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Imaging of Carotid Dissection

  • Neuroimaging (L. Mechtler, Section Editor)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Here, we describe the four primary imaging modalities for identification of carotid artery dissection, advantages, limitations, and clinical considerations. In addition, imaging characteristics of carotid dissection associated with each modality will be described.

Recent Findings

Recent advances in etiopathogenesis describe the genetic factors implicated in cervical artery dissection. MRI/MRA (magnetic resonance angiography) with fat suppression is regarded as the best initial screening test to detect dissection. Advances in magnetic resonance imaging for the diagnosis of dissection include the use of susceptibility-weighted imaging (SWI) for the detection of intramural hematoma and multisection motion-sensitized driven equilibrium (MSDE), which causes phase dispersion of blood spin using a magnetic field to suppress blood flow signal and obtain 3D T1- or T2*-weighted images. Digital subtraction angiography (DSA) remains the gold standard for identifying and characterizing carotid artery dissections.

Summary

Carotid artery dissection is the result of a tear in the intimal layer of the carotid artery. This leads to a “double lumen” sign comprised of the true vessel lumen and the false lumen created by the tear. The most common presentation of carotid artery dissection is cranial and/or cervical pain ipsilateral to the dissection. However, severe neurological sequelae such as embolic ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage can also result from carotid artery dissection. Carotid artery dissection can be identified by a variety of different imaging modalities including computed tomographic angiography (CTA), MRI, carotid duplex imaging (CDI), and digital subtraction angiography (DSA).

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Abbreviations

CeAD:

Cervical artery dissection

CD:

Carotid Duplex

CDI:

Carotid Duplex imaging

CT:

Computed tomography

CTA:

Computed tomographic angiography

CTP:

CT perfusion

DSA:

Digital subtraction angiography

FLAIR:

Fluid attenuation inversion recovery

GFR:

Glomerular filtration rate

MR:

Magnetic resonance

MRA:

Magnetic resonance angiography

MRI:

Magnetic resonance imaging

SWI:

Susceptibility-weighted imaging

TOF:

Time of flight

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001;344(12):898–906.

    Article  CAS  PubMed  Google Scholar 

  2. Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology. 1995;45(8):1517–22.

    Article  CAS  PubMed  Google Scholar 

  3. von Babo M, De Marchis GM, Sarikaya H, Stapf C, Buffon F, Fischer U, et al. Differences and similarities between spontaneous dissections of the internal carotid artery and the vertebral artery. Stroke. 2013;44(6):1537–42.

    Article  Google Scholar 

  4. • Traenka C, Dougoud D, Simonetti BG, Metso TM, Debette S, Pezzini A, et al. Cervical artery dissection in patients >/=60 years: often painless, few mechanical triggers. Neurology. 2017;88(14):1313–20 This recent study included 2,391 patients and compares frequency of clinical features and outcomes in patients aged <60 Vs. >60 years of age.

    Article  PubMed  Google Scholar 

  5. Tzourio C, Benslamia L, Guillon B, Aidi S, Bertrand M, Berthet K, et al. Migraine and the risk of cervical artery dissection: a case-control study. Neurology. 2002;59(3):435–7.

    Article  CAS  PubMed  Google Scholar 

  6. • De Giuli V, Grassi M, Lodigiani C, Patella R, Zedde M, Gandolfo C, et al. Association between migraine and cervical artery dissection: the Italian project on stroke in young adults. JAMA Neurol. 2017;74(5):512–8 This study investigated the association between migraine subtypes and cervical dissection, and found that migraine without aura was consistently associated with cervical artery dissection.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Rubinstein SM, Peerdeman SM, van Tulder MW, Riphagen I, Haldeman S. A systematic review of the risk factors for cervical artery dissection. Stroke. 2005;36(7):1575–80.

    Article  PubMed  Google Scholar 

  8. • Lichy C, Metso A, Pezzini A, Leys D, Metso T, Lyrer P, et al. Predictors of delayed stroke in patients with cervical artery dissection. Int J Stroke. 2015;10(3):360–3 Occlusive CeAD, multiple CeAD and vertebral dissection are associated with increased risk for delayed stroke.

    Article  PubMed  Google Scholar 

  9. Hufnagel A, Hammers A, Schonle PW, Bohm KD, Leonhardt G. Stroke following chiropractic manipulation of the cervical spine. J Neurol. 1999;246(8):683–8.

    Article  CAS  PubMed  Google Scholar 

  10. Bejot Y, Daubail B, Debette S, Durier J, Giroud M. Incidence and outcome of cerebrovascular events related to cervical artery dissection: the Dijon Stroke Registry. Int J Stroke. 2014;9(7):879–82.

    Article  PubMed  Google Scholar 

  11. Lee VH, Brown RD Jr, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006;67(10):1809–12.

    Article  PubMed  Google Scholar 

  12. • Debette S, Compter A, Labeyrie MA, Uyttenboogaart M, Metso TM, Majersik JJ, et al. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol. 2015;14(6):640–54 This is a comprehensive review of epidemiology, pathophysiology, diagnosis, management, and outcomes of intracranial artery dissection, with consensus statements from experts.

