Bilateral internal carotid artery dissection in a specific unbalanced diet: A case report

Abstract

Recent research has indicated a potential link between specific diets and an increased risk of stroke or cardiovascular disease. In this report, we describe a case involving a 45-year-old male who consumed a nightly diet consisting entirely of convenience store bento or cup noodle ramen for over two decades. After two decades of this diet, he experienced a bilateral internal carotid artery dissection in the petrous and cervical portions in his 40s. This condition resulted in an infarction in the left middle cerebral artery area. After stroke treatment, he was discharged and went home without any sequelae. There was no recurrence of stroke after his diet was adjusted appropriately. Although this is a single case study and we cannot exclude that an unbalanced diet is not the cause, it highlights that certain extreme dietary habits may pose a risk of early-onset artery dissection.

Introduction

Carotid artery dissection is a major cause of early-onset strokes. ¹ While various factors such as an elongated styloid process and neck massages are known causes,^2,3 many cases of carotid dissection remain cryptogenic. ⁴ Some recent studies suggested the possibility that certain food diets are related to strokes or cardiovascular diseases.^5,6 Herein, we report an early-onset case in which a specific unbalanced diet was continued for two decades, and a bilateral carotid artery dissection was experienced.

Case

A healthy working 45-year-old male suddenly broke down at the visiting station. A couple of hours before the onset, he had felt numbness in his right hand, dropping documents from his right hand during a workplace meeting. He showed dysarthria and was transported to our hospital’s emergency department. He had no prior history of illness, had never been married, and maintained a highly unbalanced diet, eating only once a day, just before sleeping. From the age of 22, ever since he began living by himself, his meals consisted exclusively of either a convenience store bento or instant noodles, and he never went to restaurants or cooked meals himself. He regularly took a health check every 2 years, but hypertension, hyperlipidemia, or diabetes mellitus were never detected. He was a past smoker, his Brinkman Index was 360, he never drank alcohol, he had no minor trauma, neck strain history, or recent infections, and he did not do notable exercises while his physical activity was of a normal level. Concerning his family history, his mother died at the age of 58 due to an acute myocardial infarction.

His height was 164 cm, and body weight was 64 kg. His neurological findings included dysarthria and mild motor aphasia with a National Institutes of Health Stroke Scale score of 2 (dysarthria and sensory disturbance). When he arrived at the emergency room, both paresis and sensory disturbances disappeared. A cranial magnetic resonance image revealed an area of ischemic stroke in the left anterior cortex, suggesting embolism (Figure 1(a)). Magnetic resonance angiography (MRA) showed dissection of the right internal carotid artery (ICA) at the petrous portion (Figure 1(b), arrow). For further validation, we performed three-dimensional computed tomographic angiography (3D-CTA), which revealed bilateral ICA dissections (Figure 1(c) and (d), arrows). In the axial planes, false lumen thrombosis was revealed (Figure 1(e) and (f), arrows). One week after admission, cerebral angiography was performed, and the results corresponded to the 3D-CTA findings, that is, dissections at the petrous portion of the right ICA and at the cervical portion of the left ICA (Figure 1(g) and (h), arrows). The axial planes showed no abnormal relationship to bones, such as Eagle syndrome (Figure 1(i) and (j)).

Figure 1.

(a) DW-MRI at admission showed the infarction area in the left MCA area (arrowhead). (b) MRA at admission showed the flow abnormality of the right ICA at the petrous portion (arrow). (c) 3D-CT of the right ICA and (d) left ICA showed the bilateral ICA dissections (arrows). (e) 3D-CTA axial plane of the right ICA and (f) left ICA. ICA dissections (arrows). (g) Angiography of the right ICA and (h) left ICA confirmed the bilateral ICA dissections at the petrous portion of the right ICA and at the cervical portion of the left ICA (arrows). (i) Angiography axial plane of the right ICA and (j) left ICA.

