Carotid artery dissection

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Carotid artery dissection
Gray513.png
Dissection in the carotid artery
Specialty Vascular surgery, Neurology
Symptoms Sudden, severe headache, neck or facial pain, vision changes, Horner's syndrome, stroke-like symptoms
Complications Stroke
CausesSpontaneous or traumatic (e.g., minor injuries, neck movement)
Diagnostic method Ultrasound, MRI, MRA, CTA
Treatment Anticoagulants, antiplatelet agents, Stenting, Angioplasty
FrequencyCommon cause of stroke in younger adults


Carotid artery dissection is a serious condition in which a tear forms in one of the two main carotid arteries in the neck, allowing blood to enter the artery wall and separate its layers (*dissection*). This separation can lead to the formation of a blood clot, narrowing of the artery, and restricted blood flow to the brain, potentially resulting in stroke. Symptoms vary depending on the extent and location of the dissection and may include a sudden, severe headache, neck or facial pain, vision changes, a drooping eyelid (Horner's syndrome), and stroke-like symptoms such as weakness or numbness on one side of the body, difficulty speaking, or loss of coordination.

Contents

Carotid artery dissection can occur spontaneously or be triggered by trauma, including minor injuries, certain medical conditions, or activities that involve neck movement. It is a leading cause of stroke in young and middle-aged adults. The condition is typically diagnosed through imaging studies, such as ultrasound, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), or computed tomography angiography (CTA), which help visualize the blood vessels and detect abnormalities.

Management of carotid artery dissection depends on the severity and symptoms. Treatment options often include medications like anticoagulants or antiplatelet agents to prevent blood clot formation and reduce the risk of stroke. In more severe cases, surgical or endovascular interventions, such as stenting or angioplasty, may be required to restore proper blood flow. Early detection and treatment are crucial for improving outcomes, though the prognosis can vary based on the extent of the dissection and the presence of complications.

Description

Carotid artery dissection (or cervical artery dissection) is the separation of the layers within the wall of the carotid arteries, which supply oxygen-rich blood to the brain. [1] It is a significant cause of stroke in younger adults. [2]

The carotid arteries are major blood vessels in the neck that branch into smaller vessels called the external and internal carotid arteries. [3] In carotid artery dissection, a tear in the arterial wall allows blood to flow between the layers of the artery, leading to potential narrowing, reduced blood flow, or clot formation, which may cause a stroke. [4]

Signs and symptoms

The signs and symptoms of carotid artery dissection may be divided into ischemic and non-ischemic categories: [5] [6]

Non-ischemic signs and symptoms:

Ischemic signs and symptoms:

Causes

Dissection in ultrasound US CAROTID DOPPLER 0001.jpg
Dissection in ultrasound

Dissection may occur after direct physical trauma, traffic collision, strangulation, or any phenomenon that causes hyperextension of the neck. They can also happen spontaneously. [8] [9]

The causes of carotid artery dissection can be broadly categorized into two classes: spontaneous or traumatic. [10]


Dissection may occur after direct physical trauma, traffic collision, strangulation, or any phenomenon that causes hyperextension of the neck. They can also happen spontaneously. [8] [11]

Spontaneous

Once considered uncommon, spontaneous carotid artery dissection is an increasingly recognized cause of stroke that preferentially affects the middle-aged. [12] [13]

The incidence of spontaneous carotid artery dissection is low, and incidence rates for internal carotid artery dissection have been reported to be around 2.6 to 2.9 incidents per 100,000. [14] Though the incidence is low, it is the cause of the vast majority of strokes in young people. [15]

Observational studies and case reports published since the early 1980s show that patients with spontaneous internal carotid artery dissection may also have a history of stroke in their family and/or hereditary connective tissue disorders, such as Marfan syndrome, Ehlers-Danlos syndrome, autosomal dominant polycystic kidney disease, pseudoxanthoma elasticum, fibromuscular dysplasia, and osteogenesis imperfecta type I. [16] IgG4-related disease involving the carotid artery has also been observed as a cause. [17]

