Abstract 214: Carotid dissection and occlusion leading to acute ischemic stroke, hypotension and bradycardia

Introduction The carotid sinus regulates blood pressure and heart rate. Damage to the carotid sinus, whether from a surgical procedure or compression by a mass, can lead to hypotension and bradycardia. We report a case of carotid artery dissection resulting in symptomatic hypotension and bradycardia which has been uncommonly reported. Presentation A 65‐year‐old female presented with speech changes and altered mental status. On examination, the heart rate was in the 30s, fluctuating between the 40s and 50s. A CT scan revealed a subacute hypodensity in the territory of the left middle cerebral artery. CT angiography showed luminal irregularity in the distal common carotid artery and carotid bifurcation, occlusion of the internal carotid artery with reconstitution at the supraclinoid segment, suggesting a possible dissection. MRI identified an acute ischemic infarct in the anterior left insular cortex and adjacent left frontal lobe. MRA of the neck confirmed the occlusion of the left internal carotid artery, with no evidence of calcified or low‐density fatty plaque at the bifurcation. During her stay, the patient also developed hypotension with systolic blood pressure in the 80s and 90s requiring fluids. EKG showed sinus bradycardia. Patients did not have a history of bradycardia or hypotension. She was not on any medication at home or in hospital which could contribute to bradycardia. Cardiology was consulted who attribute this to carotid artery dissection. Discussion The carotid sinus is a neurovascular structure located at the bifurcation of the common carotid artery and extending into the proximal internal carotid artery. Hypotension and bradycardia are commonly observed in patients who undergo carotid artery stenting due to stretching of these baroreceptors. Patients with carotid body tumor or neck mass with compression of the carotid bifurcation and internal carotid artery. Similarly, there are case reports in literature with dissection of internal carotid artery presenting with syncope, bradycardia and hypotension. While dissection of the internal carotid artery has been documented to cause these symptoms, dissection involving the carotid bifurcation and associated occlusion is less commonly reported. Prior to associating dissection as etiology, complete workup to rule carotid body dysfunction, sinus node dysfunction, or carotid sinus hypersensitivity should be carried out. Conclusion Dissection of the carotid bifurcation and internal carotid artery has been associated with hypotension, bradycardia, and syncope. However, not all cases of carotid dissection result in these symptoms. Therefore, further investigation is needed to assess the dissection's characteristics, location, and the impact of any associated stenosis or atherosclerosis on symptom development.