Spontaneous Regression Of Painless Carotid Artery Dissection In A Patient With Raynaud's Disease

Abstract

Sir, Spontaneous dissection of the carotid artery (SDCA) is rare and associated with an underlying arterial disease.[1] Exaggerated cold-induced vasoconstriction that causes digit color shifts is what defines Raynaud's disease. This is a form of vasculitic vasospasm or vasoconstriction by the exaggerated sympathetic reflex response to cold.[2] We encountered a patient with painless SDCA with Raynaud's disease revealing spontaneous regression. This is the first case report of a painless SDCA related with Raynaud's disease. A 58-year-old field workman presented with transient visual dimness in the left eye, which lasted for 30 min. Unremarkable findings including pupil reflex and accommodation were found during an eye and neurologic assessment. His past medical history was unremarkable, except for diabetes. The results of a vasculitis blood test were ordinary. There were no clinical symptoms of connective tissue diseases such as Ehlers–Danlos or Marfan's syndrome. Brain magnetic resonance angiogram (MRA) of the neck revealed diffuse narrowing and string sign of the left internal carotid artery (ICA) due to carotid dissection [Figure 1a].Figure 1: (a) MR carotid angiogram revealed diffuse luminal narrowing with string sign of the right cervical carotid artery due to carotid dissection (arrow). (b) Technitium 99 - Hydroxy di phosphonate blood flow scintigraphy of the patient revealed reduced blood flow and pooling in stimulated right hand compared to nonstimulated left hand (the uptake ratio of right/left hand = 0.64). The time–activity curve obtained by blood flow (bottom) showed decreased both the first peak height (*) and initial slope (†) ratio of the right hand compared to the left. (c) Follow-up MR carotid angiogram demonstrated complete spontaneous regression of the dissected right carotid artery (arrow). MR = magnetic resonanceA detailed medical history indicated that he was frequently exposed to a cold environment and encountered a change in color at the fingertips accompanied by pain. We conducted a hand scan for the assessment of Raynaud's phenomenon. Hand scan revealed decreased blood flow and pool in the stimulated right hand compared to the nonstimulated left hand [Figure 1b]. The right-to-left uptake ratio was 0.64. We administered antiplatelet medication to the patient, and the subsequent brain MRA after 6 months revealed spontaneous regression of the dissected ICA [Figure 1c]. This case report discusses a patient with Raynaud's disease and amaurosis fugax as a result of nontraumatic SDCA, revealing spontaneous regression. The carotid elastic properties are identified as good markers of cardiovascular risk and events.[2,3] Patients with Raynaud's phenomenon have increased carotid stiffness and decreased carotid compliance.[4] Although the underlying mechanisms are uncertain, the association between Raynaud's disease and SDCA may involve changed collagen metabolism, impaired carotid biomechanical behavior, or increased vascular tone secondary to repeated vasospasm leading to carotid stiffness.[2,4] This case report emphasizes the importance of taking into account SDCA in patients with Raynaud's phenomenon who exhibit transient ischemic attacks. Clinicians should consider conducting carotid imaging in patients with Raynaud's disease who show neurologic symptoms, to assess for possible arterial dissection. Furthermore, regular monitoring of carotid elastic properties in patients with Raynaud's disease may be a useful technique for determining cerebrovascular risk. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.