Transient Perivascular Inflammation of the Carotid Artery as a Poorly Recognized Cause of Neck Pain

Transient perivascular inflammation of the carotid artery (TIPIC) syndrome, historically named idiopathic carotidynia or Fay syndrome, is a rare condition characterized by inflammation and pain in the carotid artery. The diagnosis requires a specific clinical-radiological presentation. We describe a 37-year-old female who presented with headaches and left neck pain and was diagnosed with TIPIC syndrome with temporary perivascular infiltration.

Transient perivascular inflammation of the carotid artery-A transient but potentially recurrent disease

Transient perivascular inflammation of the carotid artery (TIPIC syndrome) is a rare, unclassified vascular syndrome that usually affects the distal part of the common carotid artery and has a favorable prognosis. The disease is often misdiagnosed even by neurologists due to the moderate intensity of clinical symptoms and their transient character. We present a case of a 52-year-old man who experienced two episodes of transient neck pain and moderate local tenderness one and a half years apart. Different imaging modalities, such as ultrasound, CT angiography, and high-resolution 3T MR, were applied to better visualize the perivascular inflammation of the common carotid arteries. Based on the clinical-radiological characteristics of our case and applying the diagnostic criteria, we established the diagnosis of TIPIC syndrome. The patient was treated with nonsteroidal anti-inflammatory drugs for few weeks, and reduction in perivascular changes was observed in both episodes. The case raises questions about the phases of the disease, its duration and the intervals between follow-ups. Our article also increases the awareness of this rare clinical-radiological entity and presents recent data from the literature.

G-CSF-induced TIPIC syndrome and large vessel vasculitis: A case report

Key Clinical Message

We report a rare adverse event of transient perivascular inflammation of the carotid artery syndrome induced by granulocyte colony-stimulating factor injections. Recognition of this syndrome is important for physicians, to avoid the exposure of the causative medication, rule out differential diagnosis and delay the use of corticosteroids given the spontaneous improvement after discontinuation of the causative medication.

Abstract

A 73 year-old Caucasian woman presented with odynophagia, carotidynia, and fever 5 days following a granulocyte colony-stimulating factor (G-CSF) injection for chemotherapy-induced neutropenia in the setting of myelodysplastic syndrome. Examination showed painful swelling of the neck. Lab results showed inflammation with CRP 328 mg/L. A CT-scan revealed tissue infiltration thickening surrounding the left internal carotid artery, the carotid bifurcation, and the common carotid artery, as well as circumferential thickening of the aortic arch. Ultrasound of the left internal carotid artery found isoechoic wall thickening. Symptoms drastically improved without steroids in a short time period. Horton's disease, Takayasu's diseases, and infectious vasculitis were not retained due to the short time delay of symptoms onset, atypical echogenicity, and spontaneous improvement. A diagnosis of G-CSF-induced large vessel vasculitis transient perivascular inflammation of the carotid artery (TIPIC) syndrome was made. Seven days later, ultrasound control showed diminished thickening infiltration. G-CSF TIPIC is a rare adverse event that should be kept in mind in patients under G-CSF.

Transient Perivascular Inflammation of the Carotid Artery (TIPIC) Syndrome: An Atypical Cause of Neck Pain

Transient perivascular inflammation of the carotid artery (TIPIC) is an uncommon condition characterized by inflammation of the carotid artery wall, leading to unilateral neck pain. While TIPIC has been acknowledged by the International Classification of Headache Disorders, only a few patient series have been published thus far. The clinical presentation of TIPIC syndrome typically manifests as unilateral neck pain localized specifically over the carotid artery. This pain is accompanied by ipsilateral tenderness and increased arterial pulsation. The condition commonly follows a self-limited course or demonstrates a favorable response to treatment with nonsteroidal anti-inflammatory drugs. When evaluating patients with suspected TIPIC syndrome, conducting a comprehensive assessment of their clinical history is imperative, while utilizing imaging studies to exclude any potential structural abnormalities of the carotid artery effectively. The authors present a case involving a 57-year-old woman who presented with a two-month history of persistent left cervical pain and tenderness. Ultrasonography findings revealed indirect indications of inflammation in the intima-media layer of the carotid artery, suggestive of carotidynia. Notably, other significant differential diagnoses such as aneurysms or carotid dissection were ruled out. Over the course of the evaluation, there was a gradual and spontaneous improvement in both clinical symptoms and radiological findings, indicating the resolution of the inflammatory process as confirmed by imaging follow-up. This case presents a rare and atypical manifestation of transient neck pain attributed to TIPIC.

