RAMB - MAIO 2017

17 / 96

Spontaneous carotid dissection
Rev Assoc Med B ras 2017; 63(5):397-400 397
IMAGE IN MEDICINE
Spontaneous carotid dissection
Carolina Dutra Queiroz Flumignan1, Ronald Luiz Gomes Flumignan2*, Luis Carlos Uta Nakano2, Jorge Eduardo de Amorim2
1MD, Research Physician, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
2MD, PhD, Adjunct Professor, EPM-Unifesp, São Paulo, SP, Brazil
Summary
Study conducted at Division of
Vascular and Endovascular Surgery,
Department of Surgery, EPM-Unifesp,
São Paulo, SP, Brazil
Article received: 8/29/2016
Accepted for publication: 10/19/2016
*Correspondence:
Address: Rua Borges Lagoa, 754
São Paulo, SP – Brazil
Postal code: 04038-001
Carotid dissection is a rare occurrence but it is the main cause of stroke in indi-
viduals aged less than 45 years, and can be the etiology in up to 25% of strokes
in young adults. We report a case with classic image of ying yang on vascular
ultrasound, which was treated according to the best available medical evidence,
yielding a favorable outcome.
Keywords: carotid artery internal dissection, evidence-based medicine, platelet
aggregation inhibitors, stroke, Doppler ultrasonography.
Introduction
Carotid dissection (CD) accounts for only 1-2% of all isch-
emic strokes. In young individuals and middle-aged adults,
however, this etiology accounts for 10-25% of these events.1
Population incidence is around 1.7 to 3/100,000 per year,
but it is the main cause of stroke in people aged less than
45 years.2 Etiopathogenesis is still controversial but it is
believed that an association of genetic predisposition
(Ehler-Danlos syndrome, Marfan, fibromuscular dysplasia,
osteogenesis imperfecta, etc.), environmental factors (recent
infection, trauma or cervical manipulation) and risk fac-
tors (hypertension, migraine, low cholesterol levels, and
body mass index) may lead to the development of CD.1-9
Clinical presentation varies according to the artery involved.
Ipsilateral headache and focal symptoms are often associ-
ated with the area of cerebral or retinal ischemia. After
clinical suspicion, additional diagnostic tests are essential
for diagnostic confirmation. Despite the good accuracy
of Doppler ultrasonography, confirmation with mag-
netic resonance imaging (MRI) or computed tomography
(CT scan) is still routine. Endovascular angiography, as a
resource in the diagnostic stage, is used with caution due
to the possibility of iatrogenic worsening.1
Case report
A 52-year-old female patient, caucasian, homemaker, com-
plaining of left hemicranial headache and speech diffi-
culty upon awakening three hours earlier. She denied
previous episodes and other complaints such as paresis
or paresthesia. She denied smoking, hypertension, diabe-
tes, trauma, migraine, recent infection, dyslipidemia, use
of oral contraceptives or any other significant personal or
family history. On admission, she presented dysphasia
with no motor or sensory deficits on neurological exami-
nation. No signs of intracranial hemorrhage were found
on non-contrasted cranial CT scan, and the intravenous
contrast phase showed no evident ischemic area. Cerebral
angiography of supra-aortic trunks revealed a suggestive
pattern of bilateral fibromuscular dysplasia in the distal
third of the internal carotid arteries (“stacked coins” ap-
pearance) and dissection of the left internal carotid artery
with stenosis of 70-80% of the lumen due to subintimal
hematoma in left internal carotid artery (Figure 1). The
patient was conservatively treated with acetylsalicylic acid
(ASA) 100 mg/day and clopidogrel 75 mg/day. She showed
favorable progression, without recurrence of stroke, and
with progressive speech recovery six months after the
event. Currently, the lesion area corresponding to language
in the left cerebral hemisphere can be identified on gado-
linium-enhanced magnetic resonance imaging (Figure 2).
Color Doppler vascular ultrasound (CDUS) at six months
after the event revealed that left internal carotid dissection
with false lumen ending in a cul-de-sac remains. A bidirec-
tional flow is observed: normal in the cranial direction
and reverse in the central direction, with a classic image
of ying yang on CDUS, which extended for about 4 cm
from the carotid bulb and did not cause significant lumen
stenosis (Figure 3). Systolic peak velocities were very