Carotid artery dissection is a separation of the layers of the artery wall that supplies oxygen-bearing blood to the head and commonly causes strokes in young adults.

What is carotid artery dissection?

A carotid artery dissection is a tear in a layer of the wall of a blood vessel called a carotid artery, one of two such arteries found in the neck. Blood vessel walls normally have three layers, and a tear in any of these can allow blood to flow into the resulting space, causing the vessel to bulge. This bulge can form a blood clot, break off, and result in a stroke .

Symptoms include headache or neck pain, a droopy eyelid and small pupil on the same side as the dissection, a ringing or whooshing sound in the ear (tinnitus) on this same side, as well as numbness or weakness, blindness, double vision, trouble speaking or swallowing, or imbalance.

Treatments include pain relief as well as methods to resolve or remove potential blood clots, prevent an initial stroke, facilitate stroke recovery, or reduce the risk of additional strokes.

Call 911 immediately. Diagnosis is done by CT or MRI, and treatment involves anti-clotting medication for at least 3-6 months. Surgery may be necessary for those who can't get this medication.

Symptoms carotid artery dissection

Symptoms of a carotid artery dissection can be categorized by main symptoms, symptoms of Horner syndrome such as a drooping eyelid, ringing in the ears, and stroke-like symptoms.

Main symptoms

The most common symptoms in a carotid artery dissection primarily includes:

Headache: You may experience a headache that will progressively worsen, or sudden-onset, severe, "thunderclap" headache if a part of the carotid artery within the skull ruptures, leading to bleeding in the skull called a subarachnoid hemorrhage.
Neck pain: This will also progressively worsen.

Horner syndrome or ringing in the ears

These symptoms are part of a collection of symptoms called "Horner syndrome," and may occur if a bulge in the carotid artery compresses nerve fibers that run on the outside of the blood vessel. Horner syndrome is present in up to 58 percent of people with carotid dissection.

A droopy eyelid: This is called ptosis, and occurs in about a quarter of people with carotid artery dissection on the same side as the dissection.
A small pupil: This also occurs in about a quarter of people with carotid artery dissection in which the pupil (the dark center of the eye) will appear smaller on the same side as the dissection.
Ringing or whooshing sound in the ears: This is unrelated to Horner syndrome specifically, but this may occur on the side of the carotid dissection.

Symptoms of a stroke

About half of people with a carotid artery dissection will experience symptoms of a stroke, which occur when the brain does not get enough blood. In some people, the symptoms of the stroke last for only a few seconds or minutes (transient ischemic attack or "mini-stroke"), while in others the symptoms of the stroke may be persistent. Symptoms of a stroke vary and may include:

Numbness or weakness: This can occur on one side of the face or body.
Blindness
Double vision
Trouble speaking or swallowing
Imbalance

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What causes carotid artery dissection?

There are two carotid arteries, one on each side of the neck, which can be felt along the side of the neck right under the angle of the jaw. As described before, blood vessel walls are normally made up of three layers of tissues. A tear in one of these layers can allow blood to flow into the blood vessel wall, causing expansion of the space within the wall of the blood vessel.

Depending on which layer the tear is located in, the blood can cause a bulge in the vessel wall that either expands inward or outward. If the bulge expands inward into the space where blood normally flows through the blood vessel, it can block off normal blood flow through the vessel. If the bulge expands outward, it can compress surrounding structures around the vessel. In both cases, blood can pool in the bulge and form a blood clot, which can break off and travel to the brain, causing a stroke.

Causes of carotid artery dissection may include minor trauma or movement of the neck, vascular and connective tissue disorders, or those related to family history or genetics.

Minor trauma or movement of the neck

About 40 percent of cases of carotid artery dissection happen after minor trauma or movement of the neck. Examples of activities that can cause carotid artery dissections include:

Sports: Such as basketball, tennis, swimming, dancing, or skating
Coughing or sneezing
Childbirth
Sexual intercourse
Chiropractic manipulation of the neck

Vascular and connective tissue disorders

Certain vascular and connective tissue disorders are associated with weakened blood vessel walls that can predispose an individual to develop spontaneous carotid artery dissections in the abscess of trauma. These include:

Fibromuscular dysplasia: This is the most common vascular cause, which results in abnormal growth of blood vessels throughout the body.
Ehlers-Danlos syndrome: This is a connective disorder that causes defects in the skin, blood vessels, and other tissues and organs.

Family history of arterial dissections

People who have a family history of dissections in the carotid artery or other arteries are more likely to develop a carotid artery dissection. This suggests that there is a genetic component to the development of carotid artery dissections.

