The Neuroradiology Journal 21: 275-278, 2008
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Spontaneous Bilateral Carotid Artery Dissection: Diagnosis and Follow-up with MDCT A Case Report
S. KURT*, B. SARIKAYA**, B. ACU**, H. KARAER*, M. MURAT FIRAT** * Neurology Department, ** Radiology Department, School of Medicine, Gaziosmanpasa University; Tokat, Turkey
Key words: CTA, dissection, young stroke, carotid artery
SUMMARY – Carotid artery dissection is usually unilateral. Rarely bilateral forms can be seen. Recent studies have shown the efficacy of computed tomography angiography (CTA) in the diagnosis of carotid dissection. Herein we report a case with bilateral carotid artery dissection diagnosis and follow-up which was carried out using mainly CTA.
Introduction Nearly 20 percent of ischemic events are related to carotid artery dissection in individuals younger than 45 years of age 1,2. Carotid artery dissection is usually unilateral. Rarely bilateral forms can be seen 1. Some papers report that magnetic resonance imaging (MRI), and MR angiography (MRA) are as sensitive as digital subtraction angiography (DSA) for the diagnosis of carotid artery dissection 3. Recent studies have shown the efficacy of computed tomography angiography (CTA) in the diagnosis of carotid dissection 4-6. Herein we report a case with bilateral carotid artery dissection diagnosis and follow-up of which was carried out using mainly CTA. To the best of our knowledge, this is the first bilateral dissection case diagnosed by CTA. Case Report A 40-year-old man without any illness or complaints felt a sudden weakness in his left arm during his lunch, and his speech deteriorated. The patient started to drag his left foot while walking. There was no associated headache nor did the patient complain of a neck pain. Noncontrast head CT obtained under emergency
conditions showed no significant abnormality, but a subacute infarct in the right parietal region was detected on MRI (figure 1). Within a week his speech, and gait improved, and he could even move his left arm a little. The patient was referred to our out-patient department and admitted to investigate the etiology of cerebrovascular disease (CVD). His vital signs were stable. His physical examination was unremarkable except neurological examination revealed left central facial paralysis, and left hemihypoesthesia. Muscular strength of the left proximal upper extremity was 3-/5, and of the distal upper extremity 0/5. Muscular strengths of other extremities were normal. Blood biochemistry and hematologic findings were within normal limits. Findings of coagulopathy, inflammation, or an autoimmune disease were not detected. His electrocardiographic, transthoracic echocardiographic, and PA chest X-ray examinations were normal. Retrospectively evaluated clinical and imaging modalities did not show any evidence of fibromuscular dysplasia (including renal arterial doppler ultrasonographic imaging). MDCT (multidetector computed tomography) angiography was performed in an 8 channel CT unit (GE medical systems, Milwaukee, WI, USA) using 100 ml of nonionic contrast medium via an automatic injector inserted into 275
Spontaneous Bilateral Carotid Artery Dissection: Diagnosis and Follow-up with MDCT
S. Kurt
Figure 1 Transverse T2W FLAIR image close to vertex demonstrating hyperintense ischemic area in the right parietal lobe.
A
B
Figure 2 Sagittal reformatted MIP (maximum intensity projection) images of the right (A) and left (B) carotid system.
an antecubital vein at a rate of 4 cc/s; with the parameters of 120 kV, 300 mA, collimation of 4×2.5 mm and a slice thickness of 2.5 mm. There were stenoses of both carotid arteries to some degree on raw images. Multiplanar reformatted images depicted stenosis of more than 90% in a 1-2 cm long segment approximately 3 276
cm distal to the origin of the right internal carotid artery (ICA), and thereafter ICA tapered distally. On the left side, stenosis of more than 90% in a 3 cm long segment was detected at approximately 7-8 cm distal to the origin of the left ICA, and distal ICA was of normal calibre (figure 2). Previously started antiaggregant
www. centauro. it
A
The Neuroradiology Journal 21: 275-278, 2008
B
Figure 3 DSA images (oblique lateral views) of the right (A) and left (B) carotid system.
A
B
Figure 4 Control CTA with sagittal reformatted MIP images of the right (A) and left (B) carotid system.
