Snap Shot A 34-year-old female presents with constant, severe, throbbing right-sided headache and facial pain and sudden drooping of the right eyelid since yesterday. She is taking oral contraceptives for birth control, and has smoked 20 cigarettes a day for the last 12 years. On PE, pulse rate is 90bpm, blood pressure is 150/95mmHg. There is a 4cm mass at the angle of her right mandible that demonstrates expansile pulsations and audible bruit. Neurological exam is significant for right sided ptosis and miosis. CT of the brain was normal. CT angiogram reveals right internal carotid dissection with severe luminal narrowing caused by intimal flap with associated thrombus. She was started on anticoagulation. Introduction Epidemiology common cause of stroke in < 50year old >50% with spontaneous carotid dissection develop stroke Types atraumatic (spontaneous) traumatic Pathoanatomy begins as intimal tear, leading to intimal flap, which causes luminal stenosis begins as intramural hemorrhage (between tunica media and adventitia), leading to pseudoaneurysm formation begins as a tear in carotid arteries, allowing hemorrhage into arterial wall. Intramural hematoma causes luminal obstruction and formation of thromboemboli Risks mechanical trauma blunt trauma penetrating trauma stretching hypertension neck manipulation (sports, yoga) seat-belt restraint during MVA arteriopathy connective tissue disorders Ehlers-Danlos Marfan syndrome cystic medial necrosis fibromuscular dysplasia polycystic kidney disease (autosomal dominant) osteogenesis imperfecta (type I) smoking oral contraceptive pills Presentation Symptoms headache, neck and facial pain constant, severe pain is initial symptom in 90% patients transient blindness (amaurosis fugax) neck swelling pulsatile tinnitus decreased taste (hypogeusia) focal weakness migraine symptoms Physical exam hemiparetic stroke partial Horner syndrome (ptosis and miosis) anhydrosis is absent because sympathetic fibers to sweat glands run on external carotid artery (not internal) cervical bruit neck hematoma or bruising massive epistaxis Evaluation Labs CBC, PT and PTT if surgery is planned serum creatinine baseline for contrast studies (CT or arteriography) EKG 2D echocardiography Imaging Helical CT angiogram shows narrowed lumen (slit-like cross-section) alternative imaging modalities include MR angiography and conventional angiography Doppler ultrasonography CT or MRI brain (for evaluation of stroke or TIA) Treatment Anticoagulation (IV heparin followed by warfarin) and antiplatelet (aspirin) therapy indications visible carotid thrombus no intracranial or extracranial hemorrhage Carotid angioplasty and stenting indications persistent ischemic symptoms in spite of anticoagulation contraindications to anticoagulation iatrogenic dissection during intravascular procedure significantly compromised cerebral blood flow Prognosis, Prevention and Complications Overall prognosis is favorable 75% good recovery <5% mortality