Treatment options and prevention

The recommended treatments for a carotid artery dissection vary depending on whether the carotid artery dissection causes a stroke. Both short-term and long-term treatments are usually recommended to treat the acute symptoms and prevent long-term recurrence of symptoms. Conservative methods through anticoagulation and antiplatelet therapy, for example, have proven to be effective in some cases.

Specific treatment options include pain medications, a series of stabilizing treatments for any strokes that may occur, a procedure to remove the blood clot, anti-clotting medication, and surgery to repair the dissection.

Pain medication

Headache or neck pain caused by a carotid artery aneurysm are usually managed with painkillers such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve).

Treating associated strokes

If the carotid artery dissection causes a stroke, the treatment team will usually administer a series of treatments in the short-term to stabilize you.

Breathing support: Your ability to maintain an open airway will be evaluated, and you may be given oxygen or other respiratory support, including intubation, if needed.
Fluids: These are usually given through an IV to ensure you remain hydrated.
Blood pressure monitoring: Blood pressure lowering medications such as labetalol (Trandate), nicardipine (Cardene) or nitroprusside (Nitropress) may be given if your blood pressure is too high.
Blood sugar monitoring: Insulin may be given if the blood sugar level is too high.

Medication to break up the blood clot

Most cases of stroke in those with carotid artery dissection are caused by a blood clot. Therefore, people with a carotid artery dissection who develop a stroke may be given a thrombolytic medication called alteplase to break up the blood clot if it is safe for them to receive it. This medication can usually only be given if it has been less than 4.5 hours since the start of the stroke symptoms.

Surgery to remove the clot

In some cases of carotid artery dissection with a stroke that cannot be treated with thrombolytic medication, the physician may recommend a procedure called a mechanical thrombectomy, in which a device is threaded up a blood vessel to physically remove the blood clot. This procedure may be done up to 24 hours after the start of the stroke symptoms.

Further anti-clotting medications

For people with a carotid artery dissection who develop a stroke, physicians may recommend taking anti-blood clotting medications for a period of time (usually three to six months) to prevent the recurrence of another stroke. The specific medication may vary depending on the location of the dissection, your risk factors, and the physician's preferences, but may include aspirin, clopidogrel (Plavix) or warfarin (Coumadin).

Surgery to repair the carotid artery dissection

Some people with a carotid artery dissection may benefit from surgery to repair the carotid artery dissection. Most cases of carotid artery dissection will heal on their own in the first few months. Therefore, surgery is usually only recommended for people who continue to get stroke symptoms despite taking anti-blood clotting medications. Surgical treatment options include:

Threading a device: A device threaded through a blood vessel will expand the area of the carotid artery dissection.
Stent placement: This will keep the blood vessel open.
Closure: The part of the blood vessel wall that is bulging outward may be occluded.
Surgery: This is to bypass the area of the vessel with the dissection.

When to seek further consultation

You should go to the emergency room or call an ambulance right away if you experience neck pain, numbness or weakness, vision changes, or trouble speaking or swallowing. A carotid artery dissection is a medical emergency that needs to be treated promptly.

Questions your doctor may ask to diagnose

Any fever today or during the last week?
Are you sick enough to consider going to the emergency room right now?
How long has your current headache been going on?
Have you experienced any nausea?
Have you been feeling more tired than usual, lethargic or fatigued despite sleeping a normal amount?

Self-diagnose with our free Buoy Assistant if you answer yes on any of these questions.

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The stories shared below are not written by Buoy employees. Buoy does not endorse any of the information in these stories. Whenever you have questions or concerns about a medical condition, you should always contact your doctor or a healthcare provider.

Terrible, Horrible Headaches EverPosted September 27, 2024 by J.

I have had headaches since I was thirty (30) years of age due to having severe neck issues, therefore, they were tension headaches. Recently in my fifties (50) they have changed drastically. They started around my eyes and face which I was told were migraines again I have been given medication to handle that and it was going so-so. Some good weeks, some bad weeks. Well now these last few months I have encountered something awful which is a horrendous headache which occurred June 2023 I will never forget the first one on the very top of my head where I felt literally like my head was going to explode. I ran to MGH (Boston) and they gave me a cocktail and my headache did get much better, thank God. Now these headaches have stayed like this at the top of my head and my neurologist is trying to work with me to figure out what is the best next step, but he says it is just related to migraines. Well a month or so later after that first headache I started experiencing severe pain on the left side of my face. It went from a sharp severe pain to a tingling pain after a two week period. Then after about a month it went away then it returned again two months later. Then it returned again a few months later. I still don't know what I have and I had to beg for another CT-Scan or MRI, but am finally having on in October 2024. I wonder if this is what I have because not only do I have facial pain, but I have severe whooshing in my ear, difficulty with speech, difficulty with balance, and my vision has decreased. Help appreciated. J. Schiavo

Don't ignore unusual symptoms.Posted January 25, 2022 by J.

