The American Journal of Medicine (2005) 118, 1111-1112 RADIOLOGY IMAGE OF THE MONTH Michael A. Bettmann, MD, Section Editor Dissection of the internal carotid artery and hemicraniectomy Meheroz H. Rabadi, MD, MRCPI Weill Medical Collge of Cornell University, Burke Rehabilitation Hospital, White Plains, NY. An 18-year-old right-handed student, while playing “war games” with his friends, on sudden turning of his head felt dizzy and fell to the ground. On admission to the local emergency room he was found to have left facial droop and left-sided hemiplegia. Admission head computed tomography scan was normal. Three days later the patient complained of slurred speech and was noted to have a decreased level of consciousness. Emergency head magnetic resonance imaging showed right cerebral hemisphere edema and an acute infarction. Head magnetic resonance arteriography showed dissection of the cervical part of the right internal carotid artery (Figure, panel A). The patient underwent a right hemi-craniectomy to relieve the cerebral edema (Figure, panel B), with placement of the skull bone in between right anterior abdominal wall muscles to preserve the bone flap (Figure, panel C, arrow). The patient was then transferred to our facility for intensive inpatient and later outpatient rehabilitation. The patient made a remarkable neurological recovery, had his cranioplasty 4 weeks later, and is now back to college. Dissection of the carotid artery is responsible for 20% of pediatric ischemic strokes.1 Many occur in the context of trauma or physical exertion.1 Infection2 and underlying vasculopathy has been found in patients with spontaneous carotid artery dissection; these include fibromuscular dysplaRequests for reprints should be addressed to Meheroz H. Rabadi, MD, Weill Medical College of Cornell University, Burke Rehabilitation Hospital, 785 Mamaroneck Ave., White Plains, NY 10605. E-mail address: mrabadi@burke.org 0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2005.02.040 sia, ␣1-antitrypsin deficiency, and hyperhomocystinuria.3-5 Patients with dissection-related cervical artery occlusion are at a significantly increased risk of suffering a disabling stroke. Early hemi-craniectomy has been found to improve functional outcome and decrease mortality.6 Hemicraniectomy has been found to be particularly beneficial in younger stroke patients.7 References 1. Chabrier S, Lasjaunias P, Husson B, Landrieu P, Tardieu M. Ischaemic stroke from dissection of the craniocervical arteries in childhood: report of 12 patients. Eur J Paediatr Neurol. 2003;7:39 – 42. 2. Guillon B, Berthet K, Benslamia L, Bertrand M, Bousser MG, Tzourio C. Infection and the risk of spontaneous cervical artery dissection: a case-control study. Stroke. 2003;34:e79 – e81. 3. Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection— clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003;250:1179 –1184. 4. Pezzini A, Magoni M, Corda L, et al. Alpha-1-antitrypsin deficiencyassociated cervical artery dissection: report of three cases. Eur Neurol. 2002;47:201–204. 5. Pezzini A, Del Zotto E, Archetti S, et al. Plasma homocysteine concentration, C677T MTHFR genotype, and 844ins68bp CBS genotype in young adults with spontaneous cervical artery dissection and atherothrombotic stroke. Stroke. 2002;33:664 – 669. 6. Schwab S, Steiner T, Aschoff A, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998; 29:1888 –1893. 7. Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35:539 –543. 1112 The American Journal of Medicine, Vol 118, No 10, October 2005 Figure Panel A: Head magnetic resonance arteriography shows dissection of the cervical portion of the right internal carotid artery. Panel B: Head computerized tomography shows massive edema in the right middle cerebral artery territory and post hemicraniectomy. Panel C: Plain abdominal x-ray with skull bone flap placed between anterior abdominal muscles for preservation (arrow).