Patient presentation, angiographic features, and treatment of strangulation-induced dissection of the internal carotid artery

Report of three cases

Adel M. Malek Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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Randall T. Higashida Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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Van V. Halbach Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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Christopher F. Dowd Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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Constantine C. Phatouros Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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Todd E. Lempert Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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Philip M. Meyers Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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Wade S. Smith Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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Ronald Stoney Department of Radiology, Division of Interventional Neurovascular Radiology, Departments of Neurosurgery and Neurology, and Division of Vascular Surgery, University of California, San Francisco, California

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✓ Domestic violence leading to strangulation by an abusive spouse can cause carotid artery dissection. This phenomenon is rare and has been described in only three previous instances. The authors present their management strategies in three additional cases.

Three young women aged 24 to 43 years were victims of manual strangulation committed by their spouses 3 months to 1 year before presentation. Two of the patients suffered delayed cerebral infarctions before presentation and angiography demonstrated focal, mirror-image severe residual stenoses in the high-cervical internal carotid artery (ICA), which were characteristic of a healed chronic dissection; there was no evidence of fibromuscular dysplasia. One of these patients underwent unilateral percutaneous angioplasty with stent placement, and the other underwent bilateral percutaneous angioplasty. Both patients have recovered from their strokes and remain clinically stable at 8 and 20 months posttreatment, respectively. The third patient presented with bilateral ischemic frontal watershed infarctions resulting from an occluded left ICA and a severely narrowed right ICA. Given the extent of the established infarctions, this case was managed with a long-term regimen of anticoagulation medications, and the patient remains neurologically impaired.

These cases illustrate the susceptibility of the manually compressed ICA to traumatic injury as a result of domestic violence. They identify bilateral symmetrical ICA dissection as a consistent finding and the real danger of delayed stroke as a consequence of strangulation. Endovascular therapy in which percutaneous angioplasty and/or stent placement are used can be useful in treating residual focal stenoses to improve cerebral perfusion and to lower the risk of embolic or ischemic stroke.

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