Background

Carotid artery dissection begins as a tear in one of

the carotid arteries of the neck, which allows blood
under arterial pressure to enter the wall of the
artery and split its layers. The result is either an
intramural hematoma or an aneurysmal dilatation,
either of which can be a source of microemboli,
with the latter also causing a mass effect on
surrounding structures.

Carotid artery dissection is a significant cause of
ischemic stroke in all age groups, but it occurs most
frequently in the fifth decade of life and accounts
for a much larger percentage of strokes in young
patients.[1] Dissection of the internal carotid artery
can occur intracranially or extracranially, with the
latter being more frequent. Internal carotid artery
dissection can be caused by major or minor trauma,
or it can be spontaneous, in which case, genetic,
familial, or heritable disorders are likely etiologies.

Although in practice, dissections are labeled
spontaneous in the absence of major blunt or
penetrating trauma,[2] when they are associated
with minor mechanism trauma they may be caused
or influenced by an underlying arteriopathy.[3]
Patients can present in a variety of settings, such as
a trauma bay with multiple traumatic injuries; a
physicians office with nonspecific head, neck, or
face pain; or an emergency department (ED) with a
partial Horner syndrome.

Sophisticated imaging techniques, which have
improved over the past 2 decades, are required to
confirm the presence of dissection. Most ischemic
cerebral symptoms arise from thromboembolic
events; therefore, early institution of antithrombotic
treatment provides the best outcome.[4]

Once diagnosed and treated, patients with carotid
artery dissection require regular follow-up and
imaging studies of both carotid arteries because
healing usually takes 3-6 months and the incidence
of contralateral dissection is higher than in the
general population. When the condition is
diagnosed early, the prognosis is usually good. A
high index of suspicion is required to make this
difficult diagnosis.

For patient education resources, see the Stroke
fundal
Disecie artera carotid ncepe ca o lacrim ntr-una
din arterele carotide alegtului , care permite
sngelui arterial sub presiune pentru a intra n
peretele arterei i mpri straturile sale . Rezultatul
este fie un hematom intramural sau o dilatare
aneurysmal , oricare dintre care poate fi o surs de
microembolilor , cuacesta din urm provoac , de
asemenea, un efect de masa asupra structurilor
nconjurtoare .

Disecie artera carotida este o cauza semnificativa
de accident vascular cerebral ischemic , n toate
grupele de vrst , dar apare cel mai frecvent n al
cincilea deceniu de via i conturi pentru un
procent mult mai mare de accident vascular
cerebral la pacientii tineri . [ 1 ] Disecia arterei
carotide interne pot aprea intracranially sau
extracranially , cu acesta din urm fiind mai
frecvente . Disecia arterei carotide interne pot fi
cauzate de traume majore sau minore , sau poate fi
spontan , n cazul n care , boli genetice , familiale ,
sau ereditare sunt etiologii probabile .

Dei, n practic , sunt etichetate dissections
spontan n absena traume sau penetrant major , [
2 ] , atunci cnd sunt asociate cu traumatisme
minore mecanism acestea pot fi provocate sau
influenate de o arteriopatie subiacent [ 3 ] .
Pacienii pot prezenta ntr-o varietate de setri ,
cum ar fi o infirmerie cu multiple leziuni
traumatice , biroul unui medic cu cap nespecifice ,
gt , sau dureri de fata , sau un departament de
urgenta ( ED ), cu un sindrom parial Horner .

Tehnici imagistice sofisticate , care s-au
imbunatatit in ultimii 2 decenii , sunt necesare
pentru a confirma prezena de disecie . Simptome
cerebrale mai ischemice apar din evenimente
tromboembolice ; . Prin urmare , instituie precoce
a tratamentului antitrombotic ofer cele mai bune
rezultate [ 4 ]

Odat diagnosticate si tratate , pacientii cu disectie
arterei carotide necesit regulate follow - up i
studii de imagistica de ambele artere carotide ,
deoarece vindecarea dureaz de obicei 3-6 luni si a
incidentei de disecie contralateral este mai mare
dect n populaia general . n cazul n care
condiia este diagnosticat precoce , prognosticul
este de obicei bun . Un indice ridicat de suspiciune
Center, as well as Worst Headache of Your Life,
Transient Ischemic Attack (Mini-stroke), and
Stroke.

