What Is Carotid Artery Dissection?
A carotid artery dissection is a tear in a layer of the wall of a blood vessel called a carotid artery, one of two such arteries found in the neck. Blood vessel walls normally have three layers, and a tear in any of these can allow blood to flow into the resulting space, causing the vessel to bulge. This bulge can form a blood clot, break off, and result in a stroke [1,2].
Symptoms include headache or neck pain, a droopy eyelid and small pupil on the same side as the dissection, a ringing or whooshing sound in the ear (tinnitus) on this same side, as well as numbness or weakness, blindness, double vision, trouble speaking or swallowing, or imbalance.
Treatments include pain relief as well as methods to resolve or remove potential blood clots, prevent an initial stroke, facilitate stroke recovery, or reduce the risk of additional strokes.
Call 911 immediately. Diagnosis is done by CT or MRI, and treatment involves anti-clotting medication for at least 3-6 months. Surgery may be necessary for those who can't get this medication.
Carotid Artery Dissection Symptoms
Symptoms of a carotid artery dissection can be categorized by main symptoms, symptoms of Horner syndrome such as a drooping eyelid, ringing in the ears, and stroke-like symptoms.
The most common symptoms in a carotid artery dissection primarily includes:
- Headache: You may experience a headache that will progressively worsen, or sudden-onset, severe, "thunderclap" headache if a part of the carotid artery within the skull ruptures, leading to bleeding in the skull called a subarachnoid hemorrhage.
- Neck pain: This will also progressively worsen.
Horner syndrome or ringing in the ears
These symptoms are part of a collection of symptoms called "Horner syndrome," and may occur if a bulge in the carotid artery compresses nerve fibers that run on the outside of the blood vessel. Horner syndrome is present in up to 58 percent of people with carotid dissection [3,4].
- A droopy eyelid: This is called ptosis, and occurs in about a quarter of people with carotid artery dissection on the same side as the dissection.
- A small pupil: This also occurs in about a quarter of people with carotid artery dissection in which the pupil (the dark center of the eye) will appear smaller on the same side as the dissection.
- Ringing or whooshing sound in the ears: This is unrelated to Horner syndrome specifically, but this may occur on the side of the carotid dissection.
Symptoms of a stroke
About half of people with a carotid artery dissection will experience symptoms of a stroke, which occur when the brain does not get enough blood. In some people, the symptoms of the stroke last for only a few seconds or minutes (transient ischemic attack or "mini-stroke"), while in others the symptoms of the stroke may be persistent. Symptoms of a stroke vary and may include:
Carotid Artery Dissection Causes
There are two carotid arteries, one on each side of the neck, which can be felt along the side of the neck right under the angle of the jaw. As described before, blood vessel walls are normally made up of three layers of tissues. A tear in one of these layers can allow blood to flow into the blood vessel wall, causing expansion of the space within the wall of the blood vessel.
Depending on which layer the tear is located in, the blood can cause a bulge in the vessel wall that either expands inward or outward. If the bulge expands inward into the space where blood normally flows through the blood vessel, it can block off normal blood flow through the vessel. If the bulge expands outward, it can compress surrounding structures around the vessel. In both cases, blood can pool in the bulge and form a blood clot, which can break off and travel to the brain, causing a stroke.
Causes of carotid artery dissection may include minor trauma or movement of the neck, vascular and connective tissue disorders, or those related to family history or genetics.
Minor trauma or movement of the neck
About 40 percent of cases of carotid artery dissection happen after minor trauma or movement of the neck [5,6]. Examples of activities that can cause carotid artery dissections include:
- Sports: Such as basketball, tennis, swimming, dancing, or skating
- Coughing or sneezing
- Sexual intercourse
- Chiropractic manipulation of the neck
Vascular and connective tissue disorders
Certain vascular and connective tissue disorders are associated with weakened blood vessel walls that can predispose an individual to develop spontaneous carotid artery dissections in the abscess of trauma. These include:
- Fibromuscular dysplasia: This is the most common vascular cause, which results in abnormal growth of blood vessels throughout the body.
- Ehlers-Danlos syndrome: This is a connective disorder that causes defects in the skin, blood vessels, and other tissues and organs .
Family history of arterial dissections
People who have a family history of dissections in the carotid artery or other arteries are more likely to develop a carotid artery dissection. This suggests that there is a genetic component to the development of carotid artery dissections.
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Treatment Options and Prevention
The recommended treatments for a carotid artery dissection vary depending on whether the carotid artery dissection causes a stroke. Both short-term and long-term treatments are usually recommended to treat the acute symptoms and prevent long-term recurrence of symptoms. Conservative methods through anticoagulation and antiplatelet therapy, for example, have proven to be effective in some cases .