However, although an association with connective tissue disorders does exist, most people with spontaneous arterial dissections do not have associated connective tissue disorders. Also, the reports on the prevalence of hereditary connective tissue diseases in people with spontaneous dissections are highly variable, ranging from 0% to 0.6% in one study to 5% to 18% in another study. [16]

Internal carotid artery dissection can also be associated with an elongated styloid process (known as Eagle syndrome when the elongated styloid process causes symptoms). [18] [19]

Traumatic

Carotid artery dissection is thought to be more commonly caused by severe violent trauma to the head and/or neck. An estimated 0.67% of patients admitted to the hospital after major motor vehicle accidents were found to have blunt carotid injury, including intimal dissections, pseudoaneurysms, thromboses, or fistulas. [20] Of these, 76% had intimal dissections, pseudoaneurysms, or a combination of the two. Sports-related activities such as surfing [21] and Jiu-Jitsu [22] have been reported as causes of carotid artery dissection.

The probable mechanism of injury for most internal carotid injuries is rapid deceleration, with resultant hyperextension and rotation of the neck, which stretches the internal carotid artery over the upper cervical vertebrae, producing an intimal tear. [20] After such an injury, the patient may remain asymptomatic, have a hemispheric transient ischemic event, or have a stroke. [23]

Artery dissection has also been reported in association with some forms of neck manipulation. [8] There is significant controversy about the level of risk of stroke from neck manipulation. It may be that manipulation can cause dissection, [24] or it may be that the dissection is already present in some people who seek manipulative treatment. [25]

Pathophysiology

Arterial dissection of the carotid arteries is a condition that arises when a small tear forms in the innermost lining of the arterial wall, known as the tunica intima. This tear allows blood to enter the space between the inner and outer layers of the vessel, leading to either narrowing (stenosis) or complete occlusion. Notably, the stenosis in the early stages of arterial dissection is a dynamic process, and some occlusions can quickly transition back to stenosis. When complete occlusion occurs, it can result in ischemia, a condition characterized by insufficient blood supply to a particular area. [26]

In cases of complete occlusion, symptoms may not always be evident due to the presence of collateral circulation, which helps to adequately perfuse the brain. However, complications can arise when blood clots develop at the site of the tear and subsequently break off, forming emboli. These emboli can then travel through the arteries and reach the brain, where they may block the blood supply. This blockage leads to an ischemic stroke, also known as a cerebral infarction. [27] It is believed that blood clots or emboli originating from the dissection are responsible for causing infarctions in the majority of cases involving strokes in the presence of carotid artery dissection. [28] [29]

Cerebral infarction, as a result of carotid artery dissection, can cause irreversible damage to the brain. Studies have demonstrated a significant number of patients with dissections go on to experience full blown strokes, often some time after the original dissection event. [30] [31] This emphasizes the serious and potentially life-altering consequences associated with this condition.

Treatment

The goal of treatment is to prevent the development of an actual stroke or limit the continuation of neurologic deficits should a stroke occur after dissection. Treatments include observation, anti-platelet agents, anticoagulation, stent implantation, carotid endarterectomy, and carotid artery ligation. [10] [32]

Epidemiology

Carotid dissections events can occur at any age. They tend to occur more often in younger individuals under 50. Such events are slightly more common in men than in women. [33] Spontaneous internal carotid artery dissection is a rare event with an incidence rate of approximately 2.6 to 2.9 per 100,000 individuals. However, such events account for ~5% to ~22% of strokes in patients under the age of 45 years. [34]

See also

Related Research Articles

A transient ischemic attack (TIA), commonly known as a mini-stroke, is a minor stroke whose noticeable symptoms usually end in less than an hour. A TIA causes the same symptoms associated with a stroke, such as weakness or numbness on one side of the body, sudden dimming or loss of vision, difficulty speaking or understanding language, slurred speech, or confusion.

