Extracranial traumatic carotid artery dissections in children: a review of current diagnosis and treatment options

Roukoz B. Chamoun Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital and

Search for other papers by Roukoz B. Chamoun in
jns
Google Scholar
PubMed
Close
 M.D.
,
Michel E. Mawad Division of Neurointerventional Radiology, Department of Radiology, Baylor College of Medicine, Houston, Texas

Search for other papers by Michel E. Mawad in
jns
Google Scholar
PubMed
Close
 M.D.
,
William E. Whitehead Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital and

Search for other papers by William E. Whitehead in
jns
Google Scholar
PubMed
Close
 M.D.
,
Thomas G. Luerssen Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital and

Search for other papers by Thomas G. Luerssen in
jns
Google Scholar
PubMed
Close
 M.D.
, and
Andrew Jea Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital and

Search for other papers by Andrew Jea in
jns
Google Scholar
PubMed
Close
 M.D.
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $536.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $536.00
USD  $636.00
Print or Print + Online Sign in

Object

Currently, no diagnostic or treatment standards exist for extracranial carotid artery dissection (CAD) in children after trauma. The purpose of this study was to review and describe the characteristics, diagnosis, and treatment of this rather uncommon sequelae of pediatric trauma.

Methods

A systematic review of the literature was performed to examine the pertinent studies of traumatic extracranial carotid artery (CA) injuries in children.

Results

No randomized trials were identified; however, 19 case reports or small case series consisting of 34 pediatric patients were found in the literature. The diagnosis of CAD was made in 33 of 34 patients only after the onset of ischemic symptomatology. Twenty-four of 34 patients underwent cerebral angiography to confirm diagnosis; MR angiography affirmed the diagnosis in 6 of 34 patients. There was little published experience with CA ultrasonography or CT angiography for diagnosis. Thirty of 34 patients were treated with medical therapy or observation; 2 of 4 patients treated with observation alone died. There was little experience with open surgical treatment of CAD in the pediatric population, and there were no studies on the endovascular treatment of traumatic CAD in children. The literature does not support anticoagulation therapy over antiplatelet therapy.

Conclusions

As a result of this review of the literature, the authors propose the algorithms for the evaluation and treatment of traumatic extracranial CADs in children. These recommendations include utilizing MR angiography as a screening tool in cases in which the clinical suspicion of CAD is high, using conventional cerebral angiography to confirm the diagnosis, implementing antiplatelet therapy as initial medical management, and reserving endovascular stenting in cases of failed medical treatment.

Abbreviations used in this paper:

CA = carotid artery; CAD = CA dissection; TIA = transient ischemic attack.
  • Collapse
  • Expand
  • 1

    Adkins AL, , Zelenock GB, , Bendick PJ, & Shanley CJ: Duplex ultrasound recognition of spontaneous carotid dissection—a case report and review of the literature. Vasc Endovascular Surg 38:455460, 2004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    An T: Fatal dissecting aneurysm of the internal carotid artery with delayed symptoms following facial impact. J Forensic Sci 37:646651, 1992

  • 3

    Bar T, , Zagury A, , Nahlieli O, , London D, , Yoffe B, & Bibi H: Delayed signs and symptoms after oropharyngeal trauma in a child. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94:1517, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Beletsky V, , Nadareishvili Z, , Lynch J, , Shuaib A, , Woolfenden A, & Norris J, et al.: Cervical arterial dissection: time for a therapeutic trial?. Stroke 34:28562860, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Borges G, , Bonilha L, , Santos SF, , Carelli EF, , Fernandes YB, & Ramina R, et al.: Thrombosis of the internal carotid artery secondary to soft palate injury in children and childhood. Report of two cases. Pediatr Neurosurg 32:150153, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Brandt T, , Orberk E, , Weber R, , Werner I, , Busse O, & Müller B, et al.: Pathogenesis of cervical artery dissections: association with connective tissue abnormalities. Neurology 57:2430, 2001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Chabrier S, , Lasjaunias P, , Husson B, , Landrieu P, & Tardieu M: Ischaemic stroke from dissection of the craniocervical arteries in childhood: report of 12 patients. Eur J Paediatr Neurol 7:3942, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Chaves C, , Estol C, , Esnaola MM, , Gorson K, , O'Donoghue M, & De Witt LD, et al.: Spontaneous intracranial internal carotid artery dissection: report of 10 patients. Arch Neurol 59:977981, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Criado FJ, , Wellons E, & Clark NS: Evolving indications for and early results of carotid artery stenting. Am J Surg 174:111114, 1997

