Dissecção Espontânea da Carótida Interna

Dissecgoo espontanea da carotida interna: relata de caso e revisoo da literatura Ricardo J. Gaspar e cols.um era sabidamente hipertenso, 11eram fumantes, urn apresentavadislipidemia e nenhum deles eradiabetico.. A DEECl ocorre em pacientesjovens com idade media de 40 anossem desproporyao significativa comrelayao ao sex06.7,8,12,31,32.36.0 quadroclinico pode se apresentar comoparalisia de nervos craniais, Sindromede Horner, cefaleia, dor facial esintomas cerebrais, tais como deficitmotor e sensitivo, ou da retina comoamaurose monocular transit6ria oupermanente 22 , 24, 30. Os dados daliteratura sugerem que 1/3 a 1/2 dospacientes sofrem AVC que pode serprecedido por AIT em 1/50 dospacientes22, 24.o diagn6stico da DEECl pode serevocado quando 0 AVC estaassociado a cefaleia e Sindrome deHorner ipsilaterais, mas estaassociayao nao e comum 5 • Em casosmenos tipicos, que sao a maioria, 0diagn6stico somente e feito medianteestudo angiografico. 0 duplex scanpode mostrar estenose ou oclusiio,mas estes achados nao saoespecificos e a angiografia, mesmoassim, e necessaria. Por outro lado, 0duplex, por ser nao invasivg,constitui-se na tecnica ideal paraacompanhament05,16.39. No casopresente realizamos estudo comressonancia nuclear magnetica (RNM)com cortes transversais quemostravam imagens de septayiioevidenciando luz e trombo.Bogousslavsky e col.6 avaliaram1.200 pacientes consecutivos quetiveram urn primeiro AVC, dos quais2,5% (30 pacientes) foram causadosporDEECI.Em estudo desses 30 pacientes,com acompanhamento por seis anos,dos 2)3 que sobreviveram afase aguda,realizaram segmento com duplex quemostrou 57% de recanalizayiio. Amaioria ocorreu dentro do primeiromes, mas alguns, nos primeiros dias.Em nosso pacientes, 0 duplex realizadono 12°. dia ap6s AVC naomostrou estenose da Cl, possivelmentepor recanalizayao ou pelofato de 0 transdutor niio terconseguido acuidade mais distalmente.Melhora ou normalizayao doaspecto angiografico tern sido publicad04,I ~.14, 19, 20, 22, 23, 25, 26, 28, 29, 30, 31, 36,38, 40, 41 mas niio ha dados quanta aotempo de recanalizayao. Recorrenciade dissecyao e extremamente rara.Ainda com relayiio ao aspectoangiografico, Bogousslavsky e col.5mostraram que dos 30 pacientesestudados, a Car6tida lnternaEsquerda foi comprometida em 13, aCar6tida lnterna Direita em 16 e adissecyao foi bilateral em urnpaciente. A oclusao estava situadaentre dois e cinco centimetrosdistalmente abifurcayao da car6tida.Dupla luz, assim como pseudoaneurisma,foi visto em urn paciente.Em todos os pacientes foram vistasirregularidades parietais, masanormalidades sugerindo displasiafibromuscular foram observadas emsomente quatro pacientes na car6tidainterna ipsilateral ou contralateral.Oclusiio de ramos intracerebraisipsilateral a dissecyiio sugerindoembolizayao distal foi vista em setedos dezenove pacientes nos quais seteve acesso angiografico.Segundo Sturzenegger 42 , emborarevisoes recentes ainda cosiderem aangiografia como padriio ouro, suacasuistica e outras sugerem que aRNM, metodo niio invasivo, e maissensivel e mais especifica.Com relayao ao tratamentocirurgico, em 14 tentativas dereparayao operat6ria com variayao detaticas houve oito falhas e apenasdois sucessos documentadosl 5 , 17. Osoutros 4 casos niio tiveramdocumentayiio.Ha alguma controversia a respeitodo progn6stico da DEECI. Variosautores tern mostrado uma naodesprezivel mortalidade deaproximadamente 20% 2,8,9,10,11,18,32,35.43, mas outros tern enfatizado anatureza benigna da DEECl 15, 19,20,27,28,30,33,34,38,41,44. Esta discrepancia podeser explicada pelo fato de que as seriesmostrando boa evoluyao eramcompostas principalmente depacientes que nao apresentaramAVC,tendo sido 0 diagn6stico feito a partirde episodio de AIT ou paralisia denervos cranianos, enquanto quemortalidade precoce ou sequelaneurologica grave mostradas emoutros pacientes foram devidas ainfarto cerebral maciy0 6 . Os achadosde Bogousslavsky e coP mostraramque AVC devido a oclusiio da Cl pordissecyiio niio pode ser chamado deevento "benigno", ja que houve 23%de mortalidade na primeira semana e48% dos que sobreviveram foramincapazes de reassumir suasatividades anteriores devido a gravelimitayao motora. Boa evoluyaofuncional foi associada comrecanalizayao precoce da dissecyao ecom infarto cerebral pequeno,enquanto que rna evoluyiio foiassociada com oclusao persistente daCl, com grandes infartos e evidenciade embolia cerebral dista1 6 .Tern sido descrita recanalizayiiocom terapia anticoagulante3, 12, 19,20,26,29,30,42, mas tambem sem ela4, 23, 31, 36.Embara 0 usa precoce de heparinapossa parecer logica, seus beneficiospermancem sem comprovayiio, ate queurn estudo randomizado seja realizado.CIR VASC ANGIOL 13: 73-77, 1997

