Case Report Surgical Treatment of Localized Dissection of the Internal Carotid Artery Didem M. Oztas,1 Murat Ugurlucan,1 Omer A. Sayin,1 Mehmet Barburoglu,2 Serra Sencer,2 Ufuk Alpagut,1 and Enver Dayioglu,1 Istanbul, Turkey
Dissection of the internal carotid artery is very rare; however, it is diagnosed more frequently with increasing radiographic diagnostic tools. Patients may be completely asymptomatic or may present with symptoms ranging between localized pain to severe cerebral ischemic events. Treatment is usually medical or with interventional radiographic tools. In this report, we present surgical management of internal carotid artery dissection in a 61-year-old female patient.
Dissection of the internal carotid artery (ICA) is a very rare pathology with an incidence of 2.5e3 per 100,000 in different series.1 It is an important etiology of stroke in young adults and has been found with increasing frequency in recent years. It can occur either spontaneously or secondary to trauma and patients may present with different symptoms as being completely asymptomatic or with serious hemiplegia.2 Mortality rate of intracranial carotid dissection is 75% and it is 10% when there is extracranial presentation.3 It may also result in neurological morbidity. The disease is responsible for 2% of all ischemic strokes. It is an important factor especially in the young population, and accounts for approximately 20% of strokes in patients less than 45 years of age.4 Extracranial ICA dissections are more common than intracranial dissections. It is because intracranial arteries have thinner media and adventitial layers;
however, intracranial ICA dissections have higher risk of subarachnoid hemorrhage, hence higher mortality and morbidity rates.5 Neurological outcome is worse in traumatic cervical artery dissections and it is thought to be related to dissection-induced ischemic stroke or associated traumatic lesions.6 More than half of the patients with spontaneous carotid artery dissection develop a stroke, so as till 58% of patients with dissection after a trauma have lasting neurological problems. They have a higher mortality rate compared with patients who have spontaneous carotid artery dissection. Also, the difference between mortality for intracranial carotid dissection and extracranial carotid dissection is relevant.7 In this case report, we present a 61-year-old woman with isolated left ICA dissection together with the management strategy of the disorder. The patient consented to publication.
1 Department of Cardiovascular Surgery, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.
CASE REPORT
2 Department of Radiology, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.
A 61-year-old female patient presented to the clinic with acute onset of severe head and neck pain. She was an active smoker and hypertensive. Doppler ultrasonography of the neck revealed atherosclerotic plaques in the left common carotid and internal carotid arteries as well as dissection at the left ICA. Pathology was further confirmed with computerized tomography angiography, which revealed dissection of the ICA confining to the proximal segment at the carotid bulb (Fig. 1). The patient
Correspondence to: Murat Ugurlucan, Bozkurt Caddesi, No: 110112, Benli Apartmani, Daire: 6, 80250 Kurtulus, Istanbul, Turkey; E-mail: [email protected] Ann Vasc Surg 2015; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2015.01.015 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: December 2, 2014; manuscript accepted: January 8, 2015; published online: ---.
1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Computerized tomography angiography showing dissection of the internal carotid artery confined to the proximal segment at the carotid bulb.
Fig. 2. (A) The localized dissection inside the internal carotid artery and atherosclerotic plaques in the internal and common carotid arteries are seen perioperatively. CCA, common carotid artery; ICA, internal
carotid artery. (B) Excised atherosclerotic endarterectomy material comprising the internal carotid artery dissection. CCA, common carotid artery; ICA, internal carotid artery.
did not define history of trauma, infection, or any vasculitis syndrome affecting the arterial system. Immediate surgical treatment was planned because of the symptoms of the patient and to prevent neurologic events following the consent of the patient. The operation was performed with regional anesthesia, and infiltration anesthesia with 50% mixture of prilocaine hydrochloride and bupivacaine hydrochloride was injected if the patient complained of pain or discomfort. A standard incision parallel to the sternocleidomastoid muscle was performed. The left common, internal, and external carotid arteries were dissected. A saphenous vein segment was harvested from the right leg with local anesthesia. Neurological status of the patient did not alter when the arteries were clamped for 3 min and a longitudinal arteriotomy was performed from the common carotid artery to ICA. The localized dissection inside the ICA was observed (Fig. 2). Endarterectomy from ICA extending to the common carotid artery was performed. Arterial reconstruction was performed with autologous saphenous vein graft patch (Fig. 3).
