The use of an indwelling arterial shunt has theoretical advantages in assuring intraoperative hemispheric perfusion and affording a more relaxed surgical environment. There has been little clinical demonstration, however, of superior results with carotid shunting. Although champions of routine shunting argue that it is a benign protective intervention, the possibilities of distal embolization or intimal disruption exist. The authors report a case of cervical carotid dissection far distal to the operative site that they postulate resulted from intimal disruption after routine shunt placement. This devastating complication from an otherwise benign procedure prompts reconsideration of the benefits and risks of routine shunt placement.

Pseudoaneurysm formation following gunshot wounds is associated with significant morbidity. The natural history and optimal follow-up strategy for penetrating injuries causing dissection remains poorly understood. We report a case of a giant compressive pseudoaneurysm that developed following recanalization of an occlusive internal carotid artery dissection sustained from a gunshot wound. This was detected on routine follow-up imaging six weeks later. The patient subacutely developed dysphagia and hoarseness initially felt to be caused by delayed injury to the laryngeal nerve because computed tomography angiography demonstrated no new pathology. The pseudoaneurysm was successfully treated using a covered stent graft. This case highlights the importance of close angiographic follow-up even in the setting of initial complete vessel occlusion, and the need for a high suspicion for pseudoaneurysm development in the setting of new compressive or neurologic symptoms in patients with potential vascular injury from gunshot wounds to the neck.

We followed 2 patients with extracranial internal carotid dissection and associated occlusion or preocclusive stenosis with serial magnetic resonance and carotid duplex examinations. These studies demonstrated progressive anatomic resolution in both cases.

A l'autopsie d'un garcon de 15 ans la cause de la mort est determinee: anevrysme dissequant de la carotide interne gauche. La veille de l'hospitalisation pour des troubles neurologiques de types ictus, le jeune malade avait assiste a une soiree de rock ou pendant des heures il avait agite vigoureusement la tete d'avant en arriere selon le rythme rapide; ces secousses sont considerees comme les causes directes de la dissection

SYNOPSIS The clinical features of the headache and neck pain in 21 cases of spontaneous carotid dissection are described. Twenty of 21 patients had head pain or headache and of the 20, 12 had neck pain as well. One patient had neck pain only. Typically, the headache involved the ipsilateral forequarter of the head and neck pain was of local origin in the region of the upper few inches (10 cm.) of the internal carotid artery. Recognition of the headache as a prodromal manifestation may lead to prevention of a stroke through the use of anticoagulation.

Internal carotid artery (ICA) dissection is a cause of stroke, but it is often underdiagnosed in children. ICAs’ risk factors and pathogenic mechanisms are poorly understood, and the treatment is still empirical. We report the case of a previously healthy 9-year-old girl who presented with involuntary hypertonic closure of the right hand associated with transient difficulty for both fine movements of the right arm and speech. She had a history of minor cervical trauma occurring 20 days prior to our observation without other associated risk factors. Magnetic resonance imaging and magnetic resonance angiography showed ischemic lesions due to the left ICA dissection. Treatment with both acetylsalicylic acid and levetiracetam allowed recanalization of the ICA associated with the resolution of clinical signs. Our clinical case suggests that the ICA dissection must be suspected early whenever a child manifests mild neurologic deficits after a cervical trauma, especially if they are associated with headache and/or cervical pain. Moreover, the management of ICA dissection must be improved.

A 15-year-old girl died 14 days after hemiplegia suddenly developed. On arteriography, intimal separation of the middle cerebral arteries showed as a long attenuated column of dye--the "string" sign. Pathologic examination showed intimal separation starting at the distal bifurcation of the right internal carotid artery and extending into the middle and anterior cerebral arteries. The arteriographic string sign as evidence of dissection may aid diagnosis of this cause of childhood hemiplegia.

Dr Saper has gathered information that heretofore has been scattered in various texts and journals. To this he adds insight derived from personal experience. The result is an enlightening compilation of the current views on headaches and their management. As the primary author, he successfully combines his own writings with contributions of others to present a broad spectrum of issues. Headache disorders receiving extensive coverage include migraine, cluster, muscle contraction, mixed (migraine and muscle contraction), and post-traumatic headache syndromes. Among other more recently described precipitating causes presented are pericarotid syndromes, headache and cerebrovascular disease, postendarterectomy headache, empty sella headache, spontaneous carotid dissection, and dialysis headache. Relatively new advances, such as the use of oxygen in the treatment of cluster headaches, are included among the various drug therapies. While information on the treatment of headaches with drugs is complete, Dr Saper expresses concern about excessive medication by devoting an entire chapter

In Reply. —Dr Kushner is correct that the natural prognosis of carotid dissection is poorly known. This is due to the fact that it can yield extremely varied disturbances, from isolated mild headaches or Horner's syndrome to rapidly lethal stroke; conditions in which angiography is unlikely to be performed, so that carotid dissection may not be recognized. For this reason, we have chosen to focus our study on a particular subgroup of patients (those with stroke and a picture of carotid occlusion during the acute phase), in which a selection bias is less likely to occur, because of our referral pattern that was made explicit in our article. Of course, we did not extend our conclusions to dissection with minor symptoms, such as transient ischemic attacks or headaches; this has already been emphasized in the article. Our findings on prognosis are less optimistic than Dr Kushner and we would have liked, but

Introduction Magnetic resonance imaging is now frequently used to image blood vessels. This case illustrates a pitfall of this mode of imaging. Report A 6-year-old girl sustained a severe neck injury and subsequently developed a Horner's syndrome. A time-of-flight magnetic resonance scan could be interpreted by the inexperienced as showing an extensive dissection. However, a contrast-enhanced scan confirmed the presence of a localised carotid injury only. Discussion Time-of-flight magnetic resonance scanning produces flow voids which can mimic dissection, particularly in high velocity vessels such as the carotid artery. This case is a reminder that whatever imaging modality is used, correct interpretation is essential.

A case of internal carotid artery dissection in a pregnant woman with Systemic Lupus Erythematosus (SLE) immediately following chiropractic treatment is presented. The literature regarding complications of neck manipulation during pregnancy, spontaneous dissection of craniocervical arteries in pregnancy and the postpartum period, and dissection of craniocervical arteries in SLE are reviewed. To the best of the author’s knowledge, this is the first case of carotid artery dissection following chiropractic treatment in a pregnant woman published in the literature.