treatment was discontinued, and then anticoagulant therapy was initiated. CTA findings were confirmed with DSA (figure 3) performed after a couple of months that demonstrated considerable improvement as well. The patient enrolled in a rehabilitation program, and during follow-up muscular
strengths of the proximal and distal upper extremities increased to 4/5 and 3/5 respectively. Hemihypoesthesia improved, and left central facial paralysis decreased markedly. Control CTA manifested an improvement in the stenosis of right ICA, however left ICA did not demonstrate any significant recovery (figure 4). 277
Spontaneous Bilateral Carotid Artery Dissection: Diagnosis and Follow-up with MDCT
Discussion Carotid artery dissection is not a rarely seen entity in young adults 7. Based on two population based studies the annual incidence of ICA dissection is 2.6-2.9/100.000 8,9. Dissection is usually unilateral, and seen 80% on the right side 3. Bilateral dissection is a rare entity whose actual incidence is difficult to assess 1. In a large series of Schievink et Al which included 200 patients, bilateral ICA dissection was reported as 18 percent 10. The main predisposing factors are trauma, and primary vascular wall diseases like fibromuscular dysplasia 7. Still in an undeniable number of cases, dissection develops spontaneously 11. Influential factor(s) in spontaneous bilateral dissection remained enigmatic 1. Also in our patient no known risk factor was detected. Clinical characteristics of carotid artery dissection include unilateral headache, neck and eye pain, Horner syndrome, cranial nerve paralysis, and ischemic symptoms. Symptoms and signs are usually consistent with the localization of the lesion. In a study by Sturzenegger et Al conducted on 44 patients with spontaneous ICA, unilateral headache (68%), transient ischemic attack (20%), and cerebral infarct (9%) were reported 12. Stenosis, and thrombosis resulting from dissection lead to distal embolisation ending in emergence of ischemic stroke 7.
S. Kurt
Headache seen during dissection can be confused especially with migraine possibly leading to delayed diagnosis 13. Moreover in a published study, previous migrainous episodes were detected in 40% of the cases with ICA dissection, and in 24% of the controls 7. Headache was not the the most prominent symptom seen in our patient. Only findings of ischemia related to right carotid artery dissection were observed. As seen in the series of Schievink et Al only one dissecting artery was symptomatic even in cases with bilateral dissection 10. Recent publications reported equal diagnostic sensitivity for MRI, MRA and DSA in cases suspected of dissection 3. New state-of-the art multidetector CT machines provide improved visualization especially in the Z-axis. Therefore CTA is becoming increasingly used in various anatomic parts. In our case MDCT angiography was used in the diagnosis and follow-up of our patient. CTA revealed narrowing of the vascular lumen ICA dissection. In control CTA, improvement in vascular findings of the symptomatic artery was observed complying with clinical manifestations. CTA was effective both in diagnosis and follow-up of bilateral carotid artery dissections in our case. However to reach a universal comment studies with sufficient number of cases and literature review are needed in the future.
References 1 Townend BS, Traves L, Crimmins D: Bilateral spontaneous carotid artery dissection. J Clin Neurosci 12: 592-594, 2005. 2 Leys D, Lucas C, Gobert M et Al: Cervical artery dissections. Eur Neurol 37: 3-12, 1997. 3 Pakdemirli E, Usal D, Tali ET: Spontaneous bilateral internal carotid artery dissection with hypoglossal nerve palsy. Comput Med Imaging Graph 25: 373-378, 2001. 4 Robertson WC, Given CA: Spontaneous intracranial arterial dissection in the young: diagnosis by CT angiography. BMC Neurology 6: 16, 2006. 5 Elijovich L, Kazmi K, Gauvrit JY et Al: The emerging role of multidetector row CT angiography in the diagnosis of cervical arterial dissection: preliminary study. Neuroradiology 48: 606-612, 2006. 6 Ertl-Wagner B, Brüning R, Hoffmann RT et Al: Diagnostic evaluation of carotid artery stenoses with multislice CT angiography. Review of the literature and results of a pilot study. Radiologe 44: 960-966, 2004. 7 Stapf C, Elkind MS, Mohr JP: Carotid artery dissection. Annu Rev Med 51: 329-347, 2000. 8 Giroud M, Fayolle H, Andre N et Al: Incidence of internal carotid artery dissection in the community of Dijon. J Neurol Neurosurg Psychiatry 57: 1443, 1994. 9 Schievink WI, Mokri B, Whisnant JP: Internal carotid
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10 11 12 13
artery dissection in a community. Rochester, Minnesota, 1987-1992. Stroke 24: 1678-1680, 1993. Schievink WI, Mokri B, O’Fallon WM: Recurrent spontaneous cervical-artery dissection. N Engl J Med 330: 393-397, 1994. Cardon C, Diemont F, Julia P et Al: Bilateral carotid dissection and factor V mutation: a second case. Ann Vasc Surg 14: 503-506, 2000. Sturzenegger M: Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients. J Neurol 242: 231-238, 1995. Duyff RF, Snijders CJ, Vanneste JA: Spontaneous bilateral internal carotid artery dissection and migraine: a potential diagnostic delay. Headache 37: 109-112, 1997.
