Abstract
Extracranial arterial dissections are a recognised cause of stroke, particularly in young adults. Clinical diagnosis may be difficult, and the classical triad of symptoms is uncommon. Imaging plays a pivotal role in the diagnosis of extracranial arterial dissections, and this review provides a detailed discussion of the relative merits and limitations of currently available imaging modalities. Conventional arteriography has been the reference standard for demonstrating an intimal flap and double lumen, which are the hallmarks of a dissection, and for detecting complications such as stenosis, occlusion or pseudoaneurysm. Noninvasive vascular imaging methods, such as ultrasound (US), magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are increasingly replacing conventional angiography for the diagnosis of carotid and vertebral dissections. Ultrasound provides dynamic and “real-time” information regarding blood flow. Source data of MRA and CTA and additional cross-sectional images can provide direct visualisation of the mural haematoma and information about the vessel lumen. Anticoagulation to prevent strokes is the mainstay of medical treatment, but randomised trials to define the optimal treatment regime are lacking. Surgery has a limited role in management of dissections, but endovascular procedures are gaining importance for treatment of complications and if medical management fails.
Similar content being viewed by others
References
Ducrocq X, Lacour JC, Debouverie M, Bracard S, Girard F, Weber M (1999) Accidents vasculaires cerebraux ischemiques du sujet jeune: etude prospective de 296 patients ages de 16 a 45 ans. Rev Neurol (Paris) 155:575–582
Hart RG, Easton JD (1985) Dissections. Stroke 16:925–927
Lucas C, Moulin T, Deplanque D, Tatu L, Chavot D (1998) Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 29:2646–2648
Bogousslavsky J, Regli F (1987) Ischemic stroke in adults younger than 30 years of age: cause and prognosis. Arch Neurol 44:479–482
Jentzer A (1954) Dissecting aneurysm of the left internal carotid artery. Angiology 5:232–234
Provenzale JM, Barboriak DP, Taveras JM (1995) Exercise-related dissection of craniocervical arteries: CT, MR and angiographic findings. J Comput Assit Tomogr 19:268–276
Mokri B (1990) Traumatic and spontaneous extracranial internal carotid artery dissections. J Neurol 237:356–361
Biller J, Hingtgen WL, Adams HP, Smoker WRK, Godersky JC, Toffol GJ (1986) Cervicocephalic arterial dissections. A ten-year experience. Arch Neurol 43:1234–1238
Luken MG, Ascherl GF, Correll JW, Hilal SK (1975) Spontaneous dissections of the extracranial internal carotid artery. Clin Neurosurg 26:353–357
Descamps MJ, Lewis MJ, Hart PE, Brew S, Jager HR, Greenwood R (2004) Brainstem infarction during long-haul air travel. Eur Neurol 52:181–184
Nadgir RN, Loevner LA, Ahmed T, Moonis G, Chalela J, Slawek K et al (2003) Simultaneous bilateral internal carotid and vertebral artery dissection following chiropractic manipulation: case report and review of the literature. Neuroradiol 45:311–314
Mas JL, Bousser MG, Hasboun D, Laplane D (1987) Extracranial vertebral artery dissection. A review of 13 cases. Stroke 18:889–903
Schievink WI, Michels VV, Piepgras DG (1994) Neurovascular manifestations of heritable connective tissue disorders: a review. Stroke 25:889–903
