Carotid artery dissection

Carotid artery dissection is a separation of the layers

of the artery wall supplying oxygen-bearing blood to the
head and brain and is the most common cause of stroke
in young adults.[1] (In vascular medicine, dissection is
a blister-like de-lamination between the outer and inner
walls of a vessel, generally originating with a partial leak
in the inner lining.)[2]

pseudoxanthoma elasticum, bromuscular dysplasia, and

osteogenesis imperfecta type I.[6]
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.[6]

Signs and symptoms

The signs and symptoms of carotid artery dissec- 2.2 Traumatic

tion may be divided into ischaemic and non-ischaemic
Carotid artery dissection is thought to be more commonly
categories:[3]
caused by severe violent trauma to the head and/or neck.
Non-ischaemic signs and symptoms
An estimated 0.67% of patients admitted to the hospital
after major motor vehicle accidents were found to have
Headache or neck pain
blunt carotid injury, including intimal dissections, pseu[7]
Decreased pupil size with drooping of the upper eye- doaneurysms, thromboses, or stulas. Of these, 76%
had intimal dissections, pseudoaneurysms, or a combinalid (Horner syndrome)
tion of the two.
Ischaemic signs and symptoms

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.[7] After such an injury, the patient may remain asymptomatic, have a hemispheric transient ischemic event, or suer a stroke.[8]

Transient vision loss

Ischaemic stroke

Causes

3 Pathophysiology

The causes of internal carotid artery dissection can be

broadly categorised into two classes: spontaneous or traumatic.

2.1

Arterial dissection of the carotid arteries occurs when a

small tear forms in the innermost lining of the arterial wall
(known as the tunica intima). Blood is then able to enter
the space between the inner and outer layers of the vessel,
causing narrowing (stenosis) or complete occlusion. The
stenosis that occurs in the early stages of arterial dissection is a dynamic process and some occlusions can return to stenosis very quickly.[9] When complete occlusion occurs, it may lead to ischaemia. Often, even a
complete occlusion is totally asymptomatic because bilateral circulation keeps the brain well perfused. However, when blood clots form and break o from the site
of the tear, they form emboli, which can travel through
the arteries to the brain and block the blood supply to the
brain, resulting in an ischaemic stroke, otherwise known
as a cerebral infarction. Blood clots, or emboli, originating from the dissection are thought to be the cause of

Spontaneous

Once considered uncommon, spontaneous carotid artery

dissection is an increasingly recognised cause of stroke
that preferentially aects the middle-aged.[4]
The incidence of spontaneous carotid artery dissection is
low, and incidence rates for internal carotid artery dissection have been reported to be 2.6 to 2.9 per 100,000.[5]
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,
1

infarction in the majority of cases of stroke in the presence of carotid artery dissection.[9] Cerebral infarction
causes irreversible damage to the brain. In one study of
patients with carotid artery dissection, 60% had infarcts
documented on neuroimaging.[5]

Treatment

The goal of treatment is to prevent the development

or continuation of neurologic decits. Treatments include observation, anticoagulation, stent implantation and
carotid artery ligation.

Epidemiology

70% of patients with carotid arterial dissection are between the ages of 35 and 50, with a mean age of 47
years.[1]

See also
Aortic dissection
Vertebral artery dissection

References

[1] Amal Mattu; Deepi Goyal; Barrett, Jerey W.; Joshua

Broder; DeAngelis, Michael; Peter Deblieux; Gus M.
Garmel; Richard Harrigan; David Karras; Anita L'Italien;
David Manthey (2007). Emergency medicine: avoiding
the pitfalls and improving the outcomes. Malden, Mass:
Blackwell Pub./BMJ Books. p. 46. ISBN 1-4051-41662.
[2] Mount Sinai Hospital Patient Care Health Library:
http://www.mshq.org/patient-care/health-library/
diseases-and-conditions/aortic-dissection
[3] Kerry, R, Taylor, AJ (2006). Cervical arterial dysfunction assessment and manual therapy. Manual therapy 11
(4): 24353. doi:10.1016/j.math.2006.09.006. PMID
17074613.
[4] In: Neurology 2006;67:1809-1812. Mokri, B. (1997).
Spontaneous dissections of internal carotid arteries.
Neurologist 3 (2): 104119. doi:10.1097/00127893199703000-00005.
[5] Lee, VH, Brown Jr, RD, Mandrekar, JN, Mokri, B
(2006). Incidence and outcome of cervical dissection; a population-based study. Neurology 67 (10):
18091812. doi:10.1212/01.wnl.0000244486.30455.71.
PMID 17130413.

REFERENCES

[6] De Bray, JM, Baumgartner, RW (2005).

History of spontaneous dissection of the cervical
carotid artery. Arch Neurol 62 (7): 11681170.
doi:10.1001/archneur.62.7.1168. PMID 16009782.
[7] Fabian, TC, Patton, Joe, Croce, Martin, Minard,
Gayle, Kudsk, Kenneth, Pritchard, F. (1996). Blunt
Carotid Injury. Annals of Surgery 223 (5): 51352.
doi:10.1097/00000658-199605000-00007.
[8] 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): 339343. doi:10.1583/10746218(1997)004<0339:TCADAP>2.0.CO;2.
PMID
9418195.
[9] Lucas, C, Moulin, T, Deplanque, D, Tatu, L, Chavot, D
(1998). Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 29 (12): 26462648.
doi:10.1161/01.STR.29.12.2646. PMID 9836779.

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