<span class="mw-page-title-main">Cerebrovascular disease</span> Condition that affects the arteries that supply the brain

Cerebrovascular disease includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation. Arteries supplying oxygen and nutrients to the brain are often damaged or deformed in these disorders. The most common presentation of cerebrovascular disease is an ischemic stroke or mini-stroke and sometimes a hemorrhagic stroke. Hypertension is the most important contributing risk factor for stroke and cerebrovascular diseases as it can change the structure of blood vessels and result in atherosclerosis. Atherosclerosis narrows blood vessels in the brain, resulting in decreased cerebral perfusion. Other risk factors that contribute to stroke include smoking and diabetes. Narrowed cerebral arteries can lead to ischemic stroke, but continually elevated blood pressure can also cause tearing of vessels, leading to a hemorrhagic stroke.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Ischemia</span> Restriction in blood supply to tissues

Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism. Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue i.e. hypoxia and microvascular dysfunction. It also implies local hypoxia in a part of a body resulting from constriction.

<span class="mw-page-title-main">Vascular surgery</span> Medical specialty of the blood/lymph vessels

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

<span class="mw-page-title-main">Stroke</span> Death of a region of brain cells due to poor blood flow

Stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke:

<span class="mw-page-title-main">Cerebral angiography</span> Angiography that produces images of blood vessels in and around the brain

Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms. It was pioneered in 1927 by the Portuguese neurologist Egas Moniz at the University of Lisbon, who also helped develop thorotrast for use in the procedure.

A thunderclap headache is a headache that is severe and has a sudden onset. It is defined as a severe headache that takes seconds to minutes to reach maximum intensity. Although approximately 75% are attributed to "primary" headaches—headache disorder, non-specific headache, idiopathic thunderclap headache, or uncertain headache disorder—the remainder are secondary to other causes, which can include some extremely dangerous acute conditions, as well as infections and other conditions. Usually, further investigations are performed to identify the underlying cause.

<span class="mw-page-title-main">Moyamoya disease</span> Disease characterized by constriction of brain arteries

Moyamoya disease is a disease in which certain arteries in the brain are constricted. Blood flow is blocked by constriction and blood clots (thrombosis). A collateral circulation develops around the blocked vessels to compensate for the blockage, but the collateral vessels are small, weak, and prone to bleeding, aneurysm and thrombosis. On conventional angiography, these collateral vessels have the appearance of a "puff of smoke", described as moyamoya (もやもや) in Japanese.

<span class="mw-page-title-main">Carotid endarterectomy</span> Surgical procedure

Carotid endarterectomy is a surgical procedure used to reduce the risk of stroke from carotid artery stenosis. In endarterectomy, the surgeon opens the artery and removes the plaque. The plaque forms and thickens the inner layer of the artery, or intima, hence the name of the procedure which simply means removal of part of the internal layers of the artery.

<span class="mw-page-title-main">Carotid artery stenosis</span> Narrowing of the carotid arteries

Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, usually caused by atherosclerosis.

<span class="mw-page-title-main">Cerebral infarction</span> Stroke resulting from lack of blood flow

Cerebral infarction, also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain. In mid to high income countries, a stroke is the main reason for disability among people and the 2nd cause of death. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia). This is most commonly due to a thrombotic occlusion, or an embolic occlusion of major vessels which leads to a cerebral infarct. In response to ischemia, the brain degenerates by the process of liquefactive necrosis.

Vertebrobasilar insufficiency (VBI) describes a temporary set of symptoms due to decreased blood flow (ischemia) in the posterior circulation of the brain. The posterior circulation supplies the medulla, pons, midbrain, cerebellum and supplies the posterior cerebellar artery to the thalamus and occipital cortex. As a result, symptoms vary widely depending which brain region is predominantly affected.

<span class="mw-page-title-main">Watershed stroke</span> Medical condition

A watershed stroke is defined as a brain ischemia that is localized to the vulnerable border zones between the tissues supplied by the anterior, posterior and middle cerebral arteries. The actual blood stream blockage/restriction site can be located far away from the infarcts. Watershed locations are those border-zone regions in the brain supplied by the major cerebral arteries where blood supply is decreased. Watershed strokes are a concern because they comprise approximately 10% of all ischemic stroke cases. The watershed zones themselves are particularly susceptible to infarction from global ischemia as the distal nature of the vasculature predisposes these areas to be most sensitive to profound hypoperfusion.