    Article  PubMed  Google Scholar 

  13. • Grond-Ginsbach C, Chen B, Krawczak M, Pjontek R, Ginsbach P, Jiang Y, et al. Genetic imbalance in patients with cervical artery dissection. Curr Genomics. 2017;18(2):206–13 This recent study on 565 subjects with CeAD showed the rare genetic imbalance that may contribute to risk for CeAD.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. • Debette S, Kamatani Y, Metso TM, Kloss M, Chauhan G, Engelter ST, et al. Common variation in PHACTR1 is associated with susceptibility to cervical artery dissection. Nat Genet. 2015;47(1):78–83 This study demonstrated an allele that was associated with lower risk for CeAD.

    Article  CAS  PubMed  Google Scholar 

  15. Kellert L, Grau A, Pezzini A, Debette S, Leys D, Caso V, et al. University education and cervical artery dissection. J Neurol. 2018;265(5):1065–1070.

  16. JM B. Introduction to medical imaging. In: Bushberg JT, Seibert JA, Liedholdt EM, Boone JM, editors. The essential physics of medical imaging. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002. p. 15.

    Google Scholar 

  17. • Shakir HJ, Davies JM, Shallwani H, Siddiqui AH, Levy EI. Carotid and vertebral dissection imaging. Curr Pain Headache Rep. 2016;20(12):68 Comprehensive review on imaging modalities for carotid and vertebral artery dissection.

    Article  PubMed  Google Scholar 

  18. • Larsson SC, King A, Madigan J, Levi C, Norris JW, Markus HS. Prognosis of carotid dissecting aneurysms: results from CADISS and a systematic review. Neurology. 2017;88(7):646–52 This study included patients from the CADISS trial and showed that dissecting aneurysms may have a benign prognosis, and thus are better treated medically.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Grossberg JA, Haussen DC, Cardoso FB, Rebello LC, Bouslama M, Anderson AM, et al. Cervical carotid pseudo-occlusions and false dissections: intracranial occlusions masquerading as extracranial occlusions. Stroke. 2017;48(3):774–7.

    Article  PubMed  Google Scholar 

  20. Teasdale E, Zampakis P, Santosh C, Razvi S. Multidetector computed tomography angiography: application in vertebral artery dissection. Ann Indian Acad Neurol. 2011;14(1):35–41.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol. 2009;193(4):1167–74.

    Article  PubMed  Google Scholar 

  22. Elijovich L, Kazmi K, Gauvrit JY, Law M. The emerging role of multidetector row CT angiography in the diagnosis of cervical arterial dissection: preliminary study. Neuroradiology. 2006;48(9):606–12.

    Article  PubMed  Google Scholar 

  23. Chen CJ, Tseng YC, Lee TH, Hsu HL, See LC. Multisection CT angiography compared with catheter angiography in diagnosing vertebral artery dissection. AJNR Am J Neuroradiol. 2004;25(5):769–74.

    PubMed  Google Scholar 

  24. Vertinsky AT, Schwartz NE, Fischbein NJ, Rosenberg J, Albers GW, Zaharchuk G. Comparison of multidetector CT angiography and MR imaging of cervical artery dissection. AJNR Am J Neuroradiol. 2008;29(9):1753–60.

    Article  CAS  PubMed  Google Scholar 

  25. Rodallec MH, Marteau V, Gerber S, Desmottes L, Zins M. Craniocervical arterial dissection: spectrum of imaging findings and differential diagnosis. Radiographics. 2008;28(6):1711–28.

    Article  PubMed  Google Scholar 

  26. • Latchaw RE, Albers SL. Imaging the cervical vasculature. Prog Cardiovasc Dis. 2017;59(6):555–84 Recent comprehensive review on imaging of cervical vasculature.

    Article  PubMed  Google Scholar 

  27. Korosec FR, Turski PA. Magnetic resonance angiography. In: Latchaw RE, Kucharczyk J, Moseley ME, editors. Imaging of the nervous system, diagnostic and therapeutic applications. Philadelphia: Elsevier Mosby; 2005. p. 385–410.

    Google Scholar 

  28. Saver JLEJ. Dissections and trauma of cervicocerebral arteries. In: Barnett HJM, Mohr JP, Stein BM, et al., editors. Stroke: pathophysiology, diagnosis and management. 3rd ed. New York: Churchill Livingstone; 1998. p. 769–86.

    Google Scholar 

  29. Kirsch E, Kaim A, Engelter S, Lyrer P, Stock KW, Bongartz G, et al. MR angiography in internal carotid artery dissection: improvement of diagnosis by selective demonstration of the intramural haematoma. Neuroradiology. 1998;40(11):704–9.

    Article  CAS  PubMed  Google Scholar 

  30. Provenzale JM. Dissection of the internal carotid and vertebral arteries: imaging features. AJR Am J Roentgenol. 1995;165(5):1099–104.

