Long-term outcomes of internal carotid artery dissection.

Objective: The natural history of acute carotid artery dissection is poorly characterized. The purpose of this study is to report on single institutional long-term outcomes.

Methods: A retrospective review of patients treated for acute spontaneous or posttraumatic carotid artery dissection over a 20-year period from August 1989 to July 2009 was performed.

Results: Twenty-nine patients with a mean age of 47 ± 19.6 years were identified with acute carotid dissection. Six (25%) were related to trauma, while 23 (79%) were spontaneous. Neurologic symptoms included contralateral limb weakness (55%), facial pain (35%), and Horner's syndrome (21%). Eight patients (28%) presented with an acute hemispheric stroke. Diagnostic imaging modalities used included computed tomography angiography (52%), magnetic resonance angiography (41%), and conventional angiography (48%). Twenty percent of patients had complete carotid occlusion and 25% had near occlusion. Most dissections (65%) had intracranial extension, and 35% were limited to the extracranial cervical internal carotid. The majority (96%) of patients were treated conservatively with anticoagulation or antiplatelet therapy or both. One patient underwent stenting for persistent symptoms resulting in complete recovery. There were two deaths, one from unrelated traumatic injuries and the other from unknown causes. Long-term follow-up was available for 20 patients: 14 had complete symptom resolution (70%) and five (25%) had partial clinical symptom resolution. Two patients had initial resolution of symptoms, with subsequent recurrence that was successfully managed conservatively. Follow-up imaging revealed luminal patency in 79% of patients with minimal residual stenosis. Two patients developed a small asymptomatic internal carotid aneurysm that did not require treatment. Mean follow-up was 1133.2 days.

Conclusions: Most cervical carotid dissections can safely be conservatively managed, with the majority achieving anatomic and symptomatic resolution, with low rates of recurrence over long-term follow-up.