This is the left carotid artery angiography of a patient who suffered 
from persistent headache following a road traffic accident.

a. What does the angiography show?

There is a left internal carotid artery dissection with the formation 
of a false aneurysm.
Hyperextension of the neck is a common mechanism of injury causing 
stretching of the internal carotid artery over the transverse processes 
of the cervical vertebrae. Other traumatic causes include chiropractic 
manipulation, attempted strangulation, or cerebral angiography. 

b. What ocular signs and symptoms may be present?

The most common symptom is ipsilateral headache, usually located in 
the orbital / periorbital area. In addition, there may be a severe pain over the carotid artery in the neck (carotidynia). Patients may also get an incomplete Horner's syndrome: drooping of the eyelid (ptosis) and small pupils (miosis). The patient may hear bruits (murmur in a vessel caused by flowing blood). Stroke-like or ischemic symptoms are less common.

c. How would you manage this condition?

The mainstay of treatment is  medical and aiming to prevent cerebral ischaemia. 
This consists of anticoagulation and involves the use of heparin initially and then with warfarin for about  8-12 weeks. 
Repeat angiography may be needed before stopping treatment to ensure that the vessel has healed. 
 

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