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Multidetector-row computed tomography in the diagnosis of Collet–Sicard syndrome

L T Lucato¹, R B D Passos¹, C R Campos², A B Conforto², A M McKinney³

¹ Department of Radiology, The Clinics Hospital of the University of Sao Paulo, School of Medicine, Sao Paulo, Brazil
² Department of Neurology, The Clinics Hospital of the University of Sao Paulo, School of Medicine, Sao Paulo, Brazil
³ Department of Radiology, University of Minnesota Medical School, and the Hennepin County Medical Center, Minneapolis, MN, USA

Correspondence to:
ltlucato{at}uol.com.br

Collet–Sicard syndrome (CSS) refers to the unilateral lesion of cranial nerves IX to XII. The cause in this case is spontaneous dissection of the internal carotid artery (ICA), for which multidetector-row computed tomography (MDCT) images were critical for diagnosis.

A 54-year-old man noticed an onset of headache, hoarse voice and swallowing compromise. Neurological examination disclosed left-sided palsies of cranial nerves IX to XII.

MDCT demonstrated coiling of the cervical distal portion of left ICA (fig 1A), narrowed lumen, mural thickening, increased external diameter and a thin annular ring of enhancement ("target appearance")¹ (fig 1A, B). Signs of nerve dysfunction were also noticed (fig 2).

View this figure (62K): in this window | in a new window | PowerPoint for Teaching   Figure 1 Multidetector-row CT axial images (A and B) show coiling of left internal carotid artery (A), and crescent-shaped wall thickening (arrows, A and B). Figure B better demonstrates the narrowed eccentric lumen, an increase in external diameter and a faint enhancement of the external wall. A T1-weighted magnetic resonance image (C) demonstrates the hyperintense intramural haematoma (arrow).

 

View this figure (142K): in this window | in a new window | PowerPoint for Teaching   Figure 2 Multidetector-row CT curved coronal reconstruction shows palatal and lingual asymmetry (large arrow), some fatty replacement of the tongue muscles (small arrow) and left vocal-cord palsy (arrowhead).

 

Axial T1-weighted magnetic resonance images confirmed the dissection (fig 1C).

Causes of CSS include skull-base tumours and fractures, ICA dissection and vasculitis.² Near their points of exit, the lower nerves (IX to XII) lie in a narrow space even in normal conditions,³ so any adjacent lesion can cause compression.

The role of CT in the diagnosis of ICA dissection has evolved. Early studies demonstrated arterial wall thickening,^{4 5} but MDCT modified the scenario.

MDCT, in this case, was able to provide assessment not only of ICA dissection itself, but also of the effects of lower cranial nerve palsies (corroborating neurological examination), all obtained in a single sitting. Knowledge of all the diagnostic possibilities included in a single MDCT study is of paramount importance, as MDCT can be an adequate alternative to MRI in specific clinical settings or in a resource-limited environment.

This article has been adapted from Lucato L T, Passos R B D, Campos C R, Conforto A B, McKinney A M. Multidetector-row computed tomography in the diagnosis of Collet–Sicard syndrome Journal of Neurology, Neurosurgery and Psychiatry 2008;79:521

Competing interests: None.

1. Leclerc, X, Godefroy, O, Salhi, A, et al. Helical CT for the diagnosis of extracranial internal carotid artery dissection. Stroke 1996;27:461–6.[Abstract/Free Full Text]
2. Hsu, HP, Chen, ST, Chen, CJ, et al. A case of Collet-Sicard syndrome associated with traumatic atlas fractures and congenital basilar invagination. J Neurol Neurosurg Psychiatry 2004;75:782–4.[Abstract/Free Full Text]
3. Zielinski, CJ, Gunther, SF, & Deeb, Z. Cranial-nerve palsies complicating Jefferson fracture. A case report. J Bone Joint Surg Am 1982;64:1382–4.[Free Full Text]
4. Zuber, M, Meary, E, Meder, JF, et al. Magnetic resonance imaging and dynamic CT scan in cervical artery dissections. Stroke 1994;25:576–81.[Abstract]
5. Dal Pozzo, G, Mascalchi, M, Fonda, C, et al. Lower cranial nerve palsy due to dissection of the internal carotid artery: CT and MR imaging. J Comput Assist Tomogr 1989;13:989–95.[Medline]

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