The postoperative course was uneventful and the patient was discharged symptom free from the hospital on the second postoperative day. She has been doing well for 6 months and receives acetylsalicylic acid, atorvastatin, pentoxifylline, clopidogrel, and beta-blockers.
DISCUSSION AND CONCLUSION Carotid artery dissections are very rare. The extracranial segment of the ICA is the most commonly involved and the intracranial part is very seldom for the origin of the dissection. ICA dissections are seen in young- to middle-aged population mostly. There is no sex predominance.8 Patients may be asymptomatic or present to the clinic with various symptoms associated with expansion of mural hematoma, which compresses nearby structures,9 such as headache, tinnitus, Horner’s syndrome, facial/neck pain, contralateral limb weakness,
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2015
Fig. 3. Both internal and external carotid arteries were reconstructed with autologous venous patches. CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery.
retinal ischemic events, or cerebral ischemic symptoms. Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography, and conventional angiography can be used for the diagnosis of the pathology. Treatment modalities involve medical therapy, endovascular treatment, or surgery. Generally, surgical revascularization is rarely performed when there are persisting highgrade stenosis and persisting or newly developed aneurysm of the dissected internal carotid after a medical treatment of 6 months to prevent recurrent ischemic or thromboembolic neurologic damage.10 Carotid artery dissections can occur spontaneously or may have a traumatic etiology. As extrinsic factors, traumatic neck injury, manipulation of the neck during examinations, physiotherapy for the cervical spine, and intentional or unintentional high-range rotations may be recalled. Intrinsic factors include systemic vascular disorders or vasculotides including vascular anomalies or genetic predisposing factors such as hyperhomocysteinemia, alpha 1 antitrypsin deficiency, and connective tissue disorders such as Marfan’s syndrome, EhlereDanlos syndrome, or cystic medial necrosis. In addition, infections, smoking, diabetes mellitus, hypertension, hypercholesterolemia, and contraceptive pill use may be accounted as various other intrinsic etiological factors.3 In the presence of carotid artery dissection, the false lumen may result in stenosis, occlusion, or pseudoaneurysm of the involved vessel.11 ICA dissections cause cortical infarcts or large subcortical infarcts; small subcortical infarcts and junctional infarcts are rare. These infarcts are thought to be embolic rather than of hemodynamic origin.12 Because of the risk of cerebral ischemia, early diagnosis and treatment of carotid dissections are critical.
Case Report 3
Treatment modalities include medical therapy, endovascular therapy, and surgical revascularization. Anticoagulation or antiplatelet agents are used in medication. Endovascular therapy can be offered as a minimally invasive and a safe alternative.13 However, surgical treatment is still the gold standard for atherosclerotic carotid artery disease. Endarterectomy, resection of the injured segment, carotid ligation, and extracranialeintracranial bypass techniques are used for surgical revascularization.11 In case of aneurysm and/or stenosis, acute intervention should be considered as an indication for surgery.10 On the other hand, some authors advocate the medical therapy as first stage therapy for 6 months but the risk of stroke is still significant.14 Additionally, in case of an extended dissection, that is, intimal tear originating at the orifice of the ICA and medial layer separation reaching to the intracranial levels, long-segment stenting of the ICA may be more appropriate.15 Our patient had severe headache and pain localized at the left side of the neck, which was found to be because of ICA dissection with Doppler ultrasonography and computerized tomography angiography. Interestingly, the dissected segment was confined to the orifice of the ICA and did not extend beyond. It was not a primary dissection of the smooth vessel wall, as is usual for post-traumatic or spontaneous dissection etiologies, apparently. We determined atherosclerotic plaques which complicated with the dissection of the arterial wall. Because there were atherosclerotic plaques at the region, we preferred surgical treatment rather than carotid stenting. In conclusion, dissection of the ICA is very rare. In severely symptomatic patients, an intervention should be considered as a fast therapy to prevent ischemic and thromboembolic complications and symptoms of cerebral hypoperfusion as well as local compression, and in this report we present successful surgical treatment of localized ICA dissection.
REFERENCES 1. Schievink WI, Mokri B, Whisnant JP. Internal carotid artery dissection in a community. Rochester, Minnesota, 19871992. Stroke 1993;24:1678e80. 2. Rao AS, Makaroun MS, Marone LK, et al. Long-term outcomes of internal carotid artery dissection. J Vasc Surg 2011;54:370e4. discussion 375. 3. Salvati B, Tesori MC, Lombardo F, et al. Surgical treatment of spontaneous common carotid dissection: a case report. Ann Ital Chir 2014;85. 4. Redekop GJ. Extracranial carotid and vertebral artery dissection: a review. Can J Neurol Sci 2008;35:146e52.