TIPIC-A Newly Recognized Syndrome: Multimodality Imaging of a Rare Clinicoradiological Entity

Carotidynia is a controversial clinicopathological entity vastly described in Western literature as neck pain in the region of carotid bifurcation secondary to an underlying inflammatory etiology. Radiologically, this appears as perivascular inflammation and has recently been designated as transient perivascular inflammation of the carotid artery (TIPIC) syndrome. The authors of this report discuss the multimodality imaging features of a rare case of this disease in our country to familiarize radiologists with the imaging findings and to encourage the inclusion of TIPIC syndrome as a differential diagnosis for focal neck pain.

Myocarditis and carotidynia caused by Granulocyte-Colony stimulating factor administration

A 59 year-old woman was treated with adjuvant chemotherapy for triple negative breast cancer (TNBC) stage IB. She received pegfilgrastrim as secondary prophylaxis of neutropenia. After administration of pegfilgrastrim on day 11, she was hospitalised because of carotidynia and myocarditis that improved with antibiotics and steroids as an infection was suspected. Once she was recovered, another cycle of chemotherapy with pegfilgrastrim was administrated. At this time, the patient presented to our hospital with fever, odynophagia and chest pain, with diagnosis of myocarditis coupled with cardiogenic shock. She received antibiotics and steroids, advanced life support and also a pericardial window was done, with recovery of her condition. After a complete evaluation and exclusion of other possible aetiologies, we concluded that pegfilgrastrim was responsible for inducing carotidynia and myocarditis. Few cases have been published about Granulocyte-Colony stimulating factor (G-CSF) induced carotidynia and aortitis. However, this is the first reported case about G-CSF induced myocarditis and carotidynia.

Ultrasound for the Diagnosis of Carotidynia

The purpose of this work is to draw attention to the characteristic sonographic features of carotidynia, which, in the context of a typical clinical picture support its diagnosis. Six patients presented with primary symptoms of neck pain and focal tenderness. In all patients, focal wall thickening of the distal end of the common carotid artery was found exactly in the region of tenderness, leading to mild lumen narrowing. Treatment with nonsteroidal anti-inflammatory drugs or glucocorticoids led to full symptom resolution. Carotidynia will often be encountered first on sonography performed for evaluation of neck pain and has a characteristic sonographic appearance.

Embolic Stroke due to Carotidynia Potentially Associated with Moving Carotid Artery Caused by Swallowing

A 63-year-old woman with end-stage renal disease on maintenance hemodialysis discontinued her medication for rheumatoid arthritis with prednisolone and azathioprine. One month later, she was admitted because of consciousness disturbance and right hemiparesis. Diffusion-weighted brain magnetic resonance imaging (MRI) revealed multiple hyperintensities in her left frontal and parietal lobes. She also developed high fever and left neck pain. Carotid ultrasonography showed calcified plaque with vessel wall swelling at the bifurcation of the left common carotid artery (LCCA) and surrounding hypoechoic soft tissue. The tissue was identified as an isodense lesion on noncontrast computed tomography (CT) and as a high-intensity lesion on fat-saturated T2-weighted MRI. From her symptoms and radiological findings, she was diagnosed with carotidynia. Cervical MRI also showed that the LCCA was transposed to a retropharyngeal location, suggesting a moving carotid artery. Carotid ultrasonography revealed that the LCCA moved to and from the retropharyngeal position with swallowing and was thus being compressed by the hyoid bone. After corticosteroid therapy was initiated with 30 mg of prednisolone, her symptoms and radiological findings improved. To our knowledge, this is the first report of a case of cerebral embolism due to carotidynia. The repetitive compressions by the hyoid bone during swallowing were presumed to have provoked shear stress and inflammation of the carotid vessel wall, which was aggravated by discontinuation of steroid therapy in our case. These mechanical and inflammatory stresses might cause dysfunction of endothelial cells, hypercoagulation, platelet hyperaggregation, and vulnerability and rupture of carotid plaques, and may subsequently result in embolic strokes.

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Zusammenfassung. Wir präsentieren den Fall eines 49-jährigen Patienten mit linksseitiger Carotidynie. Als Ursache fand sich eine Lymphknotentuberkulose. Unter tuberkulostatischer Therapie zeigte sich eine rasche Besserung der Symptome.

Idiopathic Carotidynia

Idiopathic carotidynia is a syndrome characterized by pain and tenderness over the carotid artery without an associated structural luminal abnormality. Controversy exists over whether this is a distinct disease entity or merely a symptom attributable to other causes of neck pain, such as carotid dissection or vasculitis. A 50-year-old woman presented with sudden-onset right neck pain. Imaging studies demonstrated transmural inflammation of the proximal internal carotid artery, without evidence of intraluminal pathology. The patient was placed on low-dose aspirin and ibuprofen. Her symptoms resolved within a week. At 3-month follow-up, her carotid artery appeared normal on duplex ultrasonography.