Spontaneous cervical internal carotid dissection presenting with intracerebral hematoma.

FIG 1. Axial computed tomographic scan on admission shows a right parietal subcortical hematoma with mild to moderate surrounding edema. Cervical internal carotid artery dissection is recognized as an uncommon cause of stroke.'-3 We describe a rare case of spontaneous cervical internal carotid dissection presenting with an intracerebral hematoma (ICH). A 49-year-old right-handed man was referred to our hospital because of right parietal ICH (Fig 1). On admission, he was confused and had left hemiparesis and hemisensory disturbance. Mild dyscalculia, dressing apraxia, and left hemianopsia were present. Hormer's sign was not present, and carotid bruit was not audible on either side. He had asthmatic diathesis but had no history of hypertension or cervicocephalic trauma. He was not a drug abuser. Routine laboratory blood analysis revealed no particular abnormality. Both bleeding time and coagulation time were within normal limits, although prothrombin time was 64% of the control. Admission computed tomography (CT) also revealed a small low-density area at the tip of the right temporal lobe (Fig 2A). This low density appeared definitely hyperintense on both Ti-and T2-weighted images on magnetic resonance imaging examination (Fig 2B and 2C). A right carotid angiography revealed an aneurysmal outpouching and distal stenosis of the cervical internal carotid artery at the level of Cl-2 (Fig 3). There was no evidence of intracranial arterial occlusion or vasculitis. The patient was treated conservatively, without anticoagulants. Four serial angiograms performed from onset to the fourth month showed progressive improvement, with resolution of the hematoma. Anti-platelet drug was started for prevention of embolism from the dissection 2 months after the onset. The patient was discharged for outpatient follow-up with minimal neurological deficits. According to the literature, common clinical manifestations of spontaneous cervical carotid dissection are focal cerebral isch-emia, headache, oculosympathetic palsy, bruit (tinnitus), amauro-sis fugax, and neck pain.1-4 None of these symptoms are associated with intracranial hemorrhage, and to our knowledge there have been no reports of a spontaneous cervical internal carotid dissec-tion presenting with an ICH. We believe the right parietal ICH was caused by cerebral embolism from the dissection for the following FIG 2. Axial computed tomographic (CT) scan (A) and Ti-weighted (B) and T2-weighted (C) magnetic resonance images taken on admission. The hyperintensity at the tip of the right temporal lobe (arrow) on Ti-and T2-weighted images corresponds to the low-density area (arrowhead) on CT scan. This lesion is considered to represent an infarcted area with slight hemorrhagic …