  • 10

    de Bray JM, , Lhoste P, , Dubas F, , Emile J, & Saumet JL: Ultrasonic features of extracranial carotid dissections: 47 cases studied by angiography. J Ultrasound Med 13:659664, 1994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Derex L, , Nighoghossian N, , Turjman F, , Hermier M, , Honnorat J, & Neuschwander P, et al.: Intravenous tPA in acute ischemic stroke related to internal carotid artery dissection. Neurology 54:21592161, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Desfontaines P, & Despland PA: Dissection of the internal carotid artery: aetiology, symptomatology, clinical and neurosonological follow-up, and treatment in 60 consecutive cases. Acta Neurol Belg 95:226234, 1995

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Djouhri H, , Guillon B, , Brunereau L, , Lévy C, , Bousson V, & Biousse V, et al.: MR angiography for the long-term follow-up of dissecting aneurysms of the extracranial internal carotid artery. AJR Am J Roentgenol 174:11371140, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Duke B, & Partington M: Blunt carotid injury in children. Pediatr Neurosurg 25:188193, 1996

  • 15

    Fabian TC, , Patton JH Jr, , Croce MA, , Minard G, , Kudsk KA, & Pritchard FE: Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg 223:513525, 1996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Fisher CM, , Ojemann RG, & Roberson GH: Spontaneous dissection of cervicocerebral arteries. Can J Neurol Sci 5:919, 1978

  • 17

    Frantzen E, , Jacobsen HH, & Therkelsen J: Cerebral artery occlusions in children due to trauma to the head and neck. A report of 6 cases verified by cerebral angiography. Neurology 11:695700, 1961

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Fullerton HJ, , Johnston SC, & Smith WS: Arterial dissection and stroke in children. Neurology 57:11551160, 2001

  • 19

    Ganesan V, & Kirkham FJ: Carotid dissection causing stroke in a child with migraine. BMJ 314:291292, 1997

  • 20

    Gomez CR, , May AK, , Terry JB, & Tulyapronchote R: Endovascular therapy of traumatic injuries of the extracranial cerebral arteries. Crit Care Clin 15:789809, 1999

  • 21

    Guillon B, , Biousse V, , Massiou H, & Bousser MG: Orbital pain as an isolated sign of internal carotid artery dissection. A diagnostic pitfall. Cephalalgia 18:222224, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Houser O, , Mokri B, , Sundt TM Jr, , Baker HL Jr, & Reese DF: Spontaneous cervical cephalic arterial dissection and its residuum: angiographic spectrum. AJNR Am J Neuroradiol 5:2734, 1984

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Jacob JC, , Maroun FB, , Heneghan WD, & House AM: Uncommon cerebrovascular lesions in children. Dev Med Child Neurol 12:446453, 1970

  • 24

    Jariwala SP, , Crowley JG, & Roychowdhury S: Trauma-induced extracranial internal carotid artery dissection leading to multiple infarcts in a young girl. Pediatr Emerg Care 22:737742, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Kak VK, & Gordon DS: Internal carotid artery thrombosis following head injury in a 17-month-old child. Neurochirurgia (Stuttg) 15:222226, 1972

  • 26

    Kasner SE, , Hankins LL, , Bratina P, & Morgenstern LB: Magnetic resonance angiography demonstrates vascular healing of carotid and vertebral artery dissections. Stroke 28:19931997, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Kirsch E, , Kaim A, , Engelter S, , Lyrer P, , Stock KW, & Bongartz G, et al.: MR angiography in internal carotid artery dissection: improvement of diagnosis by selective demonstration of the intramural haematoma. Neuroradiology 40:704709, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Klufas RA, , Hsu L, , Barnes PD, , Patel MR, & Schwartz RB: Dissection of the carotid and vertebral arteries: imaging with MR angiography. AJR Am J Roentgenol 164:673677, 1995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Laitt RD, , Lewis TT, & Bradshaw JR: Blunt carotid arterial trauma. Clin Radiol 51:117122, 1996

