Abstract:
BACKGROUND:Cervical carotid dissection is more common in extracranical vessel: internal carotid artery dissection (ICAD) is typical, vertebral artery dissection is uncommon, common carotid artery dissection (CCAD) is rare and even a more rare cause of ischemic stroke. Cervical artery dissections account up to 20-25% of ischemic strokes in young patients. Isolated and spontaneous common carotid artery dissection without aortic damage is unique. Indeed in the Literature 8 cases were identified. MRI and CTA were the most commonly used for diagnosis and follow-up. CASE REPORT:A 67-year-old came to our observation reporting burning pain in the right latero-cervical region in supine position, irradiated in the temporal region and recurrent episodes of migraine with aura (scintillating scotoma), in the last 3 months. The last Doppler Ultrasound control, performed after the onset of symptoms, showed an highlighted dissection wall with double lumen at the origin of the bulb and the internal carotid artery on the right. Aortic arch arteriography confirmed the diagnosis. The patient underwent surgery (longitudinal arteriotomy, removing four miointimal flaps, fastening the distal common carotid artery with 3 Kunlin's points). RESULTS:Any neurological or vascular problems after surgery were noticed. DISCUSSION AND COMMENTS:The pathogenesis can be related to a combination of an intrinsic weakness in the arterial wall and an external trigger. The diagnosis of CAD is made with MRI (78.0%), conventional angiography (31.1%), CTA (14.7%), and ultrasound (11.3%). CONCLUSION:No evidence-based guidelines exists for treatment of CCAD. In our patient surgical CEA treatment was the optimal solution. INTRODUZIONE:La dissecazione dei vasi epiaortici è responsabile del 20%-25% degli ictus ischemici giovanili. L’incidenza annuale riportata in uno studio francese del 2008 di Menon et coll è pari a 3 per 100.000 per la dissecazione carotidea e 1,5 per 100.000 per la dissecazione vertebrale. Dissecazioni isolate e spontanee dell’ arteria carotide comune, non associate a dissecazione aortiche sono estremamente rare: dal 1960 al 2003 sono stati riportati solo 8 casi in letteratura. CASO CLINICO:Donna di 67 anni, affetta da ipertensione arteriosa e dislipidemia in trattamento con terapia medica. Non fumatrice, anamnesi familiare positiva per patologia cardiovascolare. Pregresso intervento di EA carotidea destra ed innesto aorto-bifemorale per patologia aneurismatica dell’aorta addominale e ostruttiva delle arterie iliache comuni. Giungeva alla nostra osservazione con la seguente sintomatologia: dolore urente in regione latero-cervicale destra che compariva in clinostatismo, irradiato in regione temporale ed associato a scotomi scintillanti e tinnito. La paziente veniva sottoposta ad ECD TSA d’urgenza che metteva in evidenza dissecazione parietale con doppio lume in corrispondenza della carotide comune destra . Tale reperto veniva confermato anche all’ esame Angio TC. Si procedeva, quindi, ad arteriografia dell’arco aortico e dei vasi epiortici, per via transascellare sinistra, ma per l’anatomia sfavorevole dell’arco aortico si soprassedeva alla correzione endoluminale. Veniva, quindi, sottoposta ad intervento chirurgico, durante il quale veniva riscontrata la dissecazione intimale completa dell’arteria carotide comune (circa 4 cm) che all’estremo prossimale (origine carotide interna) presentava una placca residua. Si procedeva, quindi ad asportazione di quattro flap intimali e della placca residua e fissaggio con 3 punti di Kunlin dell’estremo distale dell’arteria carotide comune. RISULTATI:IL decorso post-operatorio è stato regolare. Ad un mese la paziente è stata sottoposta ad ECD vasi epiaortici di controllo che evidenziava la pervietà dell’asse carotideo destro senza segni di ulteriori dissecazioni. DISCUSSIONE E COMMENTI:L’eziologia della dissecazione dei vasi epiaortici non è ben definita. L’81% dei casi sono correlati a traumi cervicali maggiori o microtraumatismi ripetuti. Il restante 19% dei casi sono dissezioni spontanee. Il quadro clinico della CCA consiste in sintomi e segni locali a cui possono seguire, dopo un intervallo di tempo variabile da ore a qualche giorno, manifestazioni ischemiche cerebrali. Per la definizione diagnostica e il monitoraggio è indicato l’utilizzo di metodiche sia ultrasonografiche che angiografiche non invasive (angio-TC o angio-RM). In casi selezionati o quando sussistono dubbi, in modo particolare nel sospetto di dissecazione vertebrale, può essere giustificato ricorrere all’angiografia convenzionale. La prognosi varia secondo la sede della dissecazione: la mortalità per dissecazione carotidea intracranica è più elevata (75%) rispetto alla forma extracranica (<10%). Il rischio di recidiva è del 2% durante il primo mese e dell’ 1% all’anno per primi dieci anni ed è maggiore nei pazienti più giovani o con anamnesi familiare positiva. CONCLUSIONE:Il trattamento di una dissecazione sintomatica per TIA o ictus rimane controverso in assenza di studi clinici randomizzati. In fase acuta il trattamento con eparina seguita da anticoagulanti orali (TAO), salvo controindicazioni, è raccomandato. Procedure endovascolari sono state usate per trattare stenosi gravi o lesioni complicate da pseudoaneurismi , ma non vi sono dati da studi randomizzati che ne abbiano definito l’utilità e l’efficacia nel tempo. Nel nostro caso abbiamo optato per una terapia chirurgica in quanto la paziente era già in trattamento antiaggregante e non è stata percorribile la via del trattamento endovascolare a causa della sfavorevole anatomia.
journal_name
Ann Ital Chirjournal_title
Annali italiani di chirurgiaauthors
Salvati B,Tesori MC,Lombardo F,Donello C,Lange KJ,Capoano Rsubject
Has Abstractpub_date
2014-09-18 00:00:00issue
ePubeissn
0003-469Xissn
2239-253Xpii
S2239253X14022191journal_volume
85pub_type
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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abstract::The diagnosis of incidental thyroid carcinoma in patients submitted to thyroidectomy for a benign disease is quite frequent. A retrospective analysis was performed on 240 patients submitted to surgical intervention in order to establish the incidence of the carcinoma. One hundred sixty five patients (68.75%) were affe...
journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
pub_type: 杂志文章,评审
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journal_title:Annali italiani di chirurgia
pub_type: 杂志文章
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
pub_type: 杂志文章,评审
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journal_title:Annali italiani di chirurgia
pub_type: 杂志文章,评审
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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journal_title:Annali italiani di chirurgia
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