Atherosclerosic Dissection of the Cervical Internal Carotid Artery — A Case
Report
P. De Baets, M.D.* G. Delanote, M.D. ** G. Jackers, M.D.** P. De Puydt, M.D.***
and G.
Wilms, M.D., F.I.C.A.*
LEUVEN and
OOSTENDE, BELGIUM
Abstract Atherosclerosis as a cause of spontaneous dissection in the cervical internal carotid arteries has been described in only a few cases. The authors present a surgically and pathologically proven case of dissection on the base of atherosclerosis of the cervical internal carotid artery. A resection of the pathologic segment with arterial reconstruction by direct anastomosis with a venous patch graft was performed. The postoperative course was uneventful. Introduction
Dissections of the cervical internal carotid arteries (CICA) occur either spontaneously or posttraumatically and constitute an uncommon entity within the cerebrovascular occlusive diseases. These dissections may remain undiagnosed because of the variable clinical symptoma.tology. Their frequency has been underestimated because the lesions were not explored surgically as a consequence of their often benign evolution and of the difficult approach to the lesions. Now more cases are recognized by the increased use of digital subtraction angiography and the better definition of the angiographic signs of dissections. Atherosclerosis as a cause of spontaneous dissection in the CICA has been described in only a few cases. We present a surgically and pathologically proven case of dissection on the base of atherosclerosis of the cervical internal carotid artery.
From the *Department of Radiology, University Hospitals K.U. Leuven; **Department of Radiology, St. Jozefskliniek Oostende; and ***Department of Vascular Surgery, St. Jozefkliniek, Oostende, Belgium
161 Downloaded from ang.sagepub.com at Purdue University on June 8, 2015
162 ’
Case A
Report seventy-three-year old man, with a long-standing history of angina pectoris and hypertension, developed sudden neck pain with right hemiparesis, without facial paresis or aphasia, and with disappearing of the symptoms in thirty minutes. There was no history of head or neck trauma. Neurologic examinations on admission were normal. On auscultation a left-sided carotid bruit was detected. A computed tomographic (CT) brain scan showed no anomalies. Doppler flow studies demonstrated a high-grade stenosis of the left internal carotid artery, and on the second day after admission bilateral carotid and aortic arch angiography was performed. A marked stenosis of the left internal carotid artery close to the bifurcation and an irregular outpouching of contrast at this level were demonstrated (Fig. 1). A diagnosis was made of transient ischemic attacks associated with a dissection on atherosclerosis of the left CICA. A resection of the pathologic segment with arterial reconstruction by direct anastomosis with a venous patch graft was performed. Pathologic examination revealed an erosion of the intima by necrosis from an atheromatous plaque together with dissection in the media of the wall of the left internal carotid artery. The postoperative course was uneventful. Discussion
Blunt or penetrating trauma is the most frequent etiology of dissection of the extracranial carotid arteries, with motor vehicle accidents and direct percutaneous carotid angiography, respectively, as the most frequent causes.’ Spontaneous dissections of the cervical carotid arteries are rare and usually occur in middle-aged persons. Cystic media necrosis, fibromuscular dysplasia, arteritis, and atherosclerosis are predisposing factors to spontaneous dissections.2 These factors can lead to bleeding in the vessel wall, usually the tunica media, followed
Ftc. 1. Selective left carotid carotid artery. B-D. Progressive
angiogram (right anterior oblique projection). A. High-degree stenosis of the right internal irregular and local extravasation of contrast material.
Downloaded from ang.sagepub.com at Purdue University on June 8, 2015
163
by dissection of the vessel wall.