Based on the results of these examinations, we diagnosed him with left cerebral embolism following left ICA dissection. All the results of examinations pertaining to the causes of early-onset stroke, such as auto-antibodies, protein-S, protein-C, or infections, were negative. Connective tissue diseases, such as Marfan or Ehlers–Danlos syndromes, were not present. At the time of admission, only the value of serum homocysteine was elevated, at 20.9 nmol/mL (normal value: 3.7–13.5). General lipid values, such as those related to triglycerides and cholesterols, were within a normal range, but the ratios of both eicosapentaenoic acid/arachidonic acid and docosahexaenoic acid/arachidonic acid decreased to 0.21 and 0.28, respectively (arachidonic acid value was elevated: 313 μg/mL; normal value: 142–307 μg/mL). The apnea hypopnea index, assessed by polysomnography, was <10.

After admission, he was treated with a low dose of heparin (10,000 IU/day) to prevent further embolism. Heparin was switched to warfarin at day 7 after the onset, and warfarin was continued for 3 months. The symptoms at admission, dysarthria and sensory disturbance, disappeared completely while at the hospital. Stroke did not recur, and he was discharged and went home on day 27 after the onset without any sequelae. At the time of discharge, his level of serum homocysteine decreased to 6.9 nmol/mL after consuming an adequate hospital diet. The follow-up MRA at 6 months after the onset showed improved flow without any leaking, suggesting that vascular wall repair had progressed. The reporting of this study conforms to CARE guidelines (Supplemental Material). ⁷

Discussion

Our presented case describes an early-onset bilateral ICA dissection that occurred due to the long-term consumption of a specific unbalanced diet. Other risk factors include that he was a past smoker, had a family history, as well as hyperhomocysteinemia. However, these factors were not strongly considered as the primary cause of dissection, and hyperhomocysteinemia disappeared after consuming an adequate hospital diet. While we did not definitively prove a direct causal relationship, we suspect that his highly unbalanced diet influenced the early-onset bilateral ICA dissection. Several recent studies have highlighted the risks associated with excessive consumption of ultra-processed foods. ⁸ Chronic inflammation and oxidative stress resulting from frequent intake of such foods can negatively affect the cardiovascular system.^9,10 Our case of dissection lends support to these prior meta-analyses. Since neither hypertension nor hyperlipidemia was detected in the patient’s health check, we speculate that hyperhomocysteinemia, deficiency of micronutrients, such as vitamin B, folate, or omega-3 fatty acid, may be related to the observed dissection. These deficiencies are known to contribute to chronic inflammation and oxidative stress.^11,12 In addition, having a meal only once before sleeping can be detrimental. ¹³

There are several pathological factors related to arterial dissection: connective tissue disorders, mechanical vascular stress, genetic predisposition, hypertension, vascular fragility, and others.^14,15 Compared to these factors, the role of a diet in cervical artery dissection remains speculative. Since the occurrence of cervical artery dissection is relatively rare, a well-designed and focused study is needed to confirm the causal factors. The relationship between nutritional status and cervical artery dissection has not been well studied, but this case highlights its potential significance. We note a limitation in this case, namely that the patient’s dietary history lacked an actual dietary log and relied solely on the patient’s recall, which resulted in the lack of objective nutritional quantification.

Conclusions

This case underscores the importance of maintaining a balanced diet, particularly as a potential preventive measure against dissection.

Supplemental Material

sj-pdf-1-sco-10.1177_2050313X261443168 – Supplemental material for Bilateral internal carotid artery dissection in a specific unbalanced diet: A case report

Supplemental material, sj-pdf-1-sco-10.1177_2050313X261443168 for Bilateral internal carotid artery dissection in a specific unbalanced diet: A case report by Kosuke Matsuzono, Masayuki Suzuki, Ayuho Higaki, Katsunari Namba and Shigeru Fujimoto in SAGE Open Medical Case Reports