Vascular Imaging of the Head and Neck – Case B

This case is the second of four cases that go with the vascular capstone course. On that page, there is a scrollable case that you can go through to teach you how to approach a CTA of the head in a real patient.

This case is a 47 year-old woman with new neurologic symptoms. Take a look and see what you think before continuing on (https://bit.ly/CTAcaseB).

The patient in this case has scattered small infarcts in the left MCA distribution on diffusion weighted imaging from an MRI (top left window). This raises suspicion for an underlying vascular abnormality. Remember, for stroke and vascular supply issues, you want to include CTA of the neck because these vessels supply the vessels of the circle of Willis.

On the CTA, you see multiple abnormalities. The right internal carotid artery (ICA) is tortuous and irregular in the superior neck, which is highly atypical for a patient of this age. The left internal carotid artery (ICA) is even more abnormal, with smooth tapering of the vessel to severe narrowing just above the bifurcation. The low density filling defect is thrombus, some of which is probably under a dissection flap and some of which is free-floating in the vessel. The more distal ICA also has tortuosity and narrowing similar to the right, confirming the abnormality is bilateral.

Don’t forget to complete your search pattern, but the vertebral arteries and intracranial vessels are pretty normal.

Given the multiple areas of vascular narrowing of the cervical carotid in a middle age woman with an ICA dissection on the left, this patient most likely has fibromuscular dysplasia (FMD). Fibromuscular dysplasia is the most common vasculopathy in middle-aged women and frequently affects the renal arteries, ICAs, and vertebral arteries. Characteristic findings are the beads on a string appearance of the vessel with multifocal areas of narrowing interspersed with dilation.

Once you’ve finished this video, I recommend going back to the vascular capstone course, where you can review the other browseable cases with explanations. The capstone overview is here, if you’d like to see all the cases and videos.

Or, see all of the vascular capstone videos in the vascular imaging capstone playlist.