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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00719-2
10.1016/j.radcr.2024.07.132
Case Report
Magnetic resonance and ultrasound imaging of a patient with carotydinia
Sqalli Houssaini Adam MD adam-s-300@hotmail.fr
⁎
Lahfidi Amal MD
Guennouni Asmae MD
Kettani Najoua PhD
Fikri Meriem PhD
Touarsa Firdaous PhD
Jiddane Mohamed PhD
Department of Neuroradiology, Specialty Hospital, University Hospital Center Ibn Sina, Faculty of Medicine and Pharmacy, 10000, Rabat Morocco
⁎ Corresponding author. adam-s-300@hotmail.fr
21 8 2024
11 2024
21 8 2024
19 11 50845087
11 6 2024
22 7 2024
23 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Carotydinia, also called transient perivascular inflammation of the carotid artery (TIPIC) is a rare diagnostic entity related to an inflammation over the carotid bifurcation region. Despite the confusion about the definition of this term, neck pain remains the main symptom. Several articles revealed the relevance of imaging in the diagnosis of this disease. We report magnetic resonance and ultrasound images of a case with carotydinia, and also the elements that could eliminate differential diagnoses.

Keywords

Carotydinia
Magnetic resonance
Ultrasound
Inflammation
Wall thickening
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pmcIntroduction

Carotydinia, also called Fay syndrome or transient perivascular inflammation of the carotid artery (TIPIC), is defined as a neck pain over the carotid bifurcation. There remains controversy in the literature about what the term refers to, with some authors suggesting that the term should be used for a pain syndrome without structural abnormality while others assert that it's a defined inflammatory condition of the carotid. Despite this confusion, number of case reports have described relatively concordant imaging finding as an inflammatory process over the carotid bifurcation area. Recently, we experienced a case of carotydinia in MRI, which is why we report it. The aim of our study is to describe the typical radiological appearance of carotydinia, and to highlight the key elements for ruling out differential diagnoses.

Case report

A 47 years old woman came to our hospital due to neck mass. It appears 6months ago on the left side of her neck, along with headache of the ipsilateral side. She did not complain of fever, myalgia or sore throat, and no history of head or neck trauma has been reported. The remaining neurological and general examinations were unremarkable. Laboratory investigations showed normal values (ESR: 18 mm/h; CRP: 0,2 mg/dL).

Al Ultrasound imaging has been performed, showing hypoechoic soft mass, surrounding the upper half of the common carotid artery (Fig 1). A mild narrowing lumen has been seen but without resulting on acceleration of the blood flow (Fig 2).Fig. 1 US images: ultrasonography shows hypoechoic soft tissue mass surrounding the common carotid artery (arrow).

Fig 1

Fig. 2 US images: ultrasonography show a mild narrowing of the lumen. No acceleration of the blood flow has been noted.

Fig 2

An MRI of the head and neck was performed showing a soft tissue halo around the left common carotid artery and the bulb extending from approximately D1 to just below the carotid bifurcation at C5. The halo was thicker, measuring a maximum of 12 mm thick, along the anterior side of the common carotid artery, but seems to surround the vessel circumferentially, without distorting the lumen. No intimal flap was present. The tissue was T1 hypointense, T2 hypointense, and enhanced following gadolinium administration on fat saturation added to postcontrast T1 weighted sequence (Fig 3). No associated abnormality was reported on the fast spin echo T2 weighted images. There was no evidence of intramural hemorrhage. An adenopathy of the second chain was described on the right side. The conclusion made from the imaging studies was the diagnosis of idiopathic inflammation of the carotid artery wall, also known as carotydinia.Fig. 3 MRI images. (A) Axial T1-weighted image demonstrates that the soft tissue exhibits the same signal intensity as muscle. (B) Axial T2-weighted image shows that the signal intensity of the soft tissue is slightly higher than that of muscle. (C) Axial T1-weighted image after contrast injection reveals an intense and homogenous enhancement of the tissue surrounding the common carotid artery.

Fig 3

The patient started a nonsteroid anti-inflammatory drug daily for 1 week. Few days after the beginning of the therapy, the swelling resolved.

Discussion

Carotydinia is a rare and controversial disease, that consist of unilateral neck pain with increased pulsation over the diseased carotid bifurcation and pain worsening upon palpation [1]. Four diagnostic criteria have been reported by the classification committee of the international headache society to define the syndrome of acute idiopathic carotydinia : (1) Tenderness, swelling or increase of pulsation along the carotid artery; (2) Absence of abnormality concerning the structure of carotid artery (3) neck pain that may involve the homolateral head (4) period of symptoms less than 2 weeks [2]. Carotydinia remain rare and the estimated prevalence is low in some studies (2,8% of patients presenting with acute neck pain) [3]. Leclerc proposed a revised description of this entity after establishing a retrospective study involving 47 patients, which is significant for such a rare disease. As a consequence, a new term has been attributed to this disease: TIPIC (Transient Perivascular Inflammation of the Carotid Artery) syndrome [4]. Coulier also reported a slight female preponderance, which is concordant with our case [5].