Pathophysiology
Although the cause of internal carotid artery
dissection remains elusive, mechanical forces (eg,
trauma, blunt injury, and stretching) and underlying
arteriopathies (eg, Ehlers-Danlos syndrome IV and
other connective tissue disorders and aberrations),
either alone or in combination, account for most of
the pathophysiology. It is widely accepted that
carotid artery dissection is a multifactorial
disease.[5]

Carotid artery dissection begins as a tear in the
tunica intima or directly within the tunica media
(possibly originating from the vasa vasorum).[1]
The blood dissects along the artery to create an
intramural hematoma that leads to a thrombus,
which can narrow the carotid artery lumen and
become a nidus for distal embolization (see the
image below).[2]

Arterial dissection. (A) Tear and elevation of int
Arterial dissection. (A) Tear and elevation of
intima from wall of artery, resulting in luminal
stenosis. Illustration shows stasis of flow in false
lumen beneath elevated intima. This condition
creates blind pouch that predisposes patient to
thrombus formation. (B) Subadventitial dissection
represents hemorrhage between media and
adventitia. Artery may become dilated as result of
thickening of arterial wall, with some degree of
luminal narrowing. Elevation of intimal flap is not
commonly associated with this type of dissection.
Hemorrhage may extravasate through adventitia,
resulting in pseudoaneurysm or fistula formation.
Sometimes, the dissection plane lies between the
tunica media and the tunica adventitia, resulting in
an aneurysmal outpouching of the arterial wall that
may also become a source of distal emboli.
Aneurysmal dilatation can also cause a mass effect
on nearby structures such as sympathetic fibers and
the lower cranial nerves.[1, 2] The dilatation
resulting from an internal carotid artery dissection
may be termed a true rather than a false aneurysm
because the wall is composed of blood vessel
elements.

Etiology
este necesar pentru a face acest diagnostic dificil .

Pentru resurse de pacient de educatie , consultai
Centrul de Accident vascular cerebral , precum si
ca cel mai rau Dureri de cap din viata ta , atac
ischemic tranzitor ( mini - accident vascular
cerebral ) , i accident vascular cerebral .

Fiziopatologie
Desi cauza de disectie arterei carotide interne
rmne forele evaziv , mecanice ( de exemplu ,
traumatisme , leziuni greu de cap , i se ntinde ) i
arteriopatii de baz ( de exemplu , Ehlers - Danlos
IV i alte tulburri ale esutului conjunctiv i
aberaii ) , fie singur, fie n combinaie , considerare
pentru majoritateafiziopatologiei . Este unanim
acceptat faptul ca disectie arterei carotide este o
boal multifactorial . [ 5 ]

Disecie artera carotida ncepe ca o lacrim n
Tunica intima sau direct n mass-media tunica (
eventual, provenind de la Vasa vasorum ) [ 1 ]
disec . De sange de-a lungul arterei de a crea un
hematom intramural , care conduce la o trombilor ,
care pot reduce lumenul arterei carotide i a devenit
un nidus pentru embolizare distal ( a se vedea
imaginea de mai jos ) . [ 2 ]

