Imaging of Carotid Dissection
- 456 Downloads
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 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.
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).
KeywordsCarotid artery Craniocervical dissection Computed tomographic angiography Magnetic resonance imaging Magnetic resonance angiography Digital subtraction angiography Carotid Duplex Ultrasonography
Cervical artery dissection
Carotid Duplex imaging
Computed tomographic angiography
Digital subtraction angiography
Fluid attenuation inversion recovery
Glomerular filtration rate
Magnetic resonance angiography
Magnetic resonance imaging
Time of flight
Figure 2 courtesy of Dhruvil Pandya, MD
Compliance with Ethical Standard
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 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. PubMedCrossRefGoogle 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. PubMedPubMedCentralCrossRefGoogle 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. PubMedCrossRefGoogle 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. PubMedCrossRefGoogle 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. PubMedPubMedCentralCrossRefGoogle 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. PubMedCrossRefGoogle 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.Google Scholar
- 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
- 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. PubMedPubMedCentralCrossRefGoogle 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
- 31.Zweifler RM, Silverboard G. Arterial dissections and fibromuscular dysplasia. In: Stroke: Pathophysiology, Diagnosis and Management 6th ed Elsevier; 2016 35, 599-618e7.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. 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. PubMedCrossRefGoogle 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.PubMedCrossRefGoogle 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
- 47.Hakimi R, Garg A. Imaging of hemorrhagic stroke. Continuum (Minneap Minn). 2016;22(5, Neuroimaging):1424–50.Google Scholar