Medicine:Carotid artery dissection

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Short description: Human disease
Carotid artery dissection
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Carotid artery dissection is a separation of the layers of the artery wall in the carotid arteries supplying oxygen-bearing blood to the head. It is the most common cause of stroke in younger adults.[1] The term 'cervical artery dissection' should also be considered in the context of this article.[2]

The carotid arteries are a pair of large bore arteries in the neck, they further divide into smaller vessels, the external and internal carotids on both the right and left side of the head/neck.[3] Carotid arterial dissections occur when a tear or rip in the layers of the carotid arterial wall allows blood to flow between the layers of the artery. Artery dissection is not unique to the carotid artery system and can happen in numerous arteries in the body.

Blood within the walls of a dissected artery can compromise the flow of blood, leading to a slowing of oxygenated blood flow to the brain, complete blockage, or clot creation inducing a full blown stroke.[4]

Dissection may occur after direct physical trauma, traffic collision, strangulation, or any phenomenon that causes hyperextension of the neck. They can also happen spontaneously.[5][6]

Signs and symptoms

The signs and symptoms of carotid artery dissection may be divided into ischemic and non-ischemic categories:[7][8]

Non-ischemic signs and symptoms:

  • Neck pain and headache, sometimes escalating in intensity[9]
  • Decreased pupil size with drooping of the upper eyelid (Horner syndrome)
  • Pulsatile tinnitus

Ischemic signs and symptoms:

Causes

thumb|Dissection in ultrasound The causes of carotid artery dissection can be broadly categorized into two classes: spontaneous or traumatic.[10]

Spontaneous

Once considered uncommon, spontaneous carotid artery dissection is an increasingly recognized cause of stroke that preferentially affects the middle-aged.[11][12]

The incidence of spontaneous carotid artery dissection is low, and incidence rates for internal carotid artery dissection have been reported to be around 2.6 to 2.9 incidents per 100,000.[13] Though the incidence is low - it is the cause of the vast majority of strokes in young people.[14]

Observational studies and case reports published since the early 1980s show that patients with spontaneous internal carotid artery dissection may also have a history of stroke in their family and/or hereditary connective tissue disorders, such as Marfan syndrome, Ehlers-Danlos syndrome, autosomal dominant polycystic kidney disease, pseudoxanthoma elasticum, fibromuscular dysplasia, and osteogenesis imperfecta type I.[15] IgG4-related disease involving the carotid artery has also been observed as a cause.[16]

However, although an association with connective tissue disorders does exist, most people with spontaneous arterial dissections do not have associated connective tissue disorders. Also, the reports on the prevalence of hereditary connective tissue diseases in people with spontaneous dissections are highly variable, ranging from 0% to 0.6% in one study to 5% to 18% in another study.[15]

Internal carotid artery dissection can also be associated with an elongated styloid process (known as Eagle syndrome when the elongated styloid process causes symptoms).[17][18]

Traumatic

Carotid artery dissection is thought to be more commonly caused by severe violent trauma to the head and/or neck. An estimated 0.67% of patients admitted to the hospital after major motor vehicle accidents were found to have blunt carotid injury, including intimal dissections, pseudoaneurysms, thromboses, or fistulas.[19] Of these, 76% had intimal dissections, pseudoaneurysms, or a combination of the two. Sports-related activities such as surfing[20] and Jiu-Jitsu[21] have been reported as causes of carotid artery dissection.

The probable mechanism of injury for most internal carotid injuries is rapid deceleration, with resultant hyperextension and rotation of the neck, which stretches the internal carotid artery over the upper cervical vertebrae, producing an intimal tear.[19] After such an injury, the patient may remain asymptomatic, have a hemispheric transient ischemic event, or have a stroke.[22]

Artery dissection has also been reported in association with some forms of neck manipulation.[5] There is significant controversy about the level of risk of stroke from neck manipulation. It may be that manipulation can cause dissection,[23] or it may be that the dissection is already present in some people who seek manipulative treatment.[24]