  • 30

    Leclerc X, , Godefroy O, , Salhi A, , Lucas C, , Leys D, & Pruvo JP: Helical CT for the diagnosis of extracranial internal carotid artery dissection. Stroke 27:461466, 1996

  • 31

    Leclerc X, , Lucas C, , Godefroy O, , Tessa H, , Martinat P, & Leys D, et al.: Helical CT for the follow-up of cervical internal carotid artery dissections. AJNR Am J Neuroradiol 19:831837, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Lew SM, , Frumiento C, & Wald SL: Pediatric blunt carotid injury: a review of the National Pediatric Trauma Registry. Pediatr Neurosurg 30:239244, 1999

  • 33

    Leys D, , Lucas C, , Gobert M, , Deklunder G, & Pruvo JP: Cervical artery dissections. Eur Neurol 37:312, 1997

  • 34

    Lin JJ, , Chou ML, , Lin KL, , Wong MC, & Wang HS: Cerebral infarct secondary to traumatic carotid artery dissection. Pediatr Emerg Care 23:166168, 2007

  • 35

    Liu AY, , Paulsen RD, , Marcellus ML, , Steinberg GK, & Marks MP: Long-term outcomes after carotid stent placement treatment of carotid artery dissection. Neurosurgery 45:13681374, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Lucas C, , Moulin T, , Deplanque D, , Tatu L, & Chavot D: Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 29:26462648, 1998

  • 37

    Lyrer P, & Engelter S: Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev 4:CD000255, 2003

  • 38

    Malek AM, , Higashida RT, , Phatouros CC, , Lempert TE, , Meyers PM, & Smith WS, et al.: Endovascular management of extracranial carotid artery dissection achieved using stent angioplasty. AJNR Am J Neuroradiol 21:12801292, 2000

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Mann CI, , Dietrich RB, , Schrader MT, , Peck WW, , Demos DS, & Bradley WG Jr: Posttraumatic carotid artery dissection in children: evaluation with MR angiography. AJR Am J Roentgenol 160:134136, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Marks MP, , Dake MD, , Steinberg GK, , Norbash AM, & Lane B: Stent placement for arterial and venous cerebrovascular disease: preliminary experience. Radiology 191:441446, 1994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Martin RF, , Eldrup-Jorgensen J, , Clark DE, & Bredenberg CE: Blunt trauma to the carotid arteries. J Vasc Surg 14:789795, 1991

  • 42

    Miller PR, , Fabian TC, , Croce MA, , Cagiannos C, , Williams JS, & Vang M, et al.: Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg 236:386395, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Mokri B: Traumatic and spontaneous extracranial internal carotid artery dissections. J Neurol 237:356361, 1990

  • 44

    Mokri B, , Silbert PL, , Schievink WI, & Piepgras DG: Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery. Neurology 46:356359, 1996

  • 45

    Mokri B, , Sundt TM Jr, & Houser OW: Spontaneous internal carotid dissection, hemicrania, and Horner's syndrome. Arch Neurol 36:677680, 1979

  • 46

    Mokri B, , Sundt TM Jr, , Houser OW, & Piepgras DG: Spontaneous dissection of the cervical internal carotid artery. Ann Neurol 19:126138, 1986

  • 47

    Moriarty KP, , Harris BH, & Benitez-Marchand K: Carotid artery thrombosis and stroke after blunt pharyngeal injury. J Trauma 42:541543, 1997

  • 48

    Müller BT, , Luther B, , Hort W, , Neumann-Haefelin T, , Aulich A, & Sandmann W: Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg 31:980988, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49

    Múnera F, , Soto JA, , Palacio DM, , Castañeda J, , Morales C, & Sanabria A, et al.: Penetrating neck injuries: helical CT angiography for initial evaluation. Radiology 224:366372, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Nance J, , Abbott K, , Morris L, & Couper R: An unfortunate consequence of being tickled. Lancet 349:1142, 1997

