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Stroke in a Healthy 46-Year-Old Man

Robert J. Wityk, MD
JAMA. 2001;285(21):2757-2762. doi:10.1001/jama.285.21.2757.
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This article presents the case of a healthy 46-year-old man who experienced a dissection of the internal carotid artery. The diagnosis of this condition is not usually clear-cut, especially in a young patient with unremarkable medical history, and because of the similarity of symptoms with migraine. Often there is no obvious cause of a cerebral artery dissection, although subtle abnormalities of connective tissue may be present. Anticoagulation is generally used for therapy, but clinical trials are lacking. Carotid artery dissection should be considered as a cause of stroke in young healthy adults.

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Figure 1. Imaging of Stroke
Graphic Jump Location
A, Axial T2-weighted magnetic resonance imaging (MRI) scan showing patchy infarction in the right frontal-parietal white matter (arrow). B, Magnetic resonance angiography (MRA) of the cervical vessels. On the right side of the figure, there is a normal left carotid artery bifurcation with the internal carotid artery (ICA) well visualized. On the opposite side, the right common carotid artery and external carotid artery (ECA) are seen, but the ICA appears occluded (arrowhead). The 2 vessels in the center of the picture are cervical vertebral arteries. CCA indicates common carotid artery.
Figure 2. Angiography of the Carotid Arteries
Graphic Jump Location
A, Cerebral angiogram showing lateral view of right common carotid artery (CCA) injection and B, delayed subtraction view. There is an abrupt tapering of the internal carotid artery (ICA) distal to the bifurcation with a prolonged segment of narrowing (A, white arrowheads). On the delayed view (B), there is late filling of the distal intracranial internal carotid artery (black arrowheads), which has a more normal luminal caliber. C, Gadolinium-enhanced follow-up magnetic resonance angiography (MRA) of the right carotid artery in the neck. There is still residual narrowing (white arrowheads) distal to the carotid bifurcation, but no significant stenosis.
Figure 3. Anatomy of Carotid Artery Dissection
Graphic Jump Location
A, Diagram demonstrating hematoma tracking into the vessel wall, resulting in a long segment of narrowing distal to the carotid artery bifurcation. B, Pseudoaneurysmal dilatation of the carotid artery at the base of the skull due to dissection may injure adjacent lower cranial nerves. C, T1-weighted axial magnetic resonance imaging of the upper neck. The hematoma in the wall of the internal carotid artery appears as a bright crescent around the residual vessel lumen (appearing as a dark flow void in the center of the vessel).
Figure 4. Symptoms and Signs Associated With Carotid Artery Dissection
Graphic Jump Location
Common locations of pain and signs of Horner syndrome (ptosis, miosis) in carotid artery dissection.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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