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Carotid artery dissection

Carotid artery dissection
SpecialtyVascular surgery Edit this on Wikidata

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:

Ischemic signs and symptoms:

Causes

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. ^ Mattu, Amal; Goyal, Deepi; Barrett, Jeffrey W.; Broder, Joshua; DeAngelis, Michael; Deblieux, Peter; Garmel, Gus M.; Harrigan, Richard; Karras, David; Anita L'Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes. Malden, Massachusetts: Blackwell / BMJ Books. pp. 46. ISBN 978-1-4051-4166-6.
  2. ^ "Cervical Artery Dissection: Causes and Symptoms". Cleveland Clinic. Retrieved 2023-11-07.
  3. ^ "Carotid artery: Anatomy, function, disease, and more". www.medicalnewstoday.com. 2020-03-10. Retrieved 2023-11-04.
  4. ^ "Carotid Artery Dissection: Symptoms and Treatment". Cleveland Clinic. Retrieved 2023-11-04.
  5. ^ a b Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ (2012). "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice. 66 (10): 940–947. doi:10.1111/j.1742-1241.2012.03004.x. PMC 3506737. 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.
  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". www.uhhospitals.org. Retrieved 2023-11-07.
  9. ^ "Cervical artery dissection | Health Information | Bupa UK". www.bupa.co.uk. Retrieved 2023-11-07.
  10. ^ a b Goodfriend SD, Tadi P, Koury R (2021). "Carotid Artery Dissection". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID 28613585. 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. S2CID 72650438.
  12. ^ "Carotid Dissection | Mount Sinai − New York". Mount Sinai Health System. Retrieved 2023-11-07.
  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. S2CID 72123054.
  14. ^ "Spontaneous coronary artery dissection (SCAD) − Symptoms and causes". Mayo Clinic. Retrieved 2023-11-04.
  15. ^ a b 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. ^ Barp, Andrea; Fedrigo, Marny; Farina, Filippo Maria; Lepidi, Sandro; Causin, Francesco; Castellani, Chiara; Cester, Giacomo; Thiene; Valente, Marialuisa; Baracchini, Claudio; Angelini, Annalisa (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.
  17. ^ Sveinsson, Olafur; Kostulas, Nikolaos; Herrman, Lars (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. PMC 3702984. PMID 23761567.
  18. ^ Ogura, Takenori; Mineharu, Yohei; Todo, Kenichi; Kohara, Nobuo; Sakai, Nobuyuki (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. PMC 5364929. PMID 28663957.
  19. ^ a b 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. PMC 1235173. 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". Neurology. 64 (11): 1980. doi:10.1212/01.WNL.0000163855.78628.42. ISSN 0028-3878. PMID 15955962. S2CID 27855488.
  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. PMC 5678212. 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. S2CID 38571730.
  24. ^ Guzman J, Haldeman S, Carroll LJ, et al. (February 2009). "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. 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.; Graham, Robert M. (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. PMC 9763901. 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. PMC 9447449. PMID 36082197.
  27. ^ "Artery Dissection − an overview | ScienceDirect Topics". www.sciencedirect.com. Retrieved 2023-11-07.
  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". Swiss Medical Weekly. 147 (4950): w14538. doi:10.4414/smw.2017.14538. ISSN 1424-3997. PMID 29231236.
  29. ^ Martin, P. J.; Humphrey, P. R. D. (1998-07-01). "Disabling stroke arising five months after internal carotid artery dissection". Journal of Neurology, Neurosurgery & Psychiatry. 65 (1): 136–137. doi:10.1136/jnnp.65.1.136. ISSN 0022-3050. PMC 2170177. PMID 9667581.
  30. ^ "Articles". Cedars-Sinai. Archived from the original on 2021-09-12. Retrieved 2023-11-07.
  31. ^ Torborg, Liza (2019-07-02). "Mayo Clinic Q and A: Treating a carotid artery tear". Mayo Clinic News Network. Retrieved 2023-11-04.
  32. ^ "Carotid Dissection". www.hopkinsmedicine.org. 2022-12-28. Retrieved 2023-11-04.
  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. PMC 9926001. PMID 36772988.

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