Circ J 2008; 72: 682 683

Asymptomatic Carotid Kinking

Nicola Mumoli, MD; Marco Cei, MD
Doppler sonography has gained considerable recognition as a noninvasive method of detecting carotid artery
disease, and power Doppler sonography achieves good color-filling of all the examined vessels. Dolichoarterial
disease of the internal carotid artery occurs in 1025% of the population; these alterations are characterized by
atypical elongation of the vessel, which predisposes it to tortuosity, coiling, and kinking, which is the most
frequent morphologic anomaly and is characterized by sharp angulation (single and double Z-shaped). A patient
with double Z-shaped angulation (kinking) of the left internal carotid artery was incidentally diagnosed in an
asymptomatic state because of the broad use of these noninvasive investigations. (Circ J 2008; 72: 682 683)
Key Words: Carotid arteries; Cerebrovascular circulation; Imaging; Ultrasound

bnormalities of the internal carotid arteries are a common angiographic, magnetic resonance angiographic or Duplex scanning finding and, in the great
majority of cases, they are unrelated to neurological symptoms. Elongation, coiling and kinking of the internal carotid
artery occur in 1025% of the population and while coiling
is ascribed to embryological causes, elongation and kinking
are caused by atherosclerosis or fibromuscular dysplasia.
Doppler sonography has gained considerable recognition
as a noninvasive method for detecting carotid artery disease,
and power Doppler sonography achieves good color-filling
of all the examined vessels. Dolichoarterial disease of the internal carotid artery occurs in 1025% of the population and
is characterized by atypical elongation of the vessel, which
predisposes to tortuosity, coiling, and kinking. Kinking, the
most frequent morphologic anomaly, is characterized by
sharp angulation (single and double Z-shaped).
Most patients, as in this case report, are incidentally diagnosed in an asymptomatic state because of the broad use of
these noninvasive investigations.

phy, conventional angiography or magnetic resonance

angiography) and, in the great majority of cases, they are
unrelated to neurological symptoms.1
These alterations are characterized by atypical elongation of the vessel, which predisposes it to tortuosity,
coiling, and kinking. In the first case, the artery acquires an

Case Report
An 85-year-old healthy woman with dyslipidemia underwent a screening duplex ultrasound scan of the neck vessels.
The examination revealed kinking of the left internal carotid
artery with a double, narrow, acute angle (Z-shaped), without hemodynamic flow changes or atherosclerotic lesions
(Fig 1).

Discussion
Abnormalities of the internal carotid arteries are commonly disclosed after imaging studies (ie, duplex sonogra(Received September 17, 2007; revised manuscript received October
15, 2007; accepted November 1, 2007)
Section of Emergency Medicine and Cardiology, Department of Internal Medicine, Livorno Hospital, Livorno, Italy
Mailing address: Nicola Mumoli, MD, Section of Emergency Medicine and Cardiology, Department of Internal Medicine, Livorno
Hospital, viale Alfieri 36, 57100 Livorno, Italy. E-mail: nimumoli@
tiscali.it
All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp

Fig 1. Ultrasound examination show kinking of the left internal

carotid artery with a double, narrow, acute angle (Z-shaped) and no
atherosclerotic lesions (A). Power-Doppler sonography achieves a
good color-filling of all the examined vessels (B). CCA, common
carotid artery; ECA, external carotid artery; ICA-K, kinking of internal carotid artery.

Circulation Journal Vol.72, April 2008

Asymptomatic Carotid Kinking

S or C shape; in the second, the elongation is simply

more emphasized and the artery develops 1 or more loops;
whereas kinking, the most frequent morphologic anomaly,
is characterized by sharp angulation (single and double Zshaped).2,3
In a series of 469 subjects studied by Del Corso et al,4
tortuosities, kinkings, and coilings were more prevalent in
the elderly women (p<0.001). They found significant prevalences of hyperlipemia (p<0.001), hypertension (p<0.01),
chronic cigarette smoking (p<0.01), and ischemic heart
disease (p<0.05). In 2 other, larger, Italian cohorts Pancera
et al5,6 confirmed that only kinking seems much more
prevalent in subjects suffering from arterial hypertension
and they formulated a pathogenetical hypothesis that high
endoluminal pressure could lead to kinking.
Recently, Ballotta et al have shown in a prospective trial
that surgical correction of symptomatic isolated carotid
elongations with coiling or kinking is better for stroke
prevention than medical treatment alone.7 Whether asymptomatic kinking is related to transient ischemic attacks and
stroke, and if treatment of these lesions will result in prevention of brain ischemia, still remain unresolved issues.
Up to date, in women asymptomatic carotid kinking should
be regarded as related to advanced age and should not be
considered, as a sole finding, an indication for surgery.4

Circulation Journal Vol.72, April 2008

683

Prospective trials could clarify if such cases would benefit

from medical treatment.
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