Schievink WI, Bjornsson J, Piepgras DG (1994) Coexistance of fibromuscular dysplasia and cystic medial necrosis in a patient with Marfan’s syndrome and bilateral carotid artery dissections. Stroke 25:2492–2496
Karacagil S, Hardemark HG, Bergovist D (1996) Spontaneous internal carotid artery dissection. Int Angiol 15:291–294
Mokri B, Sundt TH, Houser OW, Piepgras DG (1986) Spontaneous dissection of the cervical internal carotid artery. Ann Neurol 19:126–138
Ast G, Woimant F, Georges B, Laurian C, Haguenau M (1993) Spontaneous dissection of the internal carotid artery in 68 patients. Eur J Med 2:466–472
Provenzale JM, Morgenlander JC, Georges B, Laurian C, Haguenau M (1996) Spontaneous vertebral dissection: clinical, conventional angiographic, CT, and MR findings. J Comput Assit Tomogr 20:185–193
Chiras J, Marciano S, Molina J, Touboul J, Poirier B, Bories J (1985) Spontaneous dissecting aneurysm of the extracranial vertebral artery (20 cases). Neuroradiol 27:327–333
Mokri B, Houser OW, Sandok BA (1988) Spontaneous dissections of the vertebral arteries. Neurology 38:880–885
Sturzenegger M (1994) Headache and neck pain: the warning symptoms of vertebral artery dissection. Headache 34:187–193
Biousse V, D’Anglejan-Chatillon J, Massiou H, Bousser MG (1994) Head pain in nontraumatic carotid artery dissection: a series of 65 patients. Cephalgia 14:33–36
Davies MJ, Treasure T, Richardson PD (1996) The pathogenesis of spontaneous arterial dissection. Heart 75:434–435
Anson J, Crowell RM (1991) Cervicocranial arterial dissection. Neurosurg 29:89–96
Fisher CM, Ojemann RG, Roberson GH (1978) Spontaneous dissection of cervico-cerebral arteries. Can J Neurol Sci 5:9–19
Schievink WI, Mokri B, O’Fallon WM (1994) Recurrent spontaneous cervical-artery dissection. N Engl J Med 330:393–397
Vilela P, Goulao A (2005) Ischemic stroke: carotid and vertebral artery disease. Eur Radiol 15:427–433
Wityk RJ (2001) Stroke in a healthy 46-year-old man. JAMA 285:2757–2762
Levy C, Laissy JP, Raveau V, Amarenco P, Servois V, Bousser MG et al (1994) Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography. Radiology 190:97–103
Caplan LP, Zarins CK, Hemmati M (1985) Spontaneous dissection of the extracranial vertebral arteries. Stroke 16:1030–1038
Hinse P, Thie A, Lachenmayer L (1991) Dissection of the extracranial vertebral artery: a report of four cases and a review of the literature. J Neurol Neurosurg Psychiatry 54:863–869
Mokri B, Silbert PL, Schievink WI, Piepgras DG (1996) Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery. Neurology 46:356–359
Gobert M, Mounier-Vehier F, Lucas C, Leclerc X, Leys D (1996) Cranial nerve palsies due to internal carotid artery dissection: seven cases. Acta Neurol Belg 96:55–61
Schievink WI, Mokri B, Piepgras DG (1994) Spontaneous dissections of the cervicocephalic arteries in childhood and adolescence. Neurology 44:1607–1612
Caplan LR, Baquis GD, Pessin MS, D’Alton J, Adelman LS, DeWitt LD et al (1988) Dissection of the intracranial vertebral artery. Neurology 38:868–877
Ramgren B, Cronqvist M, Romner B, Brandt L, Holtas S, Larsson EM (2005) Vertebrobasilar dissection with subarachnoid hemorrhage: a retrospective study of 29 patients. Neuroradiol 47:158–164
Rabinov J, Hellinger F, Morris P, Ogilvy C, Putman C (2003) Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 24:1421–1428
Sandmann W, Hennerici M, Aulich A, Kniemeyer H, Kremer KW (1984) Progress in carotid artery surgery at the base of the skull. J Vasc Surg 1:734–743
