Carotidynia: A Rare Diagnosis for Unilateral Neck Pain Revealed by Cross-Sectional Imaging

Abstract

Idiopathic carotidynia (IC) is a rare and poorly understood syndrome consisting of unilateral neck pain, tenderness, and increased pulsations over the affected carotid bifurcation. A growing body of evidence supports the hypothesis that IC is a distinct clinicopathologic entity with characteristic imaging features. We report the case of a 34-year-old Caucasian male presenting with intense unilateral neck pain in the emergency setting. Computed tomography and ultrasonography revealed fusiform eccentric thickening of the ipsilateral carotid bifurcation without vessel narrowing. Contrast-enhanced magnetic resonance imaging depicted major perivascular enhancement without evidence of dissection. Further imaging and laboratory work-up excluded vasculitis. The diagnosis of IC was made. The patient was treated with nonsteroidal anti-inflammatory drugs and symptoms and imaging findings disappeared within a few weeks. Cross-sectional imaging allows not only ruling out IC mimickers but also making the correct diagnosis of this rare condition, in particular, as the clinical presentation of IC is often nonspecific.

Figure 1

(a) Axial contrast-enhanced CT scan (soft tissue window) shows poorly delineated thickening of the left carotid bulb wall (arrow). Note obliteration of the pericarotid fatty tissue. Minimal vessel narrowing (<20%) due to fibrolipid plaque (arrowhead). (b, c) Axial and longitudinal views of Doppler US examination show fusiform eccentric wall thickening of the left proximal internal carotid artery (ICA) and external carotid artery (ECA) isoechoic to muscle (arrowheads). (d) Sagittal multiplanar reformatted (MPR) image from a 3D volume turbo spin echo acquisition centered on the left carotid bulb (asterisk) shows no evidence of spontaneously T1 hyperintense parietal hematoma, thus ruling out carotid artery dissection. No aneurysm is seen. (e) Axial T1-weighted MR image reveals a hypointense circumferential lesion involving the left carotid bulb and pericarotid fatty tissue (arrows). (f) Intense enhancement (arrowhead) of the mass-like soft tissue lesion on the axial postcontrast fat-saturated T1-weighted MR image. Note that perivascular enhancement and vessel wall enhancement can be hardly differentiated from one another. ICA: internal carotid artery and ECA: external carotid artery.

Figure 2

US longitudinal view (a) and corresponding color Doppler image (b) obtained 4 months later show regression of the fusiform wall thickening (arrowheads) of the left carotid bulb. ICA: internal carotid artery. See for comparison Figures 1(b) and 1(c) obtained 4 months earlier.