Traumatic Dissection of the Internal Carotid Artery at the Skull Base

Aim: Traumatic dissection of the cervical internal carotid artery (ICA) is a well-described phenomenon. However, isolated dissection of this vessel occurring at the level of the skull base without any associated injury to the cervical component is rare. This paper aims to present two patients harboring such pathologies.

Material – Method: Two patients who developed dissection of the ICA at the level of the skull base were reviewed retrospectively. Both were male and 18 years of age. The mechanism of injury was motor vehicle accident in both cases.

Results: Admission Glasgow Coma Score (GCS) for Case 1 and Case 2 were 5t and 9, respectively. The admission computed tomography (CT) did not show any major parenchymal pathology or a fracture at the skull base in Case 1, but was significant for severe traumatic subarachnoid hemorrage (SAH) and multiple fractures at the anterior skull base in Case 2. Vascular injury was suspected because of disproportional neurological worsening in Case 1 and because of the radiographic pattern of the SAH in Case 2. Digital subtraction angiography (DSA) revealed Grade 4 dissection with complete occlusion of the ICA in Case 1 and Grade 3 dissection with two associated aneurysms in Case 2.

An emergency decompressive craniectomy was performed for Case 1 due to a massive ICA infarct with mass effect. The dissection was managed conservatively. In Case 2, the dissecting aneurysms were treated endovascularly using flow diverters and coils.

Both patients were discharged with a Glasgow Outcome Score of 3, and a modified Rankin Score of 3.

Conclusion: Isolated dissection of the ICA (w/wo aneurysms) at the level of the skull base without associated injury to the cervical ICA is rare. Awareness of this potentially devastating entity is of paramount importance for timely diagnosis and management.