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Common Carotid Artery Dissection: a Case Report 57 2 and Review of the Literature 58 3 59 4 60 5 61 6 Victor Zach, MD, Svetlana Zhovtis, MD, Kathryn F

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Common Carotid Artery Dissection: a Case Report 57 2 and Review of the Literature 58 3 59 4 60 5 61 6 Victor Zach, MD, Svetlana Zhovtis, MD, Kathryn F ARTICLE IN PRESS 54 55 56 1 Common Carotid Artery Dissection: A Case Report 57 2 and Review of the Literature 58 3 59 4 60 5 61 6 Victor Zach, MD, Svetlana Zhovtis, MD, Kathryn F. Kirchoff-Torres, MD, 62 7 and Jesse M. Weinberger, MD 63 8 64 9 65 10 66 11 67 12 68 13 Common carotid artery dissection (CCAD) is a rare and poorly characterized cause 69 14 of ischemic stroke. We describe a case of multiple cerebral infarcts in a patient with 70 CCAD initially detected by carotid duplex ultrasonography, and review the litera- 15 71 ture on CCAD. A Medline search from 1960 to the present for cases of CCAD yielded 16 72 17 46 cases. We extracted demographic data, anatomical location, symptoms, neuroso- nography, neuroradiology, pathological findings, treatment, and outcomes. The 73 18 mean age of the patients was 48.8 6 15.8 years (range, 19–89 years). Our search 74 19 found 20 cases of spontaneous CCAD, 11 cases of traumatic CCAD, 4 cases of iatro- 75 20 genic CCAD, and 12 cases of CCAD associated with aortic arch dissection. The most 76 21 common presenting neurologic symptoms of CCAD were hemiparesis, decreased 77 22 consciousness, headache/neck pain, aphasia, and monocularPROOF field deficit. The 78 23 most frequently reported neurosonographic findings included a double lumen, mu- 79 24 ral thrombus, intraluminal hyperechoic/isoechoic lesion, and intimal flap. Most 80 25 cases of CCAD were subsequently confirmed with conventional angiography, com- 81 puted tomography angiography, or magnetic resonance angiography. Treatment dif- 26 82 fered based on etiology; anticoagulation was used most commonly for spontaneous 27 83 28 CCAD, and surgical repair was most often done for traumatic and aortic dissection– associated CCAD. Prognosis was generally good; the majority of patients achieved 84 29 complete clinical recovery, but 3 died. Our findings indicate that carotid Doppler is 85 30 a widely accessible, rapid, and noninvasive technique for diagnosing CCAD. Our 86 31 case and literature review further characterizes the diverse etiologies, clinical 87 32 course, and radiographic features of CCAD. Key Words: Common carotid 88 33 Q2 artery—dissection—cerebral infarct—stroke—carotid duplex—angiography. 89 34 Ó 2010 by National Stroke Association 90 35 91 36 92 37 Arterial dissection accounts for up to 20% of ischemic patients in a stroke database were identified as having 93 1 38 strokes. Whereas internal carotid artery dissection extracranial ICAD or vertebral artery dissection (VAD); 94 2 39 (ICAD) is typical, common carotid artery dissection no cases of CCAD were described. Because of its associa- 95 3 40 (CCAD) is an very rare cause of ischemic stroke. In tion with aortic dissection, early recognition of CCAD 96 41 a recent review of cervical artery dissections, 177 of 8800 might affect the decision regarding thrombolysis for acute 97 42 ischemic stroke. We present a patient with CCAD and 98 43 review the available literature to characterize the symp- 99 44 From the Department of Neurology, Mount Sinai School Of Medi- toms, imaging, treatments, and prognosis of CCAD. 100 45 cine, New York, New York. 101 Received January 13, 2010; accepted May 5, 2010. 46 102 47 Supported in part by a postdoctoral training award in cerebrovas- Case Report cular disease research to Mount Sinai School of Medicine 103 48 Q1 (1T32NS051147). UNCORRECTEDA 50-year-old female with migraine was transferred to 104 49 Address correspondence to Victor Zach, Department of Neurology, our hospital with complaints of an atypical, rapidly ex- 105 50 Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, panding visual aura that evolved into a right visual field 106 NY 10029. E-mail: [email protected]. 51 defect, left cervicooccipital pain, disequilibrium, right 107 52 1052-3057/$—see front matter Ó 2010 by National Stroke Association hemiparesis, and expressive aphasia. The symptoms 108 53 doi:10.1016/j.jstrokecerebrovasdis.2010.05.001 lasted for 45 minutes. On arrival, the patient had 109 Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2010: pp 1-9 1 FLA 5.0 DTD YJSCD653_proof 1 June 2010 8:00 pm ce 36 ARTICLE IN PRESS 2 V. ZACH ET AL. 110 left CCA velocity (0.70 m/s.) The small circular area of 165 111 distal CCAD decreased to 3.5 mm in diameter, with com- 166 112 plete neurosonographic resolution of the ‘‘floating’’ 167 113 thrombus (Fig 5). Warfarin for 3–6 months, followed by 168 114 an antiplatelet agent and continued follow-up by CD, 169 115 are planned. 