4 Case Report
5. Mahawish K, Durairaj R, Sharma AK. Intracranial carotid artery dissection. Postgrad Med J 2010;86:190. 6. Nedeltchev K, Baumgartner R. Traumatic cervical artery dissection. In: Baumgartner RW, Bogousslavsky J, Caso V, et al. eds. Handbook on Cerebral Artery Dissection. Frontiers of Neurology and Neuroscience, Vol. 20. Basel: Karger, 2005. pp 54e63. 7. Data from Cleveland Clinic. Available at: http://my. clevelandclinic.org/services/heart/disorders/hic_Carotid_Art ery_Disease/Carotid-Artery-Dissection. Accessed January 1, 2015. 8. Mas JL. Internal carotid artery dissection. Rev Prat 1993;43: 2509e14. 9. Drexler I, Traenka C, von Hessling A, et al. Internal carotid artery dissection and asymmetrical facial flushing: the Harlequin sign. Stroke 2014;45:e78e80. 10. M€ uller BT, Luther B, Hort W, et al. Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg 2000;31:980e8.
Annals of Vascular Surgery
11. Srinivasan J, Newell DW, Sturzenegger M, et al. Transcranial Doppler in the evaluation of internal carotid artery dissection. Stroke 1996;27:1226e30. 12. Lucas C, Moulin T, Deplanque D, et al. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 1998;29:2646e8. 13. Cohen JE, Gomori JM, Itshayek E, et al. Single-center experience on endovascular reconstruction of traumatic internal carotid artery dissections. J Trauma Acute Care Surg 2012;72:216e21. 14. Charlton-Ouw KM, Azizzadeh A, Sandhu HK, et al. Management of common carotid artery dissection due to extension from acute type A (DeBakey I) aortic dissection. J Vasc Surg 2013;58:910e6. 15. Liu AY, Paulsen RD, Marcellus ML, et al. Long-term outcomes after carotid stent placement treatment of carotid artery dissection. Neurosurgery 1999;45:1368e73. discussion 1373e1374.
Dissection of the internal carotid artery is very rare; however, it is diagnosed more frequently with increasing radiographic diagnostic tools. Patients may be completely asymptomatic or may present with symptoms ranging between localized pain to severe cerebral ischemic events. Treatment is usually medical or with interventional radiographic tools. In this report, we present surgical management of internal carotid artery dissection in a 61-year-old female patient.
Dissection of the internal carotid artery (ICA) is a very rare pathology with an incidence of 2.5e3 per 100,000 in different series.1 It is an important etiology of stroke in young adults and has been found with increasing frequency in recent years. It can occur either spontaneously or secondary to trauma and patients may present with different symptoms as being completely asymptomatic or with serious hemiplegia.2 Mortality rate of intracranial carotid dissection is 75% and it is 10% when there is extracranial presentation.3 It may also result in neurological morbidity. The disease is responsible for 2% of all ischemic strokes. It is an important factor especially in the young population, and accounts for approximately 20% of strokes in patients less than 45 years of age.4 Extracranial ICA dissections are more common than intracranial dissections. It is because intracranial arteries have thinner media and adventitial layers;
however, intracranial ICA dissections have higher risk of subarachnoid hemorrhage, hence higher mortality and morbidity rates.5 Neurological outcome is worse in traumatic cervical artery dissections and it is thought to be related to dissection-induced ischemic stroke or associated traumatic lesions.6 More than half of the patients with spontaneous carotid artery dissection develop a stroke, so as till 58% of patients with dissection after a trauma have lasting neurological problems. They have a higher mortality rate compared with patients who have spontaneous carotid artery dissection. Also, the difference between mortality for intracranial carotid dissection and extracranial carotid dissection is relevant.7 In this case report, we present a 61-year-old woman with isolated left ICA dissection together with the management strategy of the disorder. The patient consented to publication.