    Article  CAS  PubMed  Google Scholar 

  31. Zweifler RM, Silverboard G. Arterial dissections and fibromuscular dysplasia. In: Stroke: Pathophysiology, Diagnosis and Management 6th ed Elsevier; 2016 35, 599-618e7.

  32. Linfante I, Llinas RH, Caplan LR, Warach S. MRI features of intracerebral hemorrhage within 2 hours from symptom onset. Stroke. 1999;30(11):2263–7.

    Article  CAS  PubMed  Google Scholar 

  33. Swartz RH, Bhuta SS, Farb RI, Agid R, Willinsky RA, Terbrugge KG, et al. Intracranial arterial wall imaging using high-resolution 3-Tesla contrast-enhanced MRI. Neurology. 2009;72(7):627–34.

    Article  CAS  PubMed  Google Scholar 

  34. Hunter MA, Santosh C, Teasdale E, Forbes KP. High-resolution double inversion recovery black-blood imaging of cervical artery dissection using 3T MR imaging. AJNR Am J Neuroradiol. 2012;33(11):E133–7.

    Article  CAS  PubMed  Google Scholar 

  35. Gao PH, Yang L, Wang G, Guo L, Liu X, Zhao B. Symptomatic unruptured isolated middle cerebral artery dissection: clinical and magnetic resonance imaging features. Clin Neuroradiol. 2016;26(1):81–91.

    Article  CAS  PubMed  Google Scholar 

  36. Obara M, Kuroda K, Wang J, Honda M, Yoneyama M, Imai Y, et al. Comparison between two types of improved motion-sensitized driven-equilibrium (iMSDE) for intracranial black-blood imaging at 3.0 Tesla. J Magn Reson Imaging. 2014;40(4):824–31.

    Article  PubMed  Google Scholar 

  37. • Choi JW, Han M, Hong JM, Lee JS, Kim SY, Kim SS. Feasibility of improved motion-sensitized driven-equilibrium (iMSDE) prepared 3D T1-weighted imaging in the diagnosis of vertebrobasilar artery dissection. J Neuroradiol. 2018;45(3):186–191. This study evaluated the diagnostic value of an improved technique for T1-weighted MRI, and demonstrated a good diagnostic performance.

  38. Lucas C, Moulin T, Deplanque D, Tatu L, Chavot D. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke. 1998;29(12):2646–8.

    Article  CAS  PubMed  Google Scholar 

  39. Baumgartner RW, Arnold M, Baumgartner I, Mosso M, Gonner F, Studer A, et al. Carotid dissection with and without ischemic events: local symptoms and cerebral artery findings. Neurology. 2001;57(5):827–32.

    Article  CAS  PubMed  Google Scholar 

  40. Levy C, Laissy JP, Raveau V, Amarenco P, Servois V, Bousser MG, et al. Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography. Radiology. 1994;190(1):97–103.

    Article  CAS  PubMed  Google Scholar 

  41. • Yamada S, Ohnishi H, Takamura Y, Takahashi K, Hayashi M, Kodama Y, et al. Diagnosing intra-cranial and cervical artery dissection using MRI as the initial modality. J Clin Neurosci. 2016;33:177–81 This study evaluated a ‘MRI first concept’ and found that MRI helped with early diagnosis and treatment of dissections.

    Article  PubMed  Google Scholar 

  42. Headache Classification Committee of the International Headache S. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629–808.

    Article  Google Scholar 

  43. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011;124(4):e54–130.

    Article  PubMed  Google Scholar 

  44. FDA. Magnevist contraindications. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/019596s063lbl.pdf. Accessed 8 Nov 2018.

  45. • Tsivgoulis G, Alexandrov AV. Ultrasound in neurology. Continuum (Minneap Minn). 2016;22(5, neuroimaging):1655–77 Comprehensive review of the utility of ultrasound in diangosis of carotid dissection.

    Google Scholar 

  46. Sturzenegger M, Mattle HP, Rivoir A, Baumgartner RW. Ultrasound findings in carotid artery dissection: analysis of 43 patients. Neurology. 1995;45(4):691–8.

    Article  CAS  PubMed  Google Scholar 

  47. Hakimi R, Garg A. Imaging of hemorrhagic stroke. Continuum (Minneap Minn). 2016;22(5, Neuroimaging):1424–50.

    Google Scholar 

  48. Brott TG, Hobson RW II, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

Figure 2 courtesy of Dhruvil Pandya, MD

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Authors and Affiliations

  1. Department of Medicine, Neurology Division, Univ. of South Carolina School of Medicine-Greenville, Greenville Health System, 200 Patewood Dr., Suite #B350, Greenville, SC, 29615, USA

    Ryan Hakimi & Sanjeev Sivakumar

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Correspondence to Ryan Hakimi.

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Hakimi, R., Sivakumar, S. Imaging of Carotid Dissection. Curr Pain Headache Rep 23, 2 (2019). https://doi.org/10.1007/s11916-019-0741-9

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