Pathophysiology

Arterial dissection of the carotid arteries is a condition that arises when a small tear forms in the innermost lining of the arterial wall, known as the tunica intima. This tear allows blood to enter the space between the inner and outer layers of the vessel, leading to either narrowing (stenosis) or complete occlusion. Notably, the stenosis in the early stages of arterial dissection is a dynamic process, and some occlusions can quickly transition back to stenosis. When complete occlusion occurs, it can result in ischemia, a condition characterized by insufficient blood supply to a particular area.[25]

It is interesting to note that even in cases of complete occlusion, symptoms may not always be evident due to the presence of collateral circulation, which helps to adequately perfuse the brain. However, complications can arise when blood clots develop at the site of the tear and subsequently break off, forming emboli. These emboli can then travel through the arteries and reach the brain, where they may block the blood supply. This blockage leads to an ischemic stroke, also known as a cerebral infarction.[26] In fact, it is believed that blood clots or emboli originating from the dissection are responsible for causing infarctions in the majority of cases involving strokes in the presence of carotid artery dissection.[27][28]

Cerebral infarction, as a result of carotid artery dissection, can cause irreversible damage to the brain. Studies have demonstrated a significant number of patients with dissections do go on to experience full blown strokes, often some time after the original dissection event.[29][30] This emphasizes the serious and potentially life-altering consequences associated with this condition.

Treatment

The goal of treatment is to prevent the development of an actual stroke or limit the continuation of neurologic deficits should a stroke occur after dissection. Treatments include observation, anti-platelet agents, anticoagulation, stent implantation, carotid endarterectomy, and carotid artery ligation.[10][31]

Epidemiology

Carotid dissections events can occur at any age. They tend to occur more often in younger individuals - under 50. Such events are slightly more common in men than in women.[32] Spontaneous internal carotid artery dissection is a rare event with an incidence rate of approximately 2.6 to 2.9 per 100,000 individuals. However, such events account for ~5% to ~22% of strokes in patients under the age of 45 years.[33]