1 Department of Cardiovascular Surgery, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.
CASE REPORT
2 Department of Radiology, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.
A 61-year-old female patient presented to the clinic with acute onset of severe head and neck pain. She was an active smoker and hypertensive. Doppler ultrasonography of the neck revealed atherosclerotic plaques in the left common carotid and internal carotid arteries as well as dissection at the left ICA. Pathology was further confirmed with computerized tomography angiography, which revealed dissection of the ICA confining to the proximal segment at the carotid bulb (Fig. 1). The patient
Correspondence to: Murat Ugurlucan, Bozkurt Caddesi, No: 110112, Benli Apartmani, Daire: 6, 80250 Kurtulus, Istanbul, Turkey; E-mail: [email protected] Ann Vasc Surg 2015; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2015.01.015 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: December 2, 2014; manuscript accepted: January 8, 2015; published online: ---.
1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Computerized tomography angiography showing dissection of the internal carotid artery confined to the proximal segment at the carotid bulb.
Fig. 2. (A) The localized dissection inside the internal carotid artery and atherosclerotic plaques in the internal and common carotid arteries are seen perioperatively. CCA, common carotid artery; ICA, internal
carotid artery. (B) Excised atherosclerotic endarterectomy material comprising the internal carotid artery dissection. CCA, common carotid artery; ICA, internal carotid artery.
did not define history of trauma, infection, or any vasculitis syndrome affecting the arterial system. Immediate surgical treatment was planned because of the symptoms of the patient and to prevent neurologic events following the consent of the patient. The operation was performed with regional anesthesia, and infiltration anesthesia with 50% mixture of prilocaine hydrochloride and bupivacaine hydrochloride was injected if the patient complained of pain or discomfort. A standard incision parallel to the sternocleidomastoid muscle was performed. The left common, internal, and external carotid arteries were dissected. A saphenous vein segment was harvested from the right leg with local anesthesia. Neurological status of the patient did not alter when the arteries were clamped for 3 min and a longitudinal arteriotomy was performed from the common carotid artery to ICA. The localized dissection inside the ICA was observed (Fig. 2). Endarterectomy from ICA extending to the common carotid artery was performed. Arterial reconstruction was performed with autologous saphenous vein graft patch (Fig. 3).
The postoperative course was uneventful and the patient was discharged symptom free from the hospital on the second postoperative day. She has been doing well for 6 months and receives acetylsalicylic acid, atorvastatin, pentoxifylline, clopidogrel, and beta-blockers.
DISCUSSION AND CONCLUSION Carotid artery dissections are very rare. The extracranial segment of the ICA is the most commonly involved and the intracranial part is very seldom for the origin of the dissection. ICA dissections are seen in young- to middle-aged population mostly. There is no sex predominance.8 Patients may be asymptomatic or present to the clinic with various symptoms associated with expansion of mural hematoma, which compresses nearby structures,9 such as headache, tinnitus, Horner’s syndrome, facial/neck pain, contralateral limb weakness,
Vol.
-,
No.
-, -
2015
Fig. 3. Both internal and external carotid arteries were reconstructed with autologous venous patches. CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery.
retinal ischemic events, or cerebral ischemic symptoms. Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography, and conventional angiography can be used for the diagnosis of the pathology. Treatment modalities involve medical therapy, endovascular treatment, or surgery. Generally, surgical revascularization is rarely performed when there are persisting highgrade stenosis and persisting or newly developed aneurysm of the dissected internal carotid after a medical treatment of 6 months to prevent recurrent ischemic or thromboembolic neurologic damage.10 Carotid artery dissections can occur spontaneously or may have a traumatic etiology. As extrinsic factors, traumatic neck injury, manipulation of the neck during examinations, physiotherapy for the cervical spine, and intentional or unintentional high-range rotations may be recalled. Intrinsic factors include systemic vascular disorders or vasculotides including vascular anomalies or genetic predisposing factors such as hyperhomocysteinemia, alpha 1 antitrypsin deficiency, and connective tissue disorders such as Marfan’s syndrome, EhlereDanlos syndrome, or cystic medial necrosis. In addition, infections, smoking, diabetes mellitus, hypertension, hypercholesterolemia, and contraceptive pill use may be accounted as various other intrinsic etiological factors.3 In the presence of carotid artery dissection, the false lumen may result in stenosis, occlusion, or pseudoaneurysm of the involved vessel.11 ICA dissections cause cortical infarcts or large subcortical infarcts; small subcortical infarcts and junctional infarcts are rare. These infarcts are thought to be embolic rather than of hemodynamic origin.12 Because of the risk of cerebral ischemia, early diagnosis and treatment of carotid dissections are critical.