Semiha Kurt, MD Department of Neurology School of Medicine Gaziosmanpasa University 60100 Tokat, Turkey Tel.: +903562129500 Fax: +903562133179 E-mail: [email protected]
www. centauro. it
Spontaneous Bilateral Carotid Artery Dissection: Diagnosis and Follow-up with MDCT A Case Report
S. KURT*, B. SARIKAYA**, B. ACU**, H. KARAER*, M. MURAT FIRAT** * Neurology Department, ** Radiology Department, School of Medicine, Gaziosmanpasa University; Tokat, Turkey
Key words: CTA, dissection, young stroke, carotid artery
SUMMARY – Carotid artery dissection is usually unilateral. Rarely bilateral forms can be seen. Recent studies have shown the efficacy of computed tomography angiography (CTA) in the diagnosis of carotid dissection. Herein we report a case with bilateral carotid artery dissection diagnosis and follow-up which was carried out using mainly CTA.
Introduction Nearly 20 percent of ischemic events are related to carotid artery dissection in individuals younger than 45 years of age 1,2. Carotid artery dissection is usually unilateral. Rarely bilateral forms can be seen 1. Some papers report that magnetic resonance imaging (MRI), and MR angiography (MRA) are as sensitive as digital subtraction angiography (DSA) for the diagnosis of carotid artery dissection 3. Recent studies have shown the efficacy of computed tomography angiography (CTA) in the diagnosis of carotid dissection 4-6. Herein we report a case with bilateral carotid artery dissection diagnosis and follow-up of which was carried out using mainly CTA. To the best of our knowledge, this is the first bilateral dissection case diagnosed by CTA. Case Report A 40-year-old man without any illness or complaints felt a sudden weakness in his left arm during his lunch, and his speech deteriorated. The patient started to drag his left foot while walking. There was no associated headache nor did the patient complain of a neck pain. Noncontrast head CT obtained under emergency
conditions showed no significant abnormality, but a subacute infarct in the right parietal region was detected on MRI (figure 1). Within a week his speech, and gait improved, and he could even move his left arm a little. The patient was referred to our out-patient department and admitted to investigate the etiology of cerebrovascular disease (CVD). His vital signs were stable. His physical examination was unremarkable except neurological examination revealed left central facial paralysis, and left hemihypoesthesia. Muscular strength of the left proximal upper extremity was 3-/5, and of the distal upper extremity 0/5. Muscular strengths of other extremities were normal. Blood biochemistry and hematologic findings were within normal limits. Findings of coagulopathy, inflammation, or an autoimmune disease were not detected. His electrocardiographic, transthoracic echocardiographic, and PA chest X-ray examinations were normal. Retrospectively evaluated clinical and imaging modalities did not show any evidence of fibromuscular dysplasia (including renal arterial doppler ultrasonographic imaging). MDCT (multidetector computed tomography) angiography was performed in an 8 channel CT unit (GE medical systems, Milwaukee, WI, USA) using 100 ml of nonionic contrast medium via an automatic injector inserted into 275
Spontaneous Bilateral Carotid Artery Dissection: Diagnosis and Follow-up with MDCT
S. Kurt
Figure 1 Transverse T2W FLAIR image close to vertex demonstrating hyperintense ischemic area in the right parietal lobe.
A
B
Figure 2 Sagittal reformatted MIP (maximum intensity projection) images of the right (A) and left (B) carotid system.
an antecubital vein at a rate of 4 cc/s; with the parameters of 120 kV, 300 mA, collimation of 4×2.5 mm and a slice thickness of 2.5 mm. There were stenoses of both carotid arteries to some degree on raw images. Multiplanar reformatted images depicted stenosis of more than 90% in a 1-2 cm long segment approximately 3 276
cm distal to the origin of the right internal carotid artery (ICA), and thereafter ICA tapered distally. On the left side, stenosis of more than 90% in a 3 cm long segment was detected at approximately 7-8 cm distal to the origin of the left ICA, and distal ICA was of normal calibre (figure 2). Previously started antiaggregant
www. centauro. it
A
The Neuroradiology Journal 21: 275-278, 2008
B
Figure 3 DSA images (oblique lateral views) of the right (A) and left (B) carotid system.
A
B
Figure 4 Control CTA with sagittal reformatted MIP images of the right (A) and left (B) carotid system.