See also

References

  1. ↑ Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan et al. (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes. Malden, Massachusetts: Blackwell / BMJ Books. pp. 46. ISBN 978-1-4051-4166-6. https://archive.org/details/emergencymedicin00matt. 
  2. ↑ "Cervical Artery Dissection: Causes and Symptoms" (in en). https://my.clevelandclinic.org/health/diseases/16857-cervical-carotid-or-vertebral-artery-dissection. 
  3. ↑ "Carotid artery: Anatomy, function, disease, and more" (in en). 2020-03-10. https://www.medicalnewstoday.com/articles/carotid-artery. 
  4. ↑ "Carotid Artery Dissection: Symptoms and Treatment" (in en). https://my.clevelandclinic.org/health/diseases/22697-carotid-artery-dissection. 
  5. ↑ 5.0 5.1 "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice 66 (10): 940–947. 2012. doi:10.1111/j.1742-1241.2012.03004.x. PMID 22994328. 
  6. ↑ Weintraub, M. I. (1993-04-28). "Beauty parlor stroke syndrome: report of five cases". JAMA 269 (16): 2085–2086. doi:10.1001/jama.1993.03500160051022. ISSN 0098-7484. PMID 8468755. https://pubmed.ncbi.nlm.nih.gov/8468755/. 
  7. ↑ Kerry, R; Taylor, AJ (2006). "Cervical arterial dysfunction assessment and manual therapy". Manual Therapy 11 (4): 243–253. doi:10.1016/j.math.2006.09.006. PMID 17074613. 
  8. ↑ "Cervical Artery Dissection (CeAD) | Treatment & Diagnosis | UH Harrington Heart & Vascular Institute | University Hospitals | Cleveland, Ohio | University Hospitals" (in en). https://www.uhhospitals.org/services/heart-and-vascular-services/conditions-and-treatments/vascular-disease/cervical-artery-dissection. 
  9. ↑ "Cervical artery dissection | Health Information | Bupa UK" (in en-GB). https://www.bupa.co.uk/health-information/heart-blood-circulation/cervical-artery-dissection. 
  10. ↑ 10.0 10.1 Carotid Artery Dissection. 2021. PMID 28613585. https://www.ncbi.nlm.nih.gov/books/NBK430835/. Retrieved 12 July 2021. 
  11. ↑ Mokri, B. (1997). "Spontaneous dissections of internal carotid arteries". Neurologist 3 (2): 104–119. doi:10.1097/00127893-199703000-00005. 
  12. ↑ "Carotid Dissection | Mount Sinai - New York" (in en-US). https://www.mountsinai.org/care/surgery/services/vascular-surgery/conditions/arterial-conditions/carotid-dissection. 
  13. ↑ Lee, VH; Brown Jr, RD; Mandrekar, JN; Mokri, B (2006). "Incidence and outcome of cervical dissection; a population-based study". Neurology 67 (10): 1809–1812. doi:10.1212/01.wnl.0000244486.30455.71. PMID 17130413. 
  14. ↑ "Spontaneous coronary artery dissection (SCAD) - Symptoms and causes" (in en). https://www.mayoclinic.org/diseases-conditions/spontaneous-coronary-artery-dissection/symptoms-causes/syc-20353711. 
  15. ↑ 15.0 15.1 De Bray, JM; Baumgartner, RW (2005). "History of spontaneous dissection of the cervical carotid artery". Arch Neurol 62 (7): 1168–1170. doi:10.1001/archneur.62.7.1168. PMID 16009782. 
  16. ↑ Andrea Barp; Marny Fedrigo; Filippo Maria Farina; Sandro Lepidi; Francesco Causin; Chiara Castellani; Giacomo Cester; Thiene et al. (January–February 2016). "Carotid aneurism with acute dissection: an unusual case of IgG4-related diseases". Cardiovascular Pathology 25 (1): 59–62. doi:10.1016/j.carpath.2015.08.006. PMID 26453089. http://www.cardiovascularpathology.com/article/S1054-8807%2815%2900106-4/abstract. 
  17. ↑ Olafur Sveinsson; Nikolaos Kostulas; Lars Herrman (11 June 2013). "Internal carotid dissection caused by an elongated styloid process (Eagle syndrome)". BMJ Case Reports 2013: bcr2013009878. doi:10.1136/bcr-2013-009878. PMID 23761567. 
  18. ↑ Takenori Ogura; Yohei Mineharu; Kenichi Todo; Nobuo Kohara; Nobuyuki Sakai (2015). "Carotid Artery Dissection Caused by an Elongated Styloid Process: Three Case Reports and Review of the Literature". NMC Case Report Journal 2 (1): 21–25. doi:10.2176/nmccrj.2014-0179. PMID 28663957. PMC 5364929. https://www.jstage.jst.go.jp/article/nmccrj/2/1/2_2014-0179/_html. 
  19. ↑ 19.0 19.1 Fabian, T. C.; Patton, Joe; Croce, Martin; Minard, Gayle; Kudsk, Kenneth; Pritchard, F. (1996). "Blunt Carotid Injury". Annals of Surgery 223 (5): 513–552. doi:10.1097/00000658-199605000-00007. PMID 8651742. 
  20. ↑ Pego-Reigosa, R.; López-López, S.; Vázquez-López, M. E.; Armesto-Pérez, V.; Brañas-Fernández, F.; Martínez-Vázquez, F.; Piñeiro-Bolaño, R.; Cortés-Laiño, J. A. (2005-06-14). "Sea wave–induced internal carotid artery dissection" (in en). Neurology 64 (11): 1980. doi:10.1212/01.WNL.0000163855.78628.42. ISSN 0028-3878. PMID 15955962. 
