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CASE SNIPPET
Year : 2019  |  Volume : 65  |  Issue : 4  |  Page : 249-250

Carotidynia


1 Department of Radiology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
2 Department of Neurology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Date of Web Publication14-Oct-2019

Correspondence Address:
D A Sanghvi
Department of Radiology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.JPGM_262_19

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How to cite this article:
Sanghvi D A, Nakshiwala V B, Raut T P. Carotidynia. J Postgrad Med 2019;65:249-50

How to cite this URL:
Sanghvi D A, Nakshiwala V B, Raut T P. Carotidynia. J Postgrad Med [serial online] 2019 [cited 2019 Nov 15];65:249-50. Available from: http://www.jpgmonline.com/text.asp?2019/65/4/249/266937




A 46-year-old female presented with significant pain in the right side of the neck of 1 month duration. Point tenderness was elicited on palpation without a noticeable swelling. She was referred for an ultrasound of the neck which was reported as normal. In view of persistent pain and at the insistence of the patient, she was referred for a magnetic resonance imaging (MRI). A fiducial marker was placed at the site of maximum pain and tenderness.

MRI showed abnormal enhancing eccentric soft tissue at the posterolateral wall of the right carotid bulb and internal carotid artery (ICA) origin close to the bifurcation [Figure 1]. It caused mild indentation on the adjacent carotid artery lumen.
Figure 1: Index MRI. Axial postcontrast T1-weighted image of the neck shows eccentric enhancing perivascular soft tissue (arrows) in relation to the right carotid bulb

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Correlating this radiological finding with the clinical presentation of pain; a diagnosis of transient perivascular inflammation of the carotid artery (TIPIC) or carotidynia was made. Erythrocyte sedimentation rate (ESR) (55 mm/h) and C-reactive protein (CRP) (25 mg/dL) were elevated. Resolution of symptoms on anti-inflammatory medication validated the diagnosis. At 6 months, follow-up MRI showed significant regression of perivascular inflammatory soft tissue [Figure 2]. At 6 months follow-up on anti-inflammatory medication, ESR and CRP normalized.
Figure 2: 6 months follow-up MRI. Axial postcontrast T1-weighted image of the neck shows significant regression of eccentric enhancing perivascular soft tissue (arrows) in relation to the right carotid bulb

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A differential diagnosis of acute onset neck pain includes vascular etiologies such as vessel wall dissection and vasculitis and nonvascular entities including head and neck inflammation, sialadenitis and cervical spine degeneration. An overlooked clinicoradiological vascular etiology of acute cervical pain is carotidynia; recently described by the self-explanatory acronym TIPIC.[1]

Although a rare entity, the clinicoradiological presentation of TIPIC is classic and consistent. Patients have distinctive acute pain directly at the level of the carotid bifurcation with eccentric perivascular inflammatory (PVI) soft tissue on imaging as the most striking feature described. Some patients have mild associated narrowing of the lumen without hemodynamic abnormality.

Prior case reports theorized that the perivascular changes represent inflammation.[2],[3] Excellent response to anti-inflammatory medication, occasional reports of ipsilateral lymph node enlargement and/or bordering pharyngolaryngeal inflammation and mild elevation of inflammatory markers like ESR and CRP support this conjecture.

Lecler et al. suggested this entity should be added to the International Classification of Headache Disorders-III and proposed four major diagnostic criteria which included acute pain overlying the carotid artery, eccentric PVI on imaging, exclusion of alternative vascular or nonvascular diagnosis with imaging and finally; improvement within 2 weeks which is either spontaneous or as a response to anti-inflammatory treatment.[4],[5]

Knowledge and diagnosis of this uncommon but consistent clinicoradiological entity is constructive; as it responds well to medical treatment with nonsteroidal anti-inflammatory agents and high doses of aspirin. The condition is known to be self-limiting. Misdiagnosis as dissection or atherosclerosis is common and unfortunate as it can potentially trigger a regrettable cascade of anxiety and unnecessary further investigations.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 :: References Top

1.
Lecler A, Obadia M, Savatovsky J, Picard H, Charbonneau F, de Champfleur NM, et al. TIPIC syndrome: Beyond the myth of carotidynia, a new distinct unclassified entity. Am J Neuroradiol 2017;38:1391-8.  Back to cited text no. 1
    
2.
Andersen TT, Hansen ML, Petersen SL, Ewertsen C. Carotidynia in a patient receiving an allogeneic hematopoietic cell transplantation: A case report to support a disputed entity. Ultrasound Int Open 2018;4:106-8.  Back to cited text no. 2
    
3.
Santarosa C, Stefanelli S, Sztajzel R, Mundada P, Becker M. Carotidynia: A rare diagnosis for unilateral neck pain revealed by cross-sectional imaging. Case Rep Radiol 2017;2017:7086854.  Back to cited text no. 3
    
4.
Lecler A, Obadia M, Sadik JC. Introduction of the TIPIC syndrome in the next ICHD classification. Cephalalgia 2019;39:164-5.  Back to cited text no. 4
    
5.
Arnold M. Headache classification committee of the international headache society (IHS) the international classification of headache disorders. Cephalalgia 2018;38:73-98.  Back to cited text no. 5
    


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