Case Report 3
Treatment modalities include medical therapy, endovascular therapy, and surgical revascularization. Anticoagulation or antiplatelet agents are used in medication. Endovascular therapy can be offered as a minimally invasive and a safe alternative.13 However, surgical treatment is still the gold standard for atherosclerotic carotid artery disease. Endarterectomy, resection of the injured segment, carotid ligation, and extracranialeintracranial bypass techniques are used for surgical revascularization.11 In case of aneurysm and/or stenosis, acute intervention should be considered as an indication for surgery.10 On the other hand, some authors advocate the medical therapy as first stage therapy for 6 months but the risk of stroke is still significant.14 Additionally, in case of an extended dissection, that is, intimal tear originating at the orifice of the ICA and medial layer separation reaching to the intracranial levels, long-segment stenting of the ICA may be more appropriate.15 Our patient had severe headache and pain localized at the left side of the neck, which was found to be because of ICA dissection with Doppler ultrasonography and computerized tomography angiography. Interestingly, the dissected segment was confined to the orifice of the ICA and did not extend beyond. It was not a primary dissection of the smooth vessel wall, as is usual for post-traumatic or spontaneous dissection etiologies, apparently. We determined atherosclerotic plaques which complicated with the dissection of the arterial wall. Because there were atherosclerotic plaques at the region, we preferred surgical treatment rather than carotid stenting. In conclusion, dissection of the ICA is very rare. In severely symptomatic patients, an intervention should be considered as a fast therapy to prevent ischemic and thromboembolic complications and symptoms of cerebral hypoperfusion as well as local compression, and in this report we present successful surgical treatment of localized ICA dissection.
REFERENCES 1. Schievink WI, Mokri B, Whisnant JP. Internal carotid artery dissection in a community. Rochester, Minnesota, 19871992. Stroke 1993;24:1678e80. 2. Rao AS, Makaroun MS, Marone LK, et al. Long-term outcomes of internal carotid artery dissection. J Vasc Surg 2011;54:370e4. discussion 375. 3. Salvati B, Tesori MC, Lombardo F, et al. Surgical treatment of spontaneous common carotid dissection: a case report. Ann Ital Chir 2014;85. 4. Redekop GJ. Extracranial carotid and vertebral artery dissection: a review. Can J Neurol Sci 2008;35:146e52.
4 Case Report
5. Mahawish K, Durairaj R, Sharma AK. Intracranial carotid artery dissection. Postgrad Med J 2010;86:190. 6. Nedeltchev K, Baumgartner R. Traumatic cervical artery dissection. In: Baumgartner RW, Bogousslavsky J, Caso V, et al. eds. Handbook on Cerebral Artery Dissection. Frontiers of Neurology and Neuroscience, Vol. 20. Basel: Karger, 2005. pp 54e63. 7. Data from Cleveland Clinic. Available at: http://my. clevelandclinic.org/services/heart/disorders/hic_Carotid_Art ery_Disease/Carotid-Artery-Dissection. Accessed January 1, 2015. 8. Mas JL. Internal carotid artery dissection. Rev Prat 1993;43: 2509e14. 9. Drexler I, Traenka C, von Hessling A, et al. Internal carotid artery dissection and asymmetrical facial flushing: the Harlequin sign. Stroke 2014;45:e78e80. 10. M€ uller BT, Luther B, Hort W, et al. Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg 2000;31:980e8.
Annals of Vascular Surgery
11. Srinivasan J, Newell DW, Sturzenegger M, et al. Transcranial Doppler in the evaluation of internal carotid artery dissection. Stroke 1996;27:1226e30. 12. Lucas C, Moulin T, Deplanque D, et al. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 1998;29:2646e8. 13. Cohen JE, Gomori JM, Itshayek E, et al. Single-center experience on endovascular reconstruction of traumatic internal carotid artery dissections. J Trauma Acute Care Surg 2012;72:216e21. 14. Charlton-Ouw KM, Azizzadeh A, Sandhu HK, et al. Management of common carotid artery dissection due to extension from acute type A (DeBakey I) aortic dissection. J Vasc Surg 2013;58:910e6. 15. Liu AY, Paulsen RD, Marcellus ML, et al. Long-term outcomes after carotid stent placement treatment of carotid artery dissection. Neurosurgery 1999;45:1368e73. discussion 1373e1374.