Disecia arterial . ( A ) lacrimogene i altitudine de
Int
Disecia arterial . ( A ) Lacrima i ridicarea intima
din peretele arterei , rezultnd n stenoza luminale .
Ilustraie staz de flux n lumenul fals sub intima
crescute . Aceast condiie creeaz hus orb , care
predispune pacientul la formarea trombilor . (B )
disecie Subadventitial reprezint hemoragie ntre
mass-media i adventitia . Artera poate deveni
dilatat ca urmare a ingrosarea peretelui arterial , cu
un anumit grad de ingustarea lumenului . Ridicarea
clapetei intimal nu este frecvent asociat cu acest tip
de disectie . Hemoragia poate extravazare prin
adventitia , rezultnd n pseudoanevrism sau
formare de fistule .
Uneori , planul de disecie se afl ntre mass-media
tunica si adventitia tunica , rezultnd ntr- o
outpouching aneurysmal a peretelui arterial , care
poate deveni , de asemenea, o surs de emboli
distal . Dilatarea aneurysmal poate provoca , de
asemenea, un efect de mas pe structuri din
apropiere , cum ar fi fibrele simpatic si nervii
cranieni inferioare . [ 1 , 2 ]dilatare rezult dintr-o
Causes of carotid artery dissection include the
following:

Heritable connective-tissue disorders
Ehlers-Danlos syndrome type IV
Fibromuscular dysplasia
Cystic medial necrosis
Marfan syndrome
Autosomal dominant polycystic kidney disease
Osteogenesis imperfecta type I
Oral contraceptives
Hypertension
Neck manipulation or strain - This can result from
intentional manipulation or from other strain that
may occur during sports activities, yoga, or even
apparently minimal activity (eg, overhead painting)
Blunt trauma from high impact and seemingly
minor mechanisms of injury
Penetrating trauma
Wearing a 3-point restraint seat belt during a motor
vehicle crash
Smoking
Respiratory tract infection
Epidemiology
The annual incidence of symptomatic spontaneous
internal carotid artery dissection is 2.5-3 per
100,000.[1] The incidence of carotid artery
dissection as a result of blunt injuries (mainly high-
speed motor vehicle accidents) ranges from less
than 1% to 3%.[6] The actual incidence may be
higher; some dissections are asymptomatic or cause
only minor transient symptoms and remain
undiagnosed.

Age- and sex-related demographics
Internal carotid artery dissection is a common
cause of ischemic stroke in patients younger than
50 years and accounts for as many as 25% of
ischemic strokes in young and middle-aged
patients.[1] The mean age for ischemic stroke
secondary to internal carotid artery dissection from
blunt traumatic injury is even younger: 35-38 years.
Dissection of the intracranial part of the internal
carotid artery is rare at any age, because the
intracranial carotid artery is less mobile and the
skull absorbs most of the force of trauma.

No significant gender-based difference in
frequency exists for spontaneous internal carotid
artery dissection, though there may be a slight male
preponderance when traumatic causes of carotid
disecie arterei carotide interne poate fi numit un
adevrat , mai degrab dect un anevrism fals
deoarece peretele este alctuit de elemente de vas
de sange .

etiologie
Cauzele de disecie artera carotida includ
urmtoarele :

Ereditare tulburari conjunctiv - esutului
Sindromul Ehlers - Danlos tip IV
fibromuscular displazie
Necroza medial chistica
sindromul Marfan
Boala autosomal dominant rinichi polichistic
Osteogenez imperfect tip I
contraceptivele orale
hipertensiune
Manipulare gt sau tulpina - Acest lucru poate duce
la manipulare intenionat sau din alte tulpina care
pot aprea n timpul activitilor sportive , yoga ,
sau chiar aparent activitate de minim ( de exemplu ,
pictura aeriene )
Trauma greu de cap de la mare impact i
mecanisme aparent minore de prejudiciu
traumatism penetrant
Purtand o reinere de 3 puncte Centura de siguran
n timpul unui accident de vehicul cu motor
fumat
Infectii ale tractului respirator
Epidemiologie
Incidenta anuala de disecie simptomatice spontane
arterei carotide interne este de 2,5-3 la 100.000 . [ 1
] Incidenta de disectie arterei carotide ca urmare a
unor leziuni greu de cap ( n special de mare vitez
accidente de autovehicule ) variaz de la mai puin
de 1 % pn la 3 % [ 6 ]Incidena real poate fi mai
mare , unele disecii sunt asimptomatice sau
provoca simptome tranzitorii minore i rmn
nediagnosticate . .