Patients affected by this disease typically present with the classical symptom of carotydinia, which is an unilateral neck pain [6]. However, in our case, pain wasn't the main symptom the patient complained about, but the sensation of having a swelling of the left side of the neck, and also a pain projection involving the head homolaterally.

Stanbro et al. [7] reviewed 22 reports that presented radiologic findings, such as wall thickening of the carotid artery or peri vascular soft tissue enhancement that seems to be specific for carotydinia. In 13 cases, a localized soft tissue enlargement surrounding the common carotid artery have been described on color doppler ultrasound. It was also reported that the thickening affected the whole carotid wall. However, in our case, the thickening involves only the outer layers of the vessel wall. Lack of narrowing of the lumen and no irregularity of the carotid wall suggest that media and intima are spared, even if mild luminal narrowing was revealed in a third of cases [8,9]. Despite the fact that ultrasonographic techniques don't have the ability to show the enhancement of tissues, the introduction of CEUS, which is a technique that use ultrasonographic contrast agents, has rendered the observation and the quantification of the enhancement pattern possible. It has acquired growing acceptance and indications, even for the carotid vessels [10]. The use of CEUS for the evaluation of TIPIC syndrome has been firstly reported by El Nawar et al. [9]. These authors demonstrated an hypoechoic lesion surrounding the vascular wall with enhancement following the administration of microbubbles [11].

MRI is a very sensitive modality that can help to eliminate other causes of neck mass. The strong enhancement that can be seen on MRI, as in our case, can be strongly evocative of an inflammation of the carotid wall. On the other hand, the disparity concerning the enhancement between the vessel wall and the surrounding tissues are conforming with an abnormality of the carotid wall itself [12]. MRI differentiate between atherosclerotic plaque and peri vascular inflammation by revealing an excellent delineation of the adventitia. The preservation of the intima lead to the definitive diagnosis of carotydinia [13]. Fat saturation added to post contrast T1 weighted sequence could be useful to detect more easily the enhancement of the carotid wall [9].

Good interobserver agreement on US and MRI has been reported concerning recognition of intimal lesions with subsequent luminal narrowing, but was lower for computed tomography angiography. This illustrates the superiority of ultrasound to perceive subtle changes of the vessel wall [4]. Some studies reported that ultrasound may miss fine mural changes demonstrated by MRI. However, this could be explained by the fact that ultrasound was primarily used to appreciate the blood flow rather than the vessel wall itself. That's why vascular wall examination combined with doppler findings are essential to reach the diagnosis. Ultrasound also detect enlarged lymph node in a third of cases, whereas MRI detect it in less than 20% of cases [9]. As a consequence, many articles point out the fact that MRI should not be used for routine examination as it doesn't commonly furnish additional information to ultrasound findings [14].

The main differential diagnosis that should come to our mind at cross sectional imaging involve carotid dissection and large vessel vasculitis. The absence of T1 hyperintense wall hematoma can easily rule out aortic dissection. This hematoma can be even detected on MRI several months after the occurrence of the dissection. Concerning large vessel arteritis, including giant cell arteritis and Takayasu arteritis, there is an intense enhancement of the arterial wall on MRI. However, important luminal stenosis should be associated, and the enhancement may not be limited to the common carotid artery [8]. Ultrasound also play an important role and helps to eliminate vascular and nonvascular differential diagnoses such as aneurysm, acute occlusion, carotid dissection and many others by showing the hypoechoic inflammatory infiltration [14]. The list of other potential differential diagnoses is exhaustive, but the more common remain submandibular gland disease, lymphadenitis or degenerative joint disease [8].

The medical treatment remains the major treatment for carotydinia. An initial course of NSAID should be administered. If there is no alleviation of symptoms after 1week, a short course of steroids is administered [12].

Conclusion

Idiopathic carotydinia is benign clinical entity related to the inflammation of the carotid wall. Cross sectional imaging in conjunction with clinical examination are fundamental for the diagnosis of carotydinia. MRI helps to rule out easily other clinical entities that could have the same presentation, and enhancement following contrast injection is an important feature for the diagnosis. However, ultrasound is a less expensive and more accessible tool that can make the same observation by using the CEUS technique. Thereby, ultrasound should be the first line imaging modality for the assessment of TIPIC syndrome. In most of cases, the treatment is medical with a rapid recovery.

Patient consent

Informed consent for publication was obtained from patient.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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