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A 29-year-old man, with no significant history, presented with a 2-month history of episodic facial numbness on the left side associated with left-sided weakness and expressive dysphasia, lasting about 1 minute. There were no visual disturbances. He was a martial arts enthusiast and led a very active life. He denied any recent trauma to his head or neck. He was a non-smoker and consumed less than 2 units of alcohol a week.
Examination revealed a young man with a pulse rate of 90 beats/min, and blood pressure of 120/80 mmHg. There was no rash, petechiae or lymphadenopathy. Thoracic, cardiovascular and abdominal examinations were normal. No carotid bruits were heard. Nervous system examination revealed normal higher mental functions and no cranial nerve involvement. Motor examination was normal except for an equivocal left plantar response. Sensory examination revealed a patch of altered sensation over the left side of the face. The optic fundi were normal.
The results of the routine laboratory investigations revealed a haemoglobin of 15.1 g/dl, and glucose of 5.7 mmol/l. Electrolytes were within the normal range. Computed tomography of the brain appeared normal. An electroencephalogram showed intermittent slow wave activity in the right anterior and temporal regions. Magnetic resonance imaging (MRI) of the brain (figure 1) revealed multiple areas of high attenuation in the corona radiata and right temporal regions suggestive of ischaemia. A further investigation was performed (figure2).
Brain MRI
Questions
- 1
- What investigation is shown in figure 2 and what does it suggest?
- 2
- What further investigations are appropriate?
- 3
- What is the management and prognosis?
Answers
QUESTION 1
Magnetic resonance angiography suggesting bilateral carotid artery dissection.
QUESTION 2
Carotid Doppler studies confirmed the findings. Echocardiography revealed a normal heart.
QUESTION 3
Anticoagulant treatment is often used for a few months when the dissection involves the extracranial segment of the carotid artery. The prognosis of carotid dissections depends on the presence and severity of ischaemic brain damage. Normalisation of the vascular abnormalities is frequent and is an excellent argument in favour of the prognosis.
Discussion
Arterial dissection results from bleeding into the vessel wall. Some cases are associated with cervical trauma or have evidence of underlying vascular disease. In the above case, strain on the neck due to martial art manoeuvres might have been the cause. The extracranial segment of the internal carotid artery is the vessel most commonly involved. Intracranial carotid dissections are much rarer. Carotid dissection occurs predominantly in young or middle aged adults and shows no sex predominance. Although clinical manifestations can range from isolated headache to rapidly lethal stroke, the most common and suggestive syndrome associates ‘local’ symptoms (such as head or neck pain, Horner's syndrome, pulsatile tinnitus or cranial nerve palsies) and delayed symptoms of cerebral ischaemia in the territory of the internal carotid artery. Dissection can be bilateral or associated with dissection of the vertebral artery. Angiography has long been considered the gold standard for the diagnosis. As this procedure carries a risk of cerebral complications, noninvasive diagnostic approaches such as MRI and ultrasound are being increasingly used.2 Intra-arterial angiography is no longer necessary.
Final diagnosis
Bilateral carotid artery dissection.