Varsta si demografice legate de sex
Disecie artera carotid intern este o cauza
comuna de accident vascular cerebral ischemic la
pacientii mai tineri de 50 ani i conturile de cat mai
multe ca 25 % din accidente vasculare cerebrale
ischemice la pacientii tineri i de vrst mijlocie . [
1 ] Vrsta medie pentru accident vascular cerebral
ischemic secundar la artera carotid intern disecie
de leziuni traumatice bont este chiar mai mic : 35-
38 ani . Disecia parte intracraniene aarterei
artery dissection are taken into account.

Prognosis
In general, the prognosis depends on the severity of
the initial ischemic injury and the extent of
collateral circulation. Overall, the prognosis for
spontaneous internal carotid artery dissection is
favorable, with about 75% of patients making a
good recovery.[1, 7] The reported mortality is less
than 5%. Patients who have a dissection secondary
to trauma have a much higher rate of mortality on
discharge.

Morbidity from carotid artery dissection ranges in
severity from transient focal deficits to permanent
cerebral or retinal ischemic injury. More than one
half of patients with spontaneous carotid artery
dissection develop stroke,[1] although this may be
delayed by hours or days. Rates of delayed stroke
due to blunt-traumatic causes of carotid artery
injury range from 3% in grade I injuries to 44% in
grade IV injuries.[2]

In the setting of blunt trauma, 37-58% of patients
have permanent neurologic deficits on
discharge,[6] though early use of antithrombotic
therapy has essentially eliminated ischemic events
in asymptomatic patients with carotid artery
dissection.[4, 8]

As in other causes of stroke in young adults, the
functional outcome is generally good, and
recurrence of cerebral ischemia and carotid artery
dissection is rare.[5] The risk of recurrence is
highest in the first month and then remains in the
area of 1% per year for about a decade. Headache
may persist, in some cases for years after the
dissection.
carotide interne este rar la orice vrst ,
deoareceartera carotid intracraniene este mai puin
mobil icraniului absoarbe cea mai mare parte a
forei de traume .

Nici o diferenta semnificativa de gen n frecven
exist pentru disecie spontan arterei carotide
interne , dei poate exista o uoar preponderen
de sex masculin atunci cnd cauze traumatice de
disectie arterei carotide sunt luate n considerare .

prognoz
n general ,prognosticul depinde deseveritatea
leziunii ischemice iniial iamploarea circulaiei
colaterale . n general , prognosticul pentru disecie
spontan arterei carotide interne este favorabil , cu
aproximativ 75 % dintre pacienti a face o
recuperare bun . [ 1 , 7 ] Mortalitatea raportat este
mai mic de 5 % . Pacientii care au o disecie a
unei traume au o rata mult mai mare de mortalitate
privind descrcarea de gestiune .

Morbiditatea de disecie artera carotida variaz n
severitate de la deficite focale tranzitorii la leziuni
permanente cerebrale sau retiniene ischemice . Mai
mult de jumtate din pacienii cu disecie spontan
artera carotida dezvolta accident vascular cerebral ,
[ 1 ] dei acest lucru poate fi ntrziat de ore sau
zile . Ratele de accident vascular cerebral amnat
din cauza unor cauze bont - traumatice ale carotide
gama prejudiciu artera de la 3 % n clasa I leziuni
la 44 % din leziuni grad IV . [ 2 ]

n stabilirea de traume , 37-58 % dintre pacienti au
deficite neurologice permanente privind
descrcarea de gestiune , [ 6 ] , dei utilizarea
timpurie a terapiei antitrombotice a eliminat , n
esen evenimente ischemice la pacientii
asimptomatici cu disecie artera carotida . [ 4 , 8 ]

Ca i n alte cauze de accident vascular cerebral la
tineri adulti , rezultatul funcional este n general
bun , i recurena ischemie cerebrala si disectia
arterei carotide este rar . [ 5 ] , riscul de recuren
este mai mare n prima lun i apoi rmne n zona
1 % pe an, timp de aproximativ un deceniu .
Durerile de cap pot persista , n unele cazuri, de ani
de la disectie .