Cervical artery dissection is caused by the separation of the vessel wall layers following either a tear in the intima or rupture of the vasa vasorum, with bleeding within the media, and is a potential source of thromboembolism, resulting in cerebral ischemia. Cervical artery dissection can be traumatic or spontaneous; however, the exact pathophysiology of a dissection is rarely identified. We report a case of carotid artery dissection caused by stylocarotid artery syndrome (Eagle syndrome), treated by surgical resection of the styloid process.
Cervical artery dissection (CAD) is an important cause of stroke in younger patients. It accounts for 2.5% of all stroke cases and 5% to 22% of those under 45 years of age [
A 38-year-old previously healthy female visited a local hospital with sudden onset of headache and left perioral area numbness that began a few days prior to presentation. There was no associated weakness or other focal neurologic deficit. Non-contrast head computed tomography (CT) was unremarkable. CT angiography (CTA) of the head and neck showed decreased flow in the right ICA (
Typical clinical features of CAD include unilateral neck pain; headache; ipsilateral Horner’s syndrome, followed by manifestations of cerebral or ocular ischemia; and cranial nerve palsies [
Until recently, catheter angiography was the method of choice to diagnose arterial dissection; however, with the advent of Doppler ultrasonography, MRI/MRA, and CTA, most dissections can now be diagnosed noninvasively [
Treatment remains empiric and is guided by clinician discretion on a case-by-case basis. Options for treatment include intravenous and intra-arterial thrombolysis, surgical repair, anticoagulation, and antiplatelet medication [
Eagle syndrome is caused by an elongated styloid process or a calcified stylohyoid and stylomandibular ligament [
In conclusion, CAD is a major cause of stroke in young adults. The primary goals of treatment are to promptly save at-risk brain tissue and prevent additional ischemia or stroke recurrence. Therefore, the identification of the pathophysiology underlying CAD is required in order to estimate the risk of recurrent cerebral ischemia and to select optimal treatment methodology. Although Eagle syndrome is a rare cause of CAD, it can be treated with surgical resection. Therefore, when the cause of CAD is unclear, it is necessary to determine whether the distal portion of the styloid process is in close contact with the carotid artery.
No potential conflict of interest relevant to this article was reported.
Initial images demonstrate stenosis of the right internal carotid artery (RT ICA). (A) Computed tomography-angiography shows RT ICA on maximum intensity projection. (B) Magnetic resonance angiography shows narrowing and smooth irregularities of the RT ICA lumen distal to the carotid bulb. (C) Cerebral angiography shows a “flame-shaped" occlusion of the RT ICA, which is consistent with carotid artery dissection. Red arrow indicates the site of carotid artery stenosis.
Preoperative computed tomography (CT) angiography images. The right internal carotid artery (RT ICA) shows long-segment stenosis with intramural hematoma thought to be due to dissection. (A) A CT-angiography image shows the elongated styloid process (red arrow). (B) An axial image shows the styloid process (red arrow) adjacent to the RT ICA (blue arrow). (C) An axial image shows the intramural hematoma (blue arrow).
Postoperative computed tomography (CT) angiography at 6 months. (A) CT angiography shows the detachment of the styloid process (red arrow) from the right internal carotid artery (RT ICA) and marked improvement in RT ICA stenosis. (B) An axial image shows improvement in the intramural hematoma (blue arrow).