In the case of atherosclerosis the dissections originate from an erosion or rupture of the intima in a focus of necrotic atheromatous material, which results in dissection of the media of the blood vessel.3 Whether these dissections are truly nontraumatic is a question that remains unanswered. Hyperextension of the neck, head banging, and heavy coughing could be initiating factors for the disruption of the intima, and it is possible that such injuries remain unrecognized.5’6 The internal carotid arteries are most commonly involved in the dissection, but cases affecting the vertebral artery, inferior thyroid artery, and common carotid artery are also described.2’4 The neurologic manifestations are determined by the extent of the dissection, the presence of other cerebrovascular disease, and the presence of collateral circulation.’ A sudden, diffuse neck pain or headache is the first symptom in 50% of the cases.5 Transient monocular blindness or a subjective bruit is also common. A Horner syndrome occurs in those cases with involvement of the periarterial sympathetic plexus. Hemiplegia, with or without aphasia, occurs frequently and is caused by either stenosis or occlusion of the blood vessel or intracra2 nial embolism. The angiographic signs are variable’: irregular narrowing of the internal carotid artery, starting 2-3 cm above the bifurcation (string sign); a tapering occlusion in about 20% of the cases (rat-tail appearance); small, localized dissections over 2-3 cm; pseudoaneurysmatic dilatation (in case of communication between false and true lumen) with an intraluminal defect, corresponding to the displaced intima; and saccular aneurysms. 2,5,6
The natural course of the disease is often benign, and full restoration of the permeability of the vessel can be seen on follow-up angiography, explaining the reluctance to perform invasive therapeutic measures. Therapy usually consists of corticosteroids for pain relief and heparin or aspirin for anticoagulation.5 The role of surgery remains controversial. It is seldom performed, because of the extent of, and the difficult approach to, the lesions. In our case it was indicated because of the high grade of stenosis and the short extent of the dissection. G. Wilms, M.D., F.I. C.A.
Department of Radiology University Hospitals K. U. Herestraat 49 B-3000 Leuven,
Leuven
Belgium
References 1.Luken MG, et al: Spontaneous dissecting aneurysms of the extracranial internal carotid artery. Clin Neurosurg 26:353-375, 1979. 2. Bradac GB, Kaerbnach A, Bolk-Weischedel D,et al: Spontaneous dissecting aneurysms of cervical cerebral arteries. Neuroradiology 21:149-154, 1981. 3. Brown OL, Armitage JL: Spontaneous dissecting aneurysms of the cervical internal carotid artery. AJR 118:648-673, 1973. 4. Spudis EV, et al: Dissecting aneurysms in the neck and
head.
Neurology 12:867,
1962.
5. Vanneste JAL, Davies G: Spontaneous dissection of the cervical internal carotid artery. Clin Neurol Neurosurg 86:307-314, 1984. 6. Fisher CM, Ojemann RG, Roberson GH: Spontaneous dissection of the cervico-cerebral arteries. Can J Neurol Sci 5:9-19, 1978. 7. Marx A, Busse O: "Spontane" dissektionen himversorgender arterien. Angio 9:247-261, 1987.
Downloaded from ang.sagepub.com at Purdue University on June 8, 2015
Report
P. De Baets, M.D.* G. Delanote, M.D. ** G. Jackers, M.D.** P. De Puydt, M.D.***
and G.
Wilms, M.D., F.I.C.A.*
LEUVEN and
OOSTENDE, BELGIUM
Abstract Atherosclerosis as a cause of spontaneous dissection in the cervical internal carotid arteries has been described in only a few cases. The authors present a surgically and pathologically proven case of dissection on the base of atherosclerosis of the cervical internal carotid artery. A resection of the pathologic segment with arterial reconstruction by direct anastomosis with a venous patch graft was performed. The postoperative course was uneventful. Introduction
Dissections of the cervical internal carotid arteries (CICA) occur either spontaneously or posttraumatically and constitute an uncommon entity within the cerebrovascular occlusive diseases. These dissections may remain undiagnosed because of the variable clinical symptoma.tology. Their frequency has been underestimated because the lesions were not explored surgically as a consequence of their often benign evolution and of the difficult approach to the lesions. Now more cases are recognized by the increased use of digital subtraction angiography and the better definition of the angiographic signs of dissections. Atherosclerosis as a cause of spontaneous dissection in the CICA has been described in only a few cases. We present a surgically and pathologically proven case of dissection on the base of atherosclerosis of the cervical internal carotid artery.