  21. ↑ Demartini, Zeferino; Rodrigues Freire, Maxweyd; Lages, Roberto Oliver; Francisco, Alexandre Novicki; Nanni, Felipe; Maranha Gatto, Luana A.; Koppe, Gelson Luis (June 2017). "Internal Carotid Artery Dissection in Brazilian Jiu-Jitsu". Journal of Cerebrovascular and Endovascular Neurosurgery 19 (2): 111–116. doi:10.7461/jcen.2017.19.2.111. ISSN 2234-8565. PMID 29152471. 
  22. ↑ Matsuura, JH; Rosenthal, D; Jerius, H; Clark, MD; Owens, DS (1997). "Traumatic Carotid Artery Dissection and Pseudoaneurysm Treated With Endovascular Coils and Stent". Journal of Endovascular Surgery 4 (4): 339–343. doi:10.1583/1074-6218(1997)004<0339:TCADAP>2.0.CO;2. ISSN 1074-6218. PMID 9418195. 
  23. ↑ Ernst E (2010). "Vascular accidents after neck manipulation: cause or coincidence?". International Journal of Clinical Practice 64 (6): 673–7. doi:10.1111/j.1742-1241.2009.02237.x. PMID 20518945. 
  24. ↑ "Clinical practice implications of the bone and joint decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations". Journal of Manipulative and Physiological Therapeutics 32 (2 Suppl): S227–243. February 2009. doi:10.1016/j.jmpt.2008.11.023. PMID 19251069. "In persons younger than 45 years, there is an association between chiropractic care and vertebro-basilar artery (VBA) stroke; there is a similar association between family physician care and VBA stroke. This suggests that there is no increased risk of VBA stroke after chiropractic care, and that these associations are likely due to patients with headache and neck pain from vertebral artery dissection seeking care while in the prodromal stage of a VBA stroke. Unfortunately, there is no practical or proven method to screen patients with neck pain and headache for vertebral artery dissection. However, VBA strokes are extremely rare, especially in younger persons.". 
  25. ↑ Bax, Monique; Romanov, Valentin; Junday, Keerat; Giannoulatou, Eleni; Martinac, Boris; Kovacic, Jason C.; Liu, Renjing; Iismaa, Siiri E. et al. (2022-12-06). "Arterial dissections: Common features and new perspectives". Frontiers in Cardiovascular Medicine 9: 1055862. doi:10.3389/fcvm.2022.1055862. ISSN 2297-055X. PMID 36561772. 
  26. ↑ Keser, Zafer; Chiang, Chia-Chun; Benson, John C; Pezzini, Alessandro; Lanzino, Giuseppe (2022-09-02). "Cervical Artery Dissections: Etiopathogenesis and Management". Vascular Health and Risk Management 18: 685–700. doi:10.2147/VHRM.S362844. ISSN 1176-6344. PMID 36082197. 
  27. ↑ "Artery Dissection - an overview | ScienceDirect Topics". https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/artery-dissection#:~:text=Specifically,%20the%20extracranial%20carotid%20artery,to%203.0%20per%20100,000%20people.&text=Extracranial%20vertebral%20artery%20dissection%20occurs,to%201.5%20per%20100,000%20people.. 
  28. ↑ Jung, Simon; Wiest, Roland; Gralla, Jan; McKinley, Richard; Mattle, Heinrich P.; Liebeskind, David (2017-12-11). "Relevance of the cerebral collateral circulation in ischaemic stroke: time is brain, but collaterals set the pace" (in en). Swiss Medical Weekly 147 (4950): w14538. doi:10.4414/smw.2017.14538. ISSN 1424-3997. PMID 29231236. https://smw.ch/index.php/smw/article/view/2424. 
  29. ↑ Martin, P. J.; Humphrey, P. R. D. (1998-07-01). "Disabling stroke arising five months after internal carotid artery dissection" (in en). Journal of Neurology, Neurosurgery & Psychiatry 65 (1): 136–137. doi:10.1136/jnnp.65.1.136. ISSN 0022-3050. PMID 9667581. PMC 2170177. https://jnnp.bmj.com/content/65/1/136. 
  30. ↑ "Articles" (in en-US). https://www.cedars-sinai.org/health-library/articles.html. 
  31. ↑ Torborg, Liza (2019-07-02). "Mayo Clinic Q and A: Treating a carotid artery tear" (in en-US). https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-treating-a-carotid-artery-tear/. 
  32. ↑ "Carotid Dissection" (in en). 2022-12-28. https://www.hopkinsmedicine.org/health/conditions-and-diseases/carotid-dissection. 
  33. ↑ Zheng, Chong; Zhou, Hongwei; Zhao, Kexin; Kong, Derui; Ji, Tiefeng (2023-02-11). "Internal carotid artery dissection with different interventions and outcomes: two case reports". The Journal of International Medical Research 51 (2): 03000605231154379. doi:10.1177/03000605231154379. ISSN 0300-0605. PMID 36772988. 

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