Schievink WI, Mokri B, Whisnant JP (1993) Internal carotid artery dissection in a community. Rochester. Minnesota. 1987–1992. Stroke 24:1678–1680
Treiman GS, Treiman RL, Foran RF, Levin PM, Cohen JL, Wagner WH et al (1996) Spontaneous dissection of the internal carotid artery: a nineteen-year clinical experience. J Vasc Surg 24:597–605
Hirai T, Korogi Y, Ikushima I, Shigematsu Y, Morishita S, Yamashita Y (2003) Intracranial artery dissections: serial evaluation with MR imaging, MR angiography, and source images of MR angiography. Radiat Med 21:86–93
Grzyska U, Freitag mJ, Zeumer H (1990) Selective cerebral intraarterial DSA. Complication rate and control of risk factors. Neuroradiol 32:296–299
Roome NS, Aberfeld DC (1977) Spontaneous dissecting aneurysm of the internal carotid artery. Arch Neurol 34:251–252
Weinberger J (1981) Doppler pulse waveform analysis of carotid artery flow in dissecting aortic aneurysm. Arch Neurol 38:256–257
Houser OW, Mokri B, Sundt TM, Baker HL, Reese DF (1984) Spontaneous cervical cephalic arterial dissection and its residuum: angiographic spectrum. AJNR Am J Neuroradiol 5:27–34
Hart RG, Easton JD (1983) Dissections of cervical and cerebral arteries. Neurol Clin 1:155–182
Pelkonen O, Tikkakoski T, Leinonen S, Pyhtinen J, Lepojarvi M, Sotaniemi K (2003) Extracranial internal carotid and vertebral artery dissections: angiographic spectrum, course and prognosis. Neuroradiology 45:71–77
Friedman DP, Flanders AE (1992) Unusual dissection of the proximal vertebral artery: description of 3 cases. AJNR Am J Neuroradiol 13:283–286
Simeone FA, Goldberg HI (1968) Thrombosis of the vertebral artery from hyperextension injury to the neck. J Neurosurg 29:540–543
Schievink WI (2000) The treatment of spontaneous carotid and vertebral artery dissections. Curr Opin Cardiol 15:316–321
Touze E, Randoux B, Meary E, Arquizan C, Meder JF, Mas JL (2001) Aneurysmal forms of cervical artery dissection. Associated factors and outcome. Stroke 32:418–423
Steinke W, Rautenberg W, Schwartz A, Hennerici M (1994) Noninvasive monitoring of internal carotid artery dissection. Stroke 25:998–1005
Logason K, Hardemark HG, Barlin T, Bergqvist D, Ahlstom H, Karacagil S (2002) Duplex scan findings in patients with spontaneous cervical artery dissections. Eur J Vasc Endovasc Surg 23:295–298
Bluth EI, Shyn PB, Sullivan M, Merritt CR (1989) Doppler color flow imaging of carotid artery dissection. J Ultrasound Med 8:149–153
Sidhu PS, Jonker ND, Khaw KT, Patel N, Blomley MJK, Ray-Chaudhuri K et al (1997) Spontaneous dissections of the internal carotid artery: appearances on color Doppler ultrasound. Br J Radiol 70:50–57
Gardner DJ, Gosink BB, Kallman CE (1991) Internal carotid artery dissections: duplex ultrasound imaging. J Ultrasound Med 10:607–614
Sturzenegger M, Mattle HP, Rivoir A, Baumgartner RW (1995) Ultrasound findings in carotid artery dissection: analysis of 43 patients. Neurology 45:691–698
Waluch V, Bradley WG (1984) NMR even echo rephasing in slow laminar flow. J Comput Assit Tomogr 8:594–598
Aggarwal S, Kucharczyk W, Keller MA (1999) Asymptomatic postendarterectomy dissection of the internal carotid artery detected incidentally on MRI. Neuroradiol 35:586–587
Sturzenegger M, Mattle HP, Rivoir A, Rihs F, Schmid C (1993) Ultrasound findings in spontaneous extracranial vertebral artery dissection. Stroke 24:1910–1921
