Carotid artery tortuosity is the elongation of the extracranial carotid arteries with redundancy and/or altered course, which may present on imaging as kinking, coiling, and/or looping ^1,2.

Clinical presentation

Carotid artery tortuosity is mostly (~80%) asymptomatic. When symptomatic (~12.5%, range 4-20%), it presents with neurological symptoms (e.g. dizziness, tinnitus, stroke) ^3,4.

Pathology

The pathogenesis of carotid artery tortuosity is unknown ⁴.

Associations

• hypertension ³
• aging ³
• atherosclerosis/atheroma ³
• obesity ⁴
• connective tissue diseases, e.g. Marfan syndrome, Loeys-Dietz syndrome, neurofibromatosis type 1 ⁴
• congenital: failure in the development process of the third aortic arch and the dorsal aorta in the embryonic period ³

Classification

Carotid artery tortuosity can be classified into three different types ⁴:

• type 1: artery with a non-rectilinear section and an angle >90º
• type 2: artery with a section in the form of a curl that generates an angle of 360º about its transverse axis
• type 3: twist from the bending of ≥2 segments of an artery with an internal angle of 90º

Radiographic features

Ultrasound

• morphological features in grayscale
• hemodynamic values in spectral Doppler

CT

CT angiography allows for 3D reconstruction and a precise assessment of the degree of tortuosity of the artery.

Angiography (DSA)

Angiography allows characterizing the type of tortuosity and has a high sensitivity to detect it.

Treatment

• arterial transposition is criticized for not removing arterial elongation
• vascular surgery, e.g. segmental resection and end-to-end anastomosis
• endarterectomy technique with eversion, which allows correction of severe elongation and kinking of the ICA ⁵