Dissezione carotidea

Question 1

General findings
Carotid or vertebral artery dissection is the separation of the tunica media and tunica intima of a vessel. This can lead to thrombosis of the false lumen, which can, in turn, lead to stenoses or embolisms with the risk of stroke!

Answer 1

the separation of the tunica media and tunica intima of a vessel.

Primarily affect young adults and may occur spontaneously or as a result of a major trauma (e.g., car accidents). The initial symptoms are usually headaches (temporal and occipital for carotid and vertebral artery dissection respectively), which may be followed by features of ischemia (e.g., stroke) a few hours or days later. Duplex ultrasonography may provide a rapid diagnosis, but definitive diagnosis requires CT angiography or MR angiography. Treatment is primarily conservative and involves blood thinners, anticoagulants, and antiplatelet therapy. Severe cases may require surgery.

Question 2

epidemiologia

Answer 2

Accounts for up to 20% of ischemic strokes in patients < 45 years of age!

Question 3

Eziologia

Answer 3

-Frequently caused by penetrating or blunt trauma (e.g., high impact car accidents) but up to 40% of cases result from mild trauma (e.g., minor sports injuries) or other mechanical triggering events (e.g., coughing, sneezing, chiropractic maneuvers)

Spontaneous dissection
Ehlers-Danlos syndrome and Marfan syndrome
Fibromuscular dysplasia
Hypertension
Cystic medial necrosis
Respiratory tract infection!
Oral contraceptive use

Question 4

Clinica

Answer 4

◽Non-ischemic features

• Ipsilateral headache and facial/neck pain (constant, severe, throbbing or sharp)
• Partial horner syndrome: ptosis and miosis (The triad of Horner (i.e., miosis, ptosis, and anhidrosis) suggest damage to the sympathetic innervation of the ipsilateral eye/face. The triad of Horner is usually partial (without anhidrosis) because the sympathetic fibers of the facial sweat glands are located on the external (rather than the internal) carotid artery.
• Pulse-synchronous tinnitus 👓presente anche in paraganglioma e fistola carotido-cavernosa
• Neck swelling with ecchymosis
• Reduced taste sensation
• Cranial nerve lesions, usually caudal nerves (VI–XII)

◽Ischemic features

• Symptomatic middle cerebral artery infarction (see stroke) 🧨
• Amaurosis fugax (ischemic retina)

Question 5

Diagnosi

Answer 5

CT scan

Duplex ultrasonography: high resistance flow or complete absence of flow in affected artery

Conventional angiography
Intimal flap👓
Double lumen
Long tapered segment of contrast in distal portion of internal carotid artery

Question 6

Trattamento : Baseline monitoring parameters (e.g., INR, PT, aPPT) should be performed before administering anticoagulant therapy!

Answer 6

Treatment should be initiated after an intracerebral hemorrhage has been ruled out

✔Heparin therapy (in acuto) followed by oral anticoagulation for 3–6 months and/or

✔Antiplatelet agents for 1 year
Possibly angioplasty/stenting or surgical intervention may be warranted in severe cases

Asymptomatic pseudoaneurysms do not usually require treatment and most dissections heal spontaneously!