Goldberg HI, Grossman RI, Gomori JM, Asbury AK, Bilaniuk LT, Zimmerman RA (1986) Cervical internal carotid artery dissecting hemorrhage: diagnosis using MR. Radiology 158:157–161
Stringaris K, Liberopoulos K, Giaka E, Kokkinis K, Bastounis E, Klonaris EC et al (1996) Three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography in carotid artery dissections. Int Angiol 15:20–25
Kitanaka C, Tanaka J, Kuwahara M, Teraoka A (1994) Magnetic resonance imaging study of intracranial vertebrobasilar artery dissections. Stroke 25:571–575
Kirsch E, Kaim A, Engelter S, Lyrer P, Stock KW, Bongartz G et al (1998) MR angiography in internal carotid artery dissection: improvement of diagnosis by selective demonstration of the intraluminal haematoma. Neuroradiology 40:704–709
Schwaighofer B, Klein MV, Lyden PD, Hesselink JR (1990) MR imaging of vertebrobasilar vascular disease. J Comput Assit Tomogr 14:895–904
Zuber M, Meary E, Meder JF, Mas JL (1994) Magnetic resonance imaging and dynamic CT scan in cervical dissections. Stroke 25:576–581
Heinz ER, Yeates AE, Djang WT (1989) Significant extracranial carotid stenosis: detection on routine cerebral MR images. Radiology 170:843–848
Katz BH, Quencer RM, Kaplan JO, Hinks RS, Post MJ (1989) MR imaging of intracranial carotid occlusion. AJR Am J Roentgenol 152:1271–1276
Provenzale JM (1995) Dissection of the internal carotid and vertebral arteries: imaging features. AJR Am J Roentgenol 165:1099–1104
Gelbert F, Assouline E, Hodes JE, Reizine D, Woimant F, George B et al (1991) MRI in spontaneous dissection of vertebral and carotid arteries. 15 cases studied at 0.5 tesla. Neuroradiol 33:111–113
Ozdoba C, Sturzenegger MN, Schroth G (1996) Internal carotid artery dissection. MR imaging features and clinical-radiologic correlation. Radiology 199:191–198
Grolimund P, Seller RW, Aaslid R, Huber P, Zurbruegg H (1987) Evaluation of cerebrovascular disease by combined extracranial and transcranial Doppler sonography. Experience in 1,039 patients. Stroke 18:1018–1024
Middleton WD, Foley WD, Lawson TL (1988) Color-flow Doppler imaging of carotid artery abnormalities. AJR Am J Roentgenol 150:419–425
Sipponen JT, Sepponen RE, Sivula A (1983) Nuclear magnetic resonance (NMR) imaging of intracerebral hemorrhage in the acute and resolving phases. J Comput Assit Tomogr 7:954–960
Tay KY, U-King-Im JM, Trivedi RA, Higgins NJ, Cross JR, Weissberg PL et al (2005) Imaging the vertebral artery. Eur Radiol 15:1329–1343
George B, Laurian C (1987) The vertebral artery. Pathology and surgery. Springer Verlag, Vienna
Leclerc X, Lucas C, Godefroy O, Nicol L, Moretti A, Leys D et al (1999) Preliminary experience using contrast-enhanced MR angiography to assess vertebral artery structure for the follow-up of suspected dissection. AJNR Am J Neuroradiol 20:1482–1490
Schuknecht B (2004) Latest techniques in head and neck CT angiography. Neuroradiol 46:s208–s213
Leclerc X, Godefroy O, Salhi A, Lucas C, Leys D, Pruvo JP (1996) Helical CT for the diagnosis of extracranial internal carotid artery dissection. Stroke 27:461–466
Chen CJ, Tseng YC, Lee TH, Hsu HL, See LC (2004) Multisection CT angiography compared with catheter angiography in diagnosing vertebral artery dissection. AJNR Am J Neuroradiol 25:769–774
Biousse V, D’Anglejan-Chatillon J, Touboul PJ, Amarenco P, Bousser MG (1995) Time course of symptoms in extracranial carotid artery dissections. A series of 80 patients. Stroke 26:235–239