treatment was discontinued, and then anticoagulant therapy was initiated. CTA findings were confirmed with DSA (figure 3) performed after a couple of months that demonstrated considerable improvement as well. The patient enrolled in a rehabilitation program, and during follow-up muscular
strengths of the proximal and distal upper extremities increased to 4/5 and 3/5 respectively. Hemihypoesthesia improved, and left central facial paralysis decreased markedly. Control CTA manifested an improvement in the stenosis of right ICA, however left ICA did not demonstrate any significant recovery (figure 4). 277
Spontaneous Bilateral Carotid Artery Dissection: Diagnosis and Follow-up with MDCT
Discussion Carotid artery dissection is not a rarely seen entity in young adults 7. Based on two population based studies the annual incidence of ICA dissection is 2.6-2.9/100.000 8,9. Dissection is usually unilateral, and seen 80% on the right side 3. Bilateral dissection is a rare entity whose actual incidence is difficult to assess 1. In a large series of Schievink et Al which included 200 patients, bilateral ICA dissection was reported as 18 percent 10. The main predisposing factors are trauma, and primary vascular wall diseases like fibromuscular dysplasia 7. Still in an undeniable number of cases, dissection develops spontaneously 11. Influential factor(s) in spontaneous bilateral dissection remained enigmatic 1. Also in our patient no known risk factor was detected. Clinical characteristics of carotid artery dissection include unilateral headache, neck and eye pain, Horner syndrome, cranial nerve paralysis, and ischemic symptoms. Symptoms and signs are usually consistent with the localization of the lesion. In a study by Sturzenegger et Al conducted on 44 patients with spontaneous ICA, unilateral headache (68%), transient ischemic attack (20%), and cerebral infarct (9%) were reported 12. Stenosis, and thrombosis resulting from dissection lead to distal embolisation ending in emergence of ischemic stroke 7.
S. Kurt
Headache seen during dissection can be confused especially with migraine possibly leading to delayed diagnosis 13. Moreover in a published study, previous migrainous episodes were detected in 40% of the cases with ICA dissection, and in 24% of the controls 7. Headache was not the the most prominent symptom seen in our patient. Only findings of ischemia related to right carotid artery dissection were observed. As seen in the series of Schievink et Al only one dissecting artery was symptomatic even in cases with bilateral dissection 10. Recent publications reported equal diagnostic sensitivity for MRI, MRA and DSA in cases suspected of dissection 3. New state-of-the art multidetector CT machines provide improved visualization especially in the Z-axis. Therefore CTA is becoming increasingly used in various anatomic parts. In our case MDCT angiography was used in the diagnosis and follow-up of our patient. CTA revealed narrowing of the vascular lumen ICA dissection. In control CTA, improvement in vascular findings of the symptomatic artery was observed complying with clinical manifestations. CTA was effective both in diagnosis and follow-up of bilateral carotid artery dissections in our case. However to reach a universal comment studies with sufficient number of cases and literature review are needed in the future.
References 1 Townend BS, Traves L, Crimmins D: Bilateral spontaneous carotid artery dissection. J Clin Neurosci 12: 592-594, 2005. 2 Leys D, Lucas C, Gobert M et Al: Cervical artery dissections. Eur Neurol 37: 3-12, 1997. 3 Pakdemirli E, Usal D, Tali ET: Spontaneous bilateral internal carotid artery dissection with hypoglossal nerve palsy. Comput Med Imaging Graph 25: 373-378, 2001. 4 Robertson WC, Given CA: Spontaneous intracranial arterial dissection in the young: diagnosis by CT angiography. BMC Neurology 6: 16, 2006. 5 Elijovich L, Kazmi K, Gauvrit JY et Al: The emerging role of multidetector row CT angiography in the diagnosis of cervical arterial dissection: preliminary study. Neuroradiology 48: 606-612, 2006. 6 Ertl-Wagner B, Brüning R, Hoffmann RT et Al: Diagnostic evaluation of carotid artery stenoses with multislice CT angiography. Review of the literature and results of a pilot study. Radiologe 44: 960-966, 2004. 7 Stapf C, Elkind MS, Mohr JP: Carotid artery dissection. Annu Rev Med 51: 329-347, 2000. 8 Giroud M, Fayolle H, Andre N et Al: Incidence of internal carotid artery dissection in the community of Dijon. J Neurol Neurosurg Psychiatry 57: 1443, 1994. 9 Schievink WI, Mokri B, Whisnant JP: Internal carotid
278
10 11 12 13
artery dissection in a community. Rochester, Minnesota, 1987-1992. Stroke 24: 1678-1680, 1993. Schievink WI, Mokri B, O’Fallon WM: Recurrent spontaneous cervical-artery dissection. N Engl J Med 330: 393-397, 1994. Cardon C, Diemont F, Julia P et Al: Bilateral carotid dissection and factor V mutation: a second case. Ann Vasc Surg 14: 503-506, 2000. Sturzenegger M: Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients. J Neurol 242: 231-238, 1995. Duyff RF, Snijders CJ, Vanneste JA: Spontaneous bilateral internal carotid artery dissection and migraine: a potential diagnostic delay. Headache 37: 109-112, 1997.
Semiha Kurt, MD Department of Neurology School of Medicine Gaziosmanpasa University 60100 Tokat, Turkey Tel.: +903562129500 Fax: +903562133179 E-mail: [email protected]