52yo Male. Hx of one Afib episode, Aortic valve leak and low Ejection fraction. I started having headaches on the right side of my head along with scalp pain and significant pain behind and around my right eye. My vision was stable. I considered I was possibly starting to develop shingles so I went to see nice MD who listened to my concerns and treated me with antivirals and steroids. I never had a shingles breakout but my head and eye pain persisted and gradually started to worsen. About 1 month after initial pain symptoms, I noticed my right upper lid was starting to droop (ptosis) then a few days later I noticed my right pupil was smaller than my left (anisocoria). Vision still stable. Fortunately I have worked in the Ophthalmology/Optometry field for many years and recognized these Horner's Syndrome symptoms. I immediately saw an Optometrist I knew who verified that, other than a smaller pupil, my eye was healthy including optic nerve. He suggested I go to the ER to get a CT scan to rule out Carotid Dissection and aneurysm etc. The ER physician was a little skeptical but agreed to have the CT scan performed. He was surprised when, in fact, the scan confirmed I did have a Carotid Dissection. He consulted with 3 vascular surgeons who all recommended that surgical intervention was not needed. I was started on heparin drip and admitted to the hospital. After 3 days I was discharged and now on 5mg of Elequis 2x/day. Like others who have experienced this, I am hopeful this will resolve on its own in the next 3-6 months. I never sustained any injuries or suffered trauma. I did , however, have a bad flu where I was coughing and vomiting violently. I feel lucky to be alive. Don't ignore symptoms.

My experience with a carotid artery dissection (spontaneous)Posted July 5, 2021 by M.

Hello, I am one of the statistics that had one of these carotid artery dissections. Mine was spontaneous through an upper body gym workout followed by a 1km freestyle swim session. I developed the headache while lap swimming. I am a 57yo female with past medical history of Hashimoto disease and bilateral plantar fasciitis (treated with PRP injections) and bilateral golfer's elbows. I am an RN. What I want to say is—I had to see 3 different GP's and presented 3 times to A & E before being taken seriously. I had the classic mad headache, droopy eye and told the doctor I felt like I was going to stroke out. I had never had a headache like it in my life—it was excruciating. It was only on day 6 of this and still walking around undiagnosed and in absolute pain—especially when lying down as the pressure would build in my head—that I started to get chest pain as well! I had been misdiagnosed already by a hospital and was told I had a one-sided continuous headache (no scans taken!). My pulse had been 39 and the idiot junior doctors were trying to tell me this was because I was fit. In reality, I am an old fat woman. My usual resting pulse is 56 (due to existing thyroid condition). On this day of experiencing chest pain, I got on the internet and joined a Facebook group for this one-sided headache condition called "Hemicrania Continua" and the moderator who was over in America—who just happens to be a nurse—started to ask me questions and said, "You do not have this condition, go back to A & E now." I listened to her and represented. This woman from the internet saved my life—big thanks to her. I was not being taken seriously up to then and started to think maybe I was imagining how bad my headache was. I didn't want to be a whinger. And even though I am an RN, when sick my judgment on myself went out the window. I then went to A & E via taxi after being on the internet and that is when the medical staff went into overdrive and scanned my neck as well as head after I said I have chest pains now as well. I was admitted to a medical ward there—it was hell and I ended up caring for the elderly demented women in my 4-bed bay. Basic nursing care seems to have gone from what I could see. The second time I was admitted (as I was still in enormous pain and my BP was very elevated) it was to a different hospital—and, wow, it is AMAZING. I was put into the stroke ward there and got the best care. The nursing staff was superb, the medical staff excellent (big thanks to my doctor and his team) and just blew me away. Faultless. Incidentally, I now have private health—top cover—these days so I never have to go near that other hospital ever again. It's now 6 months later and I am about to go for a check-up scan to see if the CAD has healed (I don't expect it to be healed yet). My blood pressure still has days where it goes high, I still get random stabbing pains in my head and have tinnitus now. I am on a lot of medications (BP, blood thinners, statins, along with Thyroxine, etc) and not supposed to lift heavy things—no gym, no gardening, etc etc. I work part-time as a nurse still (in mental health). My life goes on. I am trying to take it easier and be less of an active old lady lol. My note to you—TAKE SEVERE HEADACHES SERIOUSLY.

Jeffrey M. Rothschild, MD, MPH.

Associate Professor of Medicine, Brigham and Women’s Hospital

Dr. Rothschild has been a faculty member at Brigham and Women’s Hospital where he is an Associate Professor of Medicine at Harvard Medical School. He currently practices as a hospitalist at Newton Wellesley Hospital. In 1978, Dr. Rothschild received his MD at the Medical College of Wisconsin and trained in internal medicine followed by a fellowship in critical care medicine. He also received an MP...

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