Animal models of ischemic stroke are procedures inducing cerebral ischemia. The aim is the study of basic processes or potential therapeutic interventions in this disease, and the extension of the pathophysiological knowledge on and/or the improvement of medical treatment of human ischemic stroke. Ischemic stroke has a complex pathophysiology involving the interplay of many different cells and tissues such as neurons, glia, endothelium, and the immune system. These events cannot be mimicked satisfactorily in vitro yet. Thus a large portion of stroke research is conducted on animals.

<span class="mw-page-title-main">Fibromuscular dysplasia</span> Human arterial disease

Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory disease of the blood vessels that causes abnormal growth within the wall of an artery. FMD has been found in nearly every arterial bed in the body, although the most commonly affected are the renal and carotid arteries.

<span class="mw-page-title-main">Vertebral artery dissection</span> Tear of the inner lining of the vertebral artery

Vertebral artery dissection (VAD) is a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain. After the tear, blood enters the arterial wall and forms a blood clot, thickening the artery wall and often impeding blood flow. The symptoms of vertebral artery dissection include head and neck pain and intermittent or permanent stroke symptoms such as difficulty speaking, impaired coordination, and visual loss. It is usually diagnosed with a contrast-enhanced CT or MRI scan.

<span class="mw-page-title-main">Eagle syndrome</span> Medical condition

Eagle syndrome is an uncommon condition commonly characterized but not limited to sudden, sharp nerve-like pain in the jaw bone and joint, back of the throat, and base of the tongue, triggered by swallowing, moving the jaw, or turning the neck. First described by American otorhinolaryngologist Watt Weems Eagle in 1937, the condition is caused by an elongated or misshapen styloid process and/or calcification of the stylohyoid ligament, either of which interferes with the functioning of neighboring regions in the body, such as the glossopharyngeal nerve.

<span class="mw-page-title-main">Anterior cerebral artery syndrome</span> Medical condition

Anterior cerebral artery syndrome is a condition whereby the blood supply from the anterior cerebral artery (ACA) is restricted, leading to a reduction of the function of the portions of the brain supplied by that vessel: the medial aspects of the frontal and parietal lobes, basal ganglia, anterior fornix and anterior corpus callosum.

<span class="mw-page-title-main">Cervical artery dissection</span> Medical condition

Cervical artery dissection is dissection of one of the layers that compose the carotid and vertebral artery in the neck (cervix). They include:

References

  1. ↑ "Cervical Artery Dissection: Causes and Symptoms". Cleveland Clinic. Retrieved 2023-11-07.
  2. ↑ Mattu, Amal (2007). Emergency Medicine: Avoiding the Pitfalls and Improving the Outcomes. Blackwell / BMJ Books. ISBN   978-1-4051-4166-6.
  3. ↑ "Carotid artery: Anatomy, function, disease, and more". Medical News Today. 2020-03-10. Retrieved 2023-11-04.
  4. ↑ "Carotid Artery Dissection: Symptoms and Treatment". Cleveland Clinic. Retrieved 2023-11-04.
  5. ↑ Kerry, Roger; Taylor, Alan J. (November 2006). "Cervical arterial dysfunction assessment and manual therapy". Manual Therapy. 11 (4): 243–253. doi:10.1016/j.math.2006.09.006. PMID   17074613.
  6. ↑ "Cervical Artery Dissection (CeAD) | Treatment & Diagnosis | UH Harrington Heart & Vascular Institute | University Hospitals | Cleveland, Ohio | University Hospitals". www.uhhospitals.org. Retrieved 2023-11-07.
  7. ↑ "Cervical artery dissection | Health Information | Bupa UK". www.bupa.co.uk. Retrieved 2023-11-07.
  8. 1 2 3 Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ (2012). "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice. 66 (10): 940–947. doi:10.1111/j.1742-1241.2012.03004.x. PMC   3506737 . PMID   22994328.
  9. ↑ Weintraub, Michael I. (28 April 1993). "Beauty Parlor Stroke Syndrome: Report of Five Cases". JAMA. 269 (16): 2085–2086. doi:10.1001/jama.1993.03500160051022. PMID   8468755.
  10. 1 2 Goodfriend, Steven D.; Tadi, Prasanna; Koury, Ron (2024). "Carotid Artery Dissection". StatPearls. StatPearls Publishing. PMID   28613585.
  11. ↑ Weintraub, Michael I. (28 April 1993). "Beauty Parlor Stroke Syndrome: Report of Five Cases". JAMA. 269 (16): 2085–2086. doi:10.1001/jama.1993.03500160051022. PMID   8468755.
  12. ↑ Mokri, Bahram (March 1997). "Spontaneous dissections of internal carotid arteries". The Neurologist. 3 (2): 104–119. doi:10.1097/00127893-199703000-00005.
  13. ↑ "Carotid Dissection | Mount Sinai − New York". Mount Sinai Health System. Retrieved 2023-11-07.
  14. ↑ Lee, Vivien H.; Brown, Robert D.; Mandrekar, Jayawant N.; Mokri, Bahram (28 November 2006). "Incidence and outcome of cervical artery dissection: A population-based study". Neurology. 67 (10): 1809–1812. doi:10.1212/01.wnl.0000244486.30455.71. PMID   17130413.
  15. ↑ "Spontaneous coronary artery dissection (SCAD) − Symptoms and causes". Mayo Clinic. Retrieved 2023-11-04.
  16. 1 2 de Bray, Jean-Michel; Baumgartner, Ralf W. (July 2005). "History of Spontaneous Dissection of the Cervical Carotid Artery". Archives of Neurology. 62 (7): 1168–1170. doi:10.1001/archneur.62.7.1168. PMID   16009782.
  17. ↑ Barp, Andrea; Fedrigo, Marny; Farina, Filippo Maria; Lepidi, Sandro; Causin, Francesco; Castellani, Chiara; Cester, Giacomo; Thiene, Gaetano; Valente, Marialuisa; Baracchini, Claudio; Angelini, Annalisa (January 2016). "Carotid aneurism with acute dissection: an unusual case of IgG4-related diseases". Cardiovascular Pathology. 25 (1): 59–62. doi:10.1016/j.carpath.2015.08.006. PMID   26453089.
  18. ↑ Sveinsson, Olafur; Kostulas, Nikolaos; Herrman, Lars (11 June 2013). "Internal carotid dissection caused by an elongated styloid process (Eagle syndrome)". BMJ Case Reports. 2013: bcr2013009878. doi:10.1136/bcr-2013-009878. PMC   3702984 . PMID   23761567.
  19. ↑ Ogura, Takenori; Mineharu, Yohei; Todo, Kenichi; Kohara, Nobuo; Sakai, Nobuyuki (2015). "Carotid Artery Dissection Caused by an Elongated Styloid Process: Three Case Reports and Review of the Literature". NMC Case Report Journal. 2 (1): 21–25. doi:10.2176/nmccrj.2014-0179. PMC   5364929 . PMID   28663957.
  20. 1 2 Fabian, T. C.; Patton, Joe; Croce, Martin; Minard, Gayle; Kudsk, Kenneth; Pritchard, F. (1996). "Blunt Carotid Injury". Annals of Surgery. 223 (5): 513–552. doi:10.1097/00000658-199605000-00007. PMC   1235173 . PMID   8651742.
  21. ↑ Pego-Reigosa, R.; López-López, S.; Vázquez-López, M. E.; Armesto-Pérez, V.; Brañas-Fernández, F.; Martínez-Vázquez, F.; Piñeiro-Bolaño, R.; Cortés-Laiño, J. A. (14 June 2005). "Sea wave–induced internal carotid artery dissection". Neurology. 64 (11): 1980. doi:10.1212/01.WNL.0000163855.78628.42. PMID   15955962.
