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Case 29

History:

38 year old female with acute headaches and left hemiplegia

Findings:

DWI and ADC map shows acute right MCA infarct. Axial T1 and FLAIR sequences through the skull base show wall hematoma manifested by crescentric T1 hyperintensity signal of the petrous portion of the right ICA and signal alteration on the correspongin flait. Axial 2D TOF shows the actual flap. Confirmatory angio was obtained.

Diagnosis:

Spontaneous internal carotid dissection

Discussion:

Some  “spontaneous” carotid dissections may be due to trivial trauma such as violent coughing, nose blowing, sneezing or simple neck turning. They are usually seen in young women.

The most common initial symptom is ipsilateral headache. Most of these (60 percent) are orbital or periorbital. They may also produce sudden onset of severe pain over the carotid (carotidynia). Incomplete Horner syndrome due to involvement of plexus around the ICA may occur. MRI shows enlarged vessel due to intramural hematoma that is hyperintense of T1 WI (particularly on T1 fat Sat). Narrowing of the lumen can also be seen.

Most dissection starts at about 1 or 2 cm distal to ICA origin.

Optimal treatment has not been determined. For cases without bleeding, heparin then coumadin are used.

Natural history is not well known. Many patients with minor symptoms may not present and presumably do well. In one series 75 percent of patients returned to normal, 16 percent had minor deficit and 8 percent had major deficit or died.

References:

  • Mark S. Greenberg. Handbook of neurosurgery. 5th ed. 2001.
  • Bell WE, Joynt RJ, Sahs AL. Low spinal fluid pressure syndromes. Neurology. 1960;10:512-521.
  • Lasater GM. Primary intracranial hypotension: the low spinal fluid pressure syndrome. Headache. 1970;10:63-66.
  • Rando TA, Fishman RA. Spontaneous intracranial hypotension: report of two cases and review of the literature. Neurology. 1992;42:481-487.
  • Schievink WI, Meyer FB, Atkinson JLD, et al. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg. 1996;84:598-605.
  • Wouter I. Schievink. Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension.  JAMA.2006;295:2286-2296.