170 116 171 117 Literature Search Q3 172 118 173 We searched titles in Medline from 1960 to the present 119 174 using the following index terms: ‘‘common carotid artery 120 175 dissection,’’ ‘‘common carotid artery dissections,’’ ‘‘com- 121 176 mon carotid artery stenosis,’’ ‘‘common carotid artery ste- 122 177 noses,’’ ‘‘common carotid artery injury,’’ ‘‘common carotid 123 178 artery occlusion,’’ ‘‘common carotid artery occlusions,’’ 124 179 ‘‘common carotid artery pseudoaneurysm,’’ ‘‘common ca- 125 180 rotid dissection,’’ ‘‘common carotid occlusion,’’ and ‘‘com- 126 181 mon carotid pseudoaneurysm.’’ In addition, we searched 127 182 the Journal of Neuroimaging using Medline and the key- 128 183 word ‘‘common carotid.’’ We retrieved data using the 129 184 Mount Sinai School of Medicine’s Levy Library. Our 130 Figure 1. Carotid ultrasound. Axial view of the left CCA (L CCA) show- 185 searches yielded a total of 369 titles. We excluded any 131 ing an intimal flap (arrowheads) with an underlying thrombus measuring 186 5.7 mm (arrow). L IJV, left internal jugular vein. papers that providedPROOF no clinical, radiographic, or patho- 132 187 logical evidence of CCAD. We did not exclude papers 133 188 based on language. We reviewed relevant references 134 impaired object recall and labile mood with inappropriate 189 and added any additional cases to our data pool. Four 135 laughter and crying episodes. 190 papers (1 Chinese, 2 Russian, and 1 American) were 136 Urgent carotid duplex ultrasonography (CD) with 191 excluded due to their unavailability in print or online. 137 color-flow imaging revealed a circular area of dissection, 192 Each paper was read by 1 of 2 authors, and a third author 138 5.7 mm in diameter, in the mid to distal left common 193 reviewed all of the papers to ensure standardized and 139 carotid artery (CCA), and a mobile thrombus with a dense 194 complete data abstraction. Including our case study pre- 140 circular rim and lucent core ‘‘floating’’ within the lumen 195 sented here, this yielded 47 cases of CCAD.4–42 141 of the CCA on axial view (Fig 1). Peak left CCA velocity 196 Information regarding age, sex, side of the CCAD, 142 was normal, at 0.64 m/s. Magnetic resonance imaging 197 location within the CCA, presenting signs and 143 (MRI) of the brain revealed multiple foci of restricted dif- 198 symptoms, CD findings, radiographic and pathological 144 fusion in the left anterior, middle, and posterior cerebral 199 findings, treatment, and prognosis were abstracted. Due 145 artery (PCA) distributions, consistent with acute infarc- 200 to the retrospective nature of this data, information 146 tion (Fig 2). The left PCA was of carotid (ie, fetal) origin. 201 regarding each characteristic was not always available. 147 Gadolinium-enhanced magnetic resonance angiography 202 We indicate the number of published cases that 148 (MRA) of the neck confirmed the distal CCAD and prox- 203 included relevant information for each characteristic. 149 imal ICAD. There was no evidence of aortic dissection on 204 150 this study, or on MRA of the thorax and abdomen (Fig 3). 205 151 Catheter cerebral angiography confirmed the distal left Results 206 207 152 CCAD located on the anteromedial wall. Furthermore, The mean age of the 43 patients in the case studies was 208 153 irregularities of the left cervical vertebral artery and the 48.8 6 15.8 years (range, 19–89 years). Classified by etiol- 4–19 209 154 left internal carotid artery (ICA) were suggestive of ogy, there were 20 cases of spontaneous CCAD, 11 20–28 210 155 fibromuscular dysplasia (Fig 4). cases of traumatic CCAD, 4 cases of iatrogenic 29–32 211 156 Transesophageal echocardiography demonstrated CCAD, and 12 cases of CCAD associated with 33–42 212 157 a normal ejection fraction andUNCORRECTED showed no evidence of aortic arch dissection (AAD). 158 intracardiac shunt or a cardiac source of thrombus. A hy- 213 214 159 percoagulation workup revealed heterozygosity for factor Spontaneous CCAD (n 5 20) 160 V Leiden. The patient was treated with intravenous hep- 215 161 arin and discharged on warfarin with an enoxaparin These patients included 14 males and 4 females, with Q4 216 162 bridge to a therapeutic international normalized ratio a mean age of 53.1 6 15.8 years (range, 34–89 years). Six 217 163 (INR) of 2–3. CCADs occurred in the right CCA, and 12 occurred in 218 164 At a 3-month follow-up, the patient remained asymp- the left CCA. Three CCADs occurred in the proximal 219 tomatic. Follow-up CD continued to show normal peak CCA, 3 occurred in the mid-portion, 5 occurred in the 220 FLA 5.0 DTD YJSCD653_proof 1 June 2010 8:00 pm ce 36 ARTICLE IN PRESS COMMON CAROTID ARTERY DISSECTION 3 221 276 222 277 223 278 224 279 225 280 226 281 227 282 228 283 229 284 230 285 231 286 232 287 233 288 234 289 235 290 236 291 237 292 238 293 239 294 240 295 241 Figure 2. Diffusion-weighted MRI 296 242 showing multiple foci of restricted diffu- 297 sion in the distribution of the left ante- PROOF 298 243 rior, middle, and posterior cerebral 244 arteries.
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