  • 51

    Ofer A, , Nitecki SS, , Braun J, , Daitzchman M, , Goldsher D, & Hoffman A, et al.: CT angiography of the carotid arteries in trauma to the neck. Eur J Vasc Endovasc Surg 21:401407, 2001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Payton TF, , Siddiqui KM, , Sole DP, & McKinley DF: Traumatic dissection of the internal carotid artery. Pediatr Emerg Care 20:2729, 2004

  • 53

    Pierrot S, , Bernardeschi D, , Morrisseau-Durand MP, , Manach Y, & Couloigner V: Dissection of the internal carotid artery following trauma of the soft palate in children. Ann Otol Rhinol Laryngol 115:323329, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54

    Pozzati E, , Giuliani G, , Poppi M, & Faenza A: Blunt traumatic carotid dissection with delayed symptoms. Stroke 20:412416, 1989

  • 55

    Schievink WI: Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 344:898906, 2001

  • 56

    Schievink WI: The treatment of spontaneous carotid and vertebral artery dissections. Curr Opin Cardiol 15:316321, 2000

  • 57

    Schievink WI, , Thompson RC, , Lavine SD, & Yu JS: Superficial temporal artery to middle cerebral artery bypass and external carotid reconstruction for carotid restenosis after angioplasty and stent placement. Mayo Clin Proc 75:10871090, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58

    Selim M, & Caplan LR: Carotid artery dissection. Curr Treat Options Cardiovasc Med 6:249253, 2004

  • 59

    Shintani S, , Shiigai T, , Tsuruoka S, & Tsukagoshi H: TIAs in a spontaneously dissecting aneurysm of the internal carotid artery––a case report. Angiology 43:621624, 1992

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 60

    Sidhu PS, , Jonker ND, , Khaw KT, , Patel N, , Blomley MJ, & Chaudhuri KR, et al.: Spontaneous dissections of the internal carotid artery: appearances on color Doppler ultrasound. Br J Radiol 70:5057, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 61

    Singh RR, , Barry MC, , Ireland A, & Bouchier Hayes D: Current diagnosis and management of blunt internal carotid artery injury. Eur J Vasc Endovasc Surg 27:577584, 2004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 62

    Srinivasan J, , Newell DW, , Sturzenegger M, , Mayberg MR, & Winn HR: Transcranial Doppler in the evaluation of internal carotid artery dissection. Stroke 27:12261230, 1996

  • 63

    Stapf C, , Elkind MS, & Mohr JP: Carotid artery dissection. Annu Rev Med 51:329347, 2000

  • 64

    Steinke W, , Rautenberg W, , Schwartz A, & Hennerici M: Noninvasive monitoring of internal carotid artery dissection. Stroke 25:9981005, 1994

  • 65

    Stringer WL, & Kelly DL Jr: Traumatic dissection of the extracranial internal carotid artery. Neurosurgery 6:123130, 1980

  • 66

    Sturzenegger M: Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients. J Neurol 242:231238, 1995

  • 67

    Sturzenegger M, , Mattle HP, , Rivoir A, & Baumgartner RW: Ultrasound findings in carotid artery dissection: analysis of 43 patients. Neurology 45:691698, 1995

  • 68

    Treiman GS, , Treiman RL, , Foran RF, , Levin PM, , Cohen JL, & Wagner WH, et al.: Spontaneous dissection of the internal carotid artery: a nineteen-year clinical experience. J Vasc Surg 24:597607, 1996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 69

    Wong J, , Gibson RN, , Donlan J, , Norton GR, & Davis S: Fluctuating hemodynamics in spontaneous dissection of the cervical internal carotid artery. J Ultrasound Med 12:621623, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 70

    Wraige E, , Pohl KR, & Ganesan V: A proposed classification for subtypes of arterial ischaemic stroke in children. Dev Med Child Neurol 47:252256, 2005

  • 71

    Zelenock GB, , Kazmers A, , Whitehouse WM Jr, , Graham LM, , Erlandson EE, & Cronenwett JL, et al.: Extracranial internal carotid artery dissections: noniatrogenic traumatic lesions. Arch Surg 117:425432, 1982

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1566 149 23
Full Text Views 284 27 1
PDF Downloads 192 20 2
EPUB Downloads 0 0 0