Srinivasan J, Newell DW, Sturzenegger M, Mayberg MR, Winn HR (1996) Transcranial Doppler in the evaluation of internal carotid artery dissection. Stroke 27:1226–1230
Leys D, Lucas C, Gobert M, Deklunder G, Pruvo JP (1997) Cervical artery dissections. Eur Neurol 37:3–12
Arnold M, Nedeltchev K, Sturzenegger M, Schroth G, Loher TJ (2002) Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature. Arch Neurol 59:549–553
Coffin O, Maiza D, Galateau-Salle F, Martel B, Vignon C, Neri E et al (2004) Results of surgical management of internal carotid artery aneurysm by the cervical approach. Ann Vasc Surg 24:597–605
Muller BT, Luther B, Hort W, Neumann-Haefelin T, Aulich A, Sandmann W (2000) Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg 31:980–988
Kadkhodayan Y, Jeck DT, Moran CJ, Derdeyn CP, Cross DT (2005) Angioplasty and stenting in carotid dissection with or without associated pseudoaneurysm. AJNR Am J Neuroradiol 26:2328–2335
Liu AY, Paulsen RD, Marcellus ML, Steinberg GK, Marks MP (1999) Long-term outcomes after carotid stent placement for treatment of carotid artery dissection. Neurosurg 45:1368–1379
Simionato F, Righi C, Scotti G (1999) Post-traumatic dissecting aneurysm of extracranial internal carotid artery: endovascular treatment with stenting. Neuroradiol 41:543–547
Saito R, Ezura M, Takahashi A, Yoshimoto T (2000) Combined neuroendovascular stenting and coil embolization for cervical carotid artery dissection causing symptomatic mass effect. Surg Neurol 53:318–322
Heye S, Maleux G, Vandenberghe R, Wilms G (2005) Symptomatic internal carotid artery dissecting pseudoaneurysm: endovascular treatment by stent-graft. Cardiovasc Intervent Radiol 28:499–501
Lupattelli T, Garaci FG, Hopkins CE, Simonetti G (2003) Covered stent deployment and follow-up of a case of internal carotid artery pseudoaneurysm. Cerebrovasc Dis 16:98–101
Tseng A, Ramaiah V, Rodriguez-Lopez JA, Perkowshi PE, Del Santo PB, Gowda RG et al (2003) Emergent endovascular treatment of a spontaneous internal carotid artery dissection with pseudoaneurysm. J Endovascular Therapy 10:643–646
Felber S, Henkes H, Weber W, Milosavski E, Brew S, Khune D (2004) Treatment of extracranial and intracranial aneurysms and arteriovenous fistulae using stent grafts. Neurosurg 55:631–638
Sugiu K, Tokunaga K, Watanabe K, Sasahara W, Ono S, Tamiya T et al (2005) Emergent endovascular treatment of ruptured vertebral artery dissecting aneurysms. Neuroradiol 47:158–164
Rabinov JD, Hellinger FR, Morris PP, Ogilvy CS, Putman CM (2003) Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol 24:1421–1428
Schievink WI, Wijdicks EF, Michels VV, Vockley J, Godfrey M (1998) Heritable connective tissue disorders in cervical artery dissections: a prospective study. Neurology 50:1166–1169
Schievink WI, Meyer FB, Parisi JE, Wijdicks EF (1998) Fibromuscular dysplasia of the internal carotid artery associated with alpha1-antitrypsin deficiency. Neurosurg 43:229–234
Author information
Authors and Affiliations
Corresponding author
Additional information
H. Rolf Jäger and Paul S. Sidhu contributed equally as senior authors.
Rights and permissions
About this article
Cite this article
Flis, C.M., Jäger, H.R. & Sidhu, P.S. Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol 17, 820–834 (2007). https://doi.org/10.1007/s00330-006-0346-7
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-006-0346-7