24 year old lady, complaining of a long-standing history of neck stiffness and discomfort. She attended her local chiropractor and following manual adjustment, started complaining of worsening right sided neck pain and occasional headaches.
CT angiogram of the aortic arch and great vessels was performed, followed by a diagnostic angiogram
1. What is your clinical diagnosis?
2. What is the most likely precipitating factor?
3. Please outline any other Investigations you would request and pathologies to rule out?
4. What is your management and surveillance plan?
To be honest, it is too difficult to consider CCA dissection from chiropractor, especially with the patient was only complaining of neck pain and headache.
I think, I may reach this diagnosis by exclusion of common causes of headache first.
Then I may request CT brain non contrast, and a carotid doppler and when found an occlusion in the ICA, I will request CTA
Based on the angiogram given, It is most probably carotid dissection flap with thrombosed false lumen occluding the ICA
I have to rule out the presence of Aortic dissection and or embolic source, so I will request whole aortic CTA, echo, 24h ECG
For management I will go for therapeutic anticoagulation and follow up with duplex US surveillance. If become symptomatic I will go for carotid bypass.
Thank you Dr Peter. Why do you feel it’s difficult to consider carotid dissection following chiropractic manipulation? It has been reported numerous times in the past and amongst the wider range of “traumatic carotid dissections”
Q1. Carotid artery dissection
Q2. Traumatic
Q3. Echocardiography
Neuroimaging (eg, contrast and noncontrast CT or MRI of the brain)
Ct or MRI cervical to rule out cervical vertebrae disease or fracture
Electroencephalography (EEG)
Opthalmology examination
To exclude FMD vertbral artery disection and retinal artery occlusion
Q4. Anticogulation and antiplatlets
Patients should be closely monitored for delayed ischemic or embolic neurologic symptoms and for the hemorrhagic side effects of antithrombotic medication. Ischemic stroke, mainly from thromboembolic complications of the initial dissection, may occur. Hemorrhagic stroke may occur secondary to anticoagulant use in some patients.
Thank you Dr Mohamed
1. What is your clinical diagnosis?
Type III ICA Dissection
2. What is the most likely precipitating factor?
Traumatic from the chriopacter.
3. Please outline any other Investigations you would request and pathologies to rule out?
CT/MRI Brain
Fundus examination
Cranial nerve examination
4. What is your management and surveillance plan?
Conservative with anticoagulant and antiplatlet
Thank you Dr Mina
Thank you Dr Eman and Dr Abdullah.
Are there any situations where you would consider intervention for a carotid artery dissection?
If the case was fmd
Chronic carotid dissection can be effectively treated by surgical reconstruction to prevent further ischemic or thromboembolic complications, if medical treatment for 6 months with anticoagulation failed or if carotid aneurysms and/or high-grade carotid stenosis persisted or have newly developed.
Or deteriorated neurological symptome despite medical ttt.
Recurrent symptoms
if it is severely symptomatic or complicated
Q1. Carotid artery dissection
Q2. Traumatic
Q3. Echocardiography
Neuroimaging (eg, contrast and noncontrast CT or MRI of the brain)
Ct or MRI cervical to rule out cervical vertebrae disease or fracture
Electroencephalography (EEG)
Opthalmology examination
To exclude FMD vertbral artery disection and retinal artery occlusion
Q4. Anticogulation and antiplatlets
Patients should be closely monitored for delayed ischemic or embolic neurologic symptoms and for the hemorrhagic side effects of antithrombotic medication. Ischemic stroke, mainly from thromboembolic complications of the initial dissection, may occur. Hemorrhagic stroke may occur secondary to anticoagulant use in some patients.
Dissection may recur in the unaffected artery; the incidence of this development may be higher than 1% per year in patients with a known heritable arteriopathy
1carotid dissection
2 choriopeactor
3 mra
Pathology fmd
4
Conservative ttt anti platelet