Case Study: Incidental Finding of Decreased Carotid Artery Flow Void in a Patient with Neck Pain and Headaches
Case at a Glance
A 68-year-old male presented with chronic neck pain and headaches. A cervical spine MRI performed to investigate these symptoms revealed expected degenerative changes and an incidental, non-specific finding of a decreased flow void in the right internal carotid artery, necessitating further vascular imaging.
Patient's Story
A 68-year-old male presented to his primary care provider with a chief complaint of persistent, bothersome neck pain and chronic headaches. The patient's history was otherwise non-contributory for neurological events such as stroke or transient ischemic attack (TIA). Due to the chronicity of the symptoms, the provider initiated a diagnostic workup.
Initial Assessment
On initial evaluation, the patient was neurologically intact. The primary concern was musculoskeletal, likely related to age-related changes in the cervical spine. To investigate the etiology of his neck pain and rule out any compressive pathology that might contribute to his headaches, a non-contrast MRI of the cervical spine was ordered.
The Diagnostic Journey
The cervical spine MRI revealed multilevel degenerative disc disease and spondylosis, consistent with the patient's age and presenting symptoms of neck pain. However, the radiologist noted an additional, unexpected finding: 'Abnormal signal and subtle decreased flow void involving the distal cervical and proximal petrous right internal carotid artery.'
This finding raised concern for a potential vascular abnormality. On a standard T2-weighted MRI, patent blood vessels with normal flow typically appear as a dark signal 'void' (a flow void). A decrease in this signal can suggest pathology such as stenosis, dissection, or thrombosis, but can also be an artifact caused by slow or turbulent blood flow. Given the non-specific nature of this finding on a non-contrast MRI, the radiologist recommended further, more definitive imaging.
Final Diagnosis
The final diagnosis remained pending further investigation. The established diagnoses were:
- Cervical Spondylosis and Degenerative Disc Disease: Accounting for the patient's neck pain.
The incidental MRI finding prompted a differential diagnosis for the decreased flow void, including:
- Significant internal carotid artery stenosis
- Carotid artery dissection
- Flow-related artifact due to vessel tortuosity or slow flow
Treatment Plan
The immediate management plan was diagnostic rather than therapeutic. The provider scheduled a follow-up Magnetic Resonance Angiogram (MRA) of the neck, as recommended by the radiologist. The MRA is specifically designed to visualize blood vessels and would provide a conclusive assessment of the carotid artery's patency and structure.
The patient and his family were counseled that the MRI finding was inconclusive and that the MRA was necessary for clarification. This step was crucial for managing the significant anxiety the finding had caused.
Outcome and Follow-up
The patient is scheduled to undergo the MRA in the coming week. Follow-up with his provider is arranged to discuss the results. The subsequent management pathway is entirely dependent on the MRA findings. If the MRA is normal, the patient will be reassured, and focus will return to managing his cervical spondylosis. If significant stenosis or other pathology is identified, he will be started on appropriate medical therapy (e.g., antiplatelet and statin therapy) and referred to a vascular specialist for further evaluation and potential intervention. This case underscores the importance of appropriate follow-up imaging to characterize incidental findings from initial diagnostic tests.