Dissec900 espontanea da carotida interna: relata de caso e revisao da literaturaRicardo J. Gaspar e cols.Spontaneous dissection of the internal carotid artery. Case report.Introduction: Although rarely published before 1970, spontaneousdissection of the internal carotid artery is nowadays considered a not incommonvascular disease. A recent review of the literature revealed 300 cases andestablished the clinical features and the prognosis of ischemic neurologicevents due to this disease.Case discription: A thirty-two years old healthy male was admitted withan ischemic stroke due to spontaneous dissection of the internal carotid arteryas shown by arteriography and magnetic resonance of the carotid artery.After some weeks the patient cursed with almost no residual symptoms.Discussion: The physiopathologic mechanism of spontaneous dissectionof the internal carotid artery is unknown. One third to half the patients developa stroke. Of a series of 1200 patients with a first stroke, 2,5% showed it tobe caused by spontaneous dissection of the internal carotid artery. Of these,57% patients showed subsequent normalization of the carotid artery. Of 14cases submitted to a surgical procedure, there where eight faillures and inonly two cases a success could be documented. There is also controversyabout the prognosis. Functional recovery is associated with early recanalizationof the dissection whereas maintenance of neurologic symptoms showed tobe related to thrombosis of the carotid artery, cerebral infarcts and distalcerebral embolazation.Keywords: carotid artery, dissection, cerebral ischemia.1. Andersen CA, Collins GJ JR, RichNM: Spontaneous dissection of theinternal carotid artery associatedwith fibromuscular dysplasia. AmSurg 46:263-266,1980.2. Anderson RM, Schecheter MM: Acase of spontaneous dissectinganeurysm of the internal carotidartery. J Neurol Neurosurg Psychiatry22: 195-201,1959.3. Ast G, Woimant F, Georges B, LaurianC, Haguenau M: Spontaneous dissectionof the internal carotidy arteryin 68 patients. Eur J. Med 2:466-472.4. Barbizet J, Degos JD, Lamontte J:Dissection spontanee de la carotideinterne. Ann Med Intern 129:73­76,1978.5. Bogousslavsky J, Despland P, RegliF: Spontaneous carotid dissectionwith acute stroke. Arch Neuro144: 137-140,1987.6. Bogousslavsky J, Regli F J: CurchodJ: Angiopathie reversible de I'arterecarotide interne. Med Hyg 43:3064­3070,1985.7. Bogousslavsky J, Regli F, DesplandP: Aneurysmes dissequantsspontanes de l'artere carotideinterne: Evaluation prospective duprognostic et de la repermeabilisationarterielle dans 14 cas.Rev. Neurol11 :625-636,1984.8. Bostrom K, Liliquist B: Primarydissecting aneurysm of theextracranial part ofthe internal carotidand vertebral arteries. Neurology17:179-186,1967.9. Bradac GB, Kaernbach a, Bolk ­Weischeldel D: Spontaneusdissecting aneurysm of cervicalcerebral arteries: Report of six casesand review of the literature.Neuroradiology 21: 149-154,1981.10. Brice JG, Crompton MR:Spontaneous dissection aneurysm ofthe cervical internal carotid artery. BrMed J 2:790-792,1964.11. Brown OL, Armitage JL:Spontaneous dissecting aneurysmsof the cervical internal carotid artery:Two cases reports and a survey ofthe literature. AJR 118:648-653,1973.12. Chappleau CE, Robertson JT:Spontaneous cervical carotid arterydissection: Outpatient treatment withContinous heparin infusion using atotally implantable device. Neurosurgery8:83-87, 1981.13. Contamin F, Ollat H, Wesley C.:Obstruction incomplete de la carotideinterne d'evolution regressive chezune malade atteinte de dy:tPlasie• CIRVASCANGIOL 13: 73-77,1997-------------------------------

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