  22. ↑ Demartini, Zeferino; Rodrigues Freire, Maxweyd; Lages, Roberto Oliver; Francisco, Alexandre Novicki; Nanni, Felipe; Maranha Gatto, Luana A.; Koppe, Gelson Luis (2017). "Internal Carotid Artery Dissection in Brazilian Jiu-Jitsu". Journal of Cerebrovascular and Endovascular Neurosurgery. 19 (2): 111–116. doi:10.7461/jcen.2017.19.2.111. PMC   5678212 . PMID   29152471.
  23. ↑ Matsuura, John H.; Rosenthal, David; Jerius, Hilde; Clark, Michael D.; Owens, David S. (November 1997). "Traumatic Carotid Artery Dissection and Pseudoaneurysm Treated with Endovascular Coils and Stent". Journal of Endovascular Therapy. 4 (4): 339–343. doi:10.1177/152660289700400403. PMID   9418195.
  24. ↑ Ernst, E. (2010). "Vascular accidents after neck manipulation: cause or coincidence?". International Journal of Clinical Practice. 64 (6): 673–7. doi: 10.1111/j.1742-1241.2009.02237.x . PMID   20518945. S2CID   38571730.
  25. ↑ Guzman J, Haldeman S, Carroll LJ, et al. (February 2009). "Clinical practice implications of the bone and joint decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations". Journal of Manipulative and Physiological Therapeutics. 32 (2 Suppl): S227–243. doi:10.1016/j.jmpt.2008.11.023. PMID   19251069. In persons younger than 45 years, there is an association between chiropractic care and vertebro-basilar artery (VBA) stroke; there is a similar association between family physician care and VBA stroke. This suggests that there is no increased risk of VBA stroke after chiropractic care, and that these associations are likely due to patients with headache and neck pain from vertebral artery dissection seeking care while in the prodromal stage of a VBA stroke. Unfortunately, there is no practical or proven method to screen patients with neck pain and headache for vertebral artery dissection. However, VBA strokes are extremely rare, especially in younger persons.
  26. ↑ Bax, Monique; Romanov, Valentin; Junday, Keerat; Giannoulatou, Eleni; Martinac, Boris; Kovacic, Jason C.; Liu, Renjing; Iismaa, Siiri E.; Graham, Robert M. (6 December 2022). "Arterial dissections: Common features and new perspectives". Frontiers in Cardiovascular Medicine. 9. doi: 10.3389/fcvm.2022.1055862 . PMC   9763901 . PMID   36561772.
  27. ↑ Keser, Zafer; Chiang, Chia-Chun; Benson, John C; Pezzini, Alessandro; Lanzino, Giuseppe (September 2022). "Cervical Artery Dissections: Etiopathogenesis and Management". Vascular Health and Risk Management. 18: 685–700. doi: 10.2147/VHRM.S362844 . PMC   9447449 . PMID   36082197.
  28. ↑ Redekop, Gary John (May 2008). "Extracranial Carotid and Vertebral Artery Dissection: A Review". Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques. 35 (2): 146–152. doi:10.1017/s0317167100008556. PMID   18574926.
  29. ↑ Jung, Simon; Wiest, Roland; Gralla, Jan; McKinley, Richard; Mattle, Heinrich; Liebeskind, David (11 December 2017). "Relevance of the cerebral collateral circulation in ischaemic stroke: time is brain, but collaterals set the pace". Swiss Medical Weekly . 147: w14538. doi: 10.4414/smw.2017.14538 . PMID   29231236.
  30. ↑ Martin, P J; Humphrey, P R D (July 1998). "Disabling stroke arising five months after internal carotid artery dissection". Journal of Neurology, Neurosurgery & Psychiatry. 65 (1): 136–137. doi:10.1136/jnnp.65.1.136. PMC   2170177 . PMID   9667581.
  31. ↑ "Articles". Cedars-Sinai. Archived from the original on 2021-09-12. Retrieved 2023-11-07.
  32. ↑ Torborg, Liza (2019-07-02). "Mayo Clinic Q and A: Treating a carotid artery tear". Mayo Clinic News Network. Retrieved 2023-11-04.
  33. ↑ "Carotid Dissection". www.hopkinsmedicine.org. 2022-12-28. Retrieved 2023-11-04.
  34. ↑ Zheng, Chong; Zhou, Hongwei; Zhao, Kexin; Kong, Derui; Ji, Tiefeng (February 2023). "Internal carotid artery dissection with different interventions and outcomes: two case reports". Journal of International Medical Research. 51 (2). doi:10.1177/03000605231154379. PMC   9926001 . PMID   36772988.
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