From the *Department of Radiology, University Hospitals K.U. Leuven; **Department of Radiology, St. Jozefskliniek Oostende; and ***Department of Vascular Surgery, St. Jozefkliniek, Oostende, Belgium
161 Downloaded from ang.sagepub.com at Purdue University on June 8, 2015
162 ’
Case A
Report seventy-three-year old man, with a long-standing history of angina pectoris and hypertension, developed sudden neck pain with right hemiparesis, without facial paresis or aphasia, and with disappearing of the symptoms in thirty minutes. There was no history of head or neck trauma. Neurologic examinations on admission were normal. On auscultation a left-sided carotid bruit was detected. A computed tomographic (CT) brain scan showed no anomalies. Doppler flow studies demonstrated a high-grade stenosis of the left internal carotid artery, and on the second day after admission bilateral carotid and aortic arch angiography was performed. A marked stenosis of the left internal carotid artery close to the bifurcation and an irregular outpouching of contrast at this level were demonstrated (Fig. 1). A diagnosis was made of transient ischemic attacks associated with a dissection on atherosclerosis of the left CICA. A resection of the pathologic segment with arterial reconstruction by direct anastomosis with a venous patch graft was performed. Pathologic examination revealed an erosion of the intima by necrosis from an atheromatous plaque together with dissection in the media of the wall of the left internal carotid artery. The postoperative course was uneventful. Discussion
Blunt or penetrating trauma is the most frequent etiology of dissection of the extracranial carotid arteries, with motor vehicle accidents and direct percutaneous carotid angiography, respectively, as the most frequent causes.’ Spontaneous dissections of the cervical carotid arteries are rare and usually occur in middle-aged persons. Cystic media necrosis, fibromuscular dysplasia, arteritis, and atherosclerosis are predisposing factors to spontaneous dissections.2 These factors can lead to bleeding in the vessel wall, usually the tunica media, followed
Ftc. 1. Selective left carotid carotid artery. B-D. Progressive
angiogram (right anterior oblique projection). A. High-degree stenosis of the right internal irregular and local extravasation of contrast material.
Downloaded from ang.sagepub.com at Purdue University on June 8, 2015
163
by dissection of the vessel wall.
In the case of atherosclerosis the dissections originate from an erosion or rupture of the intima in a focus of necrotic atheromatous material, which results in dissection of the media of the blood vessel.3 Whether these dissections are truly nontraumatic is a question that remains unanswered. Hyperextension of the neck, head banging, and heavy coughing could be initiating factors for the disruption of the intima, and it is possible that such injuries remain unrecognized.5’6 The internal carotid arteries are most commonly involved in the dissection, but cases affecting the vertebral artery, inferior thyroid artery, and common carotid artery are also described.2’4 The neurologic manifestations are determined by the extent of the dissection, the presence of other cerebrovascular disease, and the presence of collateral circulation.’ A sudden, diffuse neck pain or headache is the first symptom in 50% of the cases.5 Transient monocular blindness or a subjective bruit is also common. A Horner syndrome occurs in those cases with involvement of the periarterial sympathetic plexus. Hemiplegia, with or without aphasia, occurs frequently and is caused by either stenosis or occlusion of the blood vessel or intracra2 nial embolism. The angiographic signs are variable’: irregular narrowing of the internal carotid artery, starting 2-3 cm above the bifurcation (string sign); a tapering occlusion in about 20% of the cases (rat-tail appearance); small, localized dissections over 2-3 cm; pseudoaneurysmatic dilatation (in case of communication between false and true lumen) with an intraluminal defect, corresponding to the displaced intima; and saccular aneurysms. 2,5,6
The natural course of the disease is often benign, and full restoration of the permeability of the vessel can be seen on follow-up angiography, explaining the reluctance to perform invasive therapeutic measures. Therapy usually consists of corticosteroids for pain relief and heparin or aspirin for anticoagulation.5 The role of surgery remains controversial. It is seldom performed, because of the extent of, and the difficult approach to, the lesions. In our case it was indicated because of the high grade of stenosis and the short extent of the dissection. G. Wilms, M.D., F.I. C.A.
Department of Radiology University Hospitals K. U. Herestraat 49 B-3000 Leuven,
Leuven
Belgium
References 1.Luken MG, et al: Spontaneous dissecting aneurysms of the extracranial internal carotid artery. Clin Neurosurg 26:353-375, 1979. 2. Bradac GB, Kaerbnach A, Bolk-Weischedel D,et al: Spontaneous dissecting aneurysms of cervical cerebral arteries. Neuroradiology 21:149-154, 1981. 3. Brown OL, Armitage JL: Spontaneous dissecting aneurysms of the cervical internal carotid artery. AJR 118:648-673, 1973. 4. Spudis EV, et al: Dissecting aneurysms in the neck and
head.
Neurology 12:867,
1962.
5. Vanneste JAL, Davies G: Spontaneous dissection of the cervical internal carotid artery. Clin Neurol Neurosurg 86:307-314, 1984. 6. Fisher CM, Ojemann RG, Roberson GH: Spontaneous dissection of the cervico-cerebral arteries. Can J Neurol Sci 5:9-19, 1978. 7. Marx A, Busse O: "Spontane" dissektionen himversorgender arterien. Angio 9:247-261, 1987.
Downloaded from ang.sagepub.com at Purdue University on June 8, 2015
