Internal carotid artery dissection due to direct mechanical damage caused by the ipsilateral elongated styloid process. A 4-year follow-up
Abstract
Internal carotid artery dissection (ICAD) is a complex clinical problem with a multi-causal etiology, in which the intima of the artery ruptures and is detached by the inflowing blood. Causes include trauma, intense exercise, vomiting, prolonged retroflexion of the neck, and spontaneous dissection. The therapy for this condition consists of treatment with anticoagulants or through endovascular intervention in recurrent cases. The aim of this paper is to present a case of ICAD in a young woman complicated by an ischemic stroke caused by an elongated styloid process. This abnormality was found in 3D computed tomography. In the described case, it was decided to start pharmacotherapy and withdraw from the endovascular treatment due to the technical difficulties of the procedure. The patient had been followed up regularly up to 4 years after the incident.
An elongated styloid process may be the cause of Eagle’s Syndrome classified into two types: classical type, and the rare carotid artery type, a component of which is ICAD. It is estimated that the styloid process in this form occurs in 4% of the population, which may indicate that the amount of ICAD caused by this variant of the styloid process is underestimated and should be included in the differential diagnosis of ischemic stroke in young people.
Keywords: carotid artery dissection (CAD)elongated styloid process (ESP)transient ischemic attack (TIA)Eagle’s syndrome
References
- Goodfriend SD, Tadi P, Koury R. Carotid Artery Dissection. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. .
- Misztal M, Kwiatkowska W, Ohly P, et al. [Internal carotid artery dissection--symptomatology, diagnosis and treatment]. Kardiol Pol. 2011; 69(9): 958–962.
- Brown SC, Falcone GJ, Hebert RM, et al. Stenting for Acute Carotid Artery Dissection. Stroke. 2020; 51(1): e3–e6.
- Engelter ST, Traenka C, Gensicke H, et al. TREAT-CAD investigators. Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial. Lancet Neurol. 2021; 20(5): 341–350.
- Lee VH, Brown RD, Mandrekar JN, et al. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006; 67(10): 1809–1812.
- Schievink W, Roiter V. Epidemiology of cervical artery dissection. Front Neurol Neurosci. 2005; 20: 12–15.
- Bogousslavsky J, Regli F. Ischemic stroke in adults younger than 30 years of age. Cause and prognosis. Arch Neurol. 1987; 44(5): 479–482.
- Blum CA, Yaghi S. Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. Arch Neurosci. 2015; 2(4).
- Paciaroni M, Georgiadis D, Arnold M, et al. Seasonal variability in spontaneous cervical artery dissection. J Neurol Neurosurg Psychiatry. 2006; 77(5): 677–679.
- Kidwell CS, Burgess RE. Dissection syndromes eMedicine. ; 25: May 2010.
- Goodfriend SD, Tadi P, Koury R. Carotid Artery Dissection. In: StatPearls. Treasure Island (FL): StatPearls Publishing; December 24, 2021. ; 28613585.
- Sokler K, Sandev S. New classification of the styloid process length-clinical application on the biological base. Coll Antropol. 2001;25(2):627-632. .
- Bokhari MR, Graham C, Mohseni M. Eagle Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 10, 2022. .
- EAGLE WW. Elongated styloid process; symptoms and treatment. AMA Arch Otolaryngol. 1958; 67(2): 172–176.
- Subedi R, Dean R, Baronos S, et al. Carotid artery dissection: a rare complication of Eagle syndrome. BMJ Case Rep. 2017; 2017.
- Razak A, Short JL, Hussain SI. Carotid artery dissection due to elongated styloid process: a self-stabbing phenomenon. J Neuroimaging. 2014; 24(3): 298–301.
- Sveinsson O, Kostulas N, Herrman L. Internal carotid dissection caused by an elongated styloid process (Eagle syndrome). BMJ Case Rep. 2013; 2013.
- Peng J, Liu Z, Luo C, et al. Treatment of Cervical Artery Dissection: Antithrombotics, Thrombolysis, and Endovascular Therapy. Biomed Res Int. 2017; 2017: 3072098.
- Engelter ST, Brandt T, Debette S, et al. Cervical Artery Dissection in Ischemic Stroke Patients (CADISP) Study Group. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke. 2007; 38(9): 2605–2611.
- Rao AS, Makaroun MS, Marone LK, et al. Long-term outcomes of internal carotid artery dissection. J Vasc Surg. 2011; 54(2): 370–4; discussion 375.