Specific treatment options include pain medications, a series of stabilizing treatments for any strokes that may occur, a procedure to remove the blood clot, anti-clotting medication, and surgery to repair the dissection.
Headache or neck pain caused by a carotid artery aneurysm are usually managed with painkillers such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve).
Treating associated strokes
If the carotid artery dissection causes a stroke, the treatment team will usually administer a series of treatments in the short-term to stabilize you.
- Breathing support: Your ability to maintain an open airway will be evaluated, and you may be given oxygen or other respiratory support, including intubation, if needed.
- Fluids: These are usually given through an IV to ensure you remain hydrated.
- Blood pressure monitoring: Blood pressure lowering medications such as labetalol (Trandate), nicardipine (Cardene) or nitroprusside (Nitropress) may be given if your blood pressure is too high.
- Blood sugar monitoring: Insulin may be given if the blood sugar level is too high.
Medication to break up the blood clot
Most cases of stroke in those with carotid artery dissection are caused by a blood clot. Therefore, people with a carotid artery dissection who develop a stroke may be given a thrombolytic medication called alteplase to break up the blood clot if it is safe for them to receive it. This medication can usually only be given if it has been less than 4.5 hours since the start of the stroke symptoms .
Surgery to remove the clot
In some cases of carotid artery dissection with a stroke that cannot be treated with thrombolytic medication, the physician may recommend a procedure called a mechanical thrombectomy, in which a device is threaded up a blood vessel to physically remove the blood clot. This procedure may be done up to 24 hours after the start of the stroke symptoms.
Further anti-clotting medications
For people with a carotid artery dissection who develop a stroke, physicians may recommend taking anti-blood clotting medications for a period of time (usually three to six months) to prevent the recurrence of another stroke. The specific medication may vary depending on the location of the dissection, your risk factors, and the physician's preferences, but may include aspirin, clopidogrel (Plavix) or warfarin (Coumadin).
Surgery to repair the carotid artery dissection
Some people with a carotid artery dissection may benefit from surgery to repair the carotid artery dissection. Most cases of carotid artery dissection will heal on their own in the first few months. Therefore, surgery is usually only recommended for people who continue to get stroke symptoms despite taking anti-blood clotting medications. Surgical treatment options include:
- Threading a device: A device threaded through a blood vessel will expand the area of the carotid artery dissection.
- Stent placement: This will keep the blood vessel open.
- Closure: The part of the blood vessel wall that is bulging outward may be occluded.
- Surgery: This is to bypass the area of the vessel with the dissection.
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When to Seek Further Consultation
You should go to the emergency room or call an ambulance right away if you experience neck pain, numbness or weakness, vision changes, or trouble speaking or swallowing. A carotid artery dissection is a medical emergency that needs to be treated promptly.
Questions Your Doctor May Ask to Diagnose
To diagnose this condition, your doctor would likely ask about the following symptoms and risk factors.
- Any fever today or during the last week?
- Are you sick enough to consider going to the emergency room right now?
- How long has your current headache been going on?
- Have you experienced any nausea?
- Have you been feeling more tired than usual, lethargic or fatigued despite sleeping a normal amount?
If you've answered yes to one or more of these questions
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- Carotid Dissection. Cedars-Sinai.org. Cedars-Sinai Link
- Cervical (Carotid or Vertebral) Artery Dissection. My.Clevelandclinic.org. Cleveland Clinic Link
- Borgman CJ. Horner syndrome secondary to internal carotid artery dissection after a short-distance endurance run: A case study and review. Journal of Optometry. 2012;5(4):209-216. J Optom Link
- Nautiyal, A, Singh, S, DiSalle, M, O'Sullivan, J. Painful Horner Syndrome as a Harbinger of Silent Carotid Dissection. Journals.plos.org. Published January 25, 2005. PLOS Link.
- Micheli S, Paciaroni M, Corea F, Agnelli G, Zampolini M, Caso V. Cervical Artery Dissection: Emerging Risk Factors. The Open Neurology Journal. 2010; 4:50-55. Open Neurol J Link
- Caswell, J. Uncommon Causes of Stroke: Whether due to a clot or a bleed there are many causes of stroke. Some are less common than others. Strokeassociation.org. Published Spring 2014. Stroke Connection Link
- Rao, AS, Makaroun, MS, Marone, LK, Cho, JS, Rhee, R, Chaer, RA. Long-term outcomes of internal carotid artery dissection. J Vasc Surg. 2011; 54(2):370-374; discussion 375. Published May 28, 2011. J Vasc Surg Link
- Stroke used to rank fourth in leading causes of U.S. death. Now it's fifth. Strokeassociation.org. Stroke Association Link
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