CTA, MR, and MRA Imaging of Carotidynia: Case Report

a particular type of idiopathic neck pain, tending to be unilateral and associated with tenderness to palpation over the carotid bifurcation. This reproduction of pain with palpation later came to be known as a positive Fay sign. Patients are afebrile and lack any other systemic symptoms associated with infection or malignancy. Despite this characterization, a large differential diagnosis exists. There are a number of case studies on the subject of carotidynia. Included in these reports are various debates as to the existence of carotidynia as a distinct pathological entity, a “catch all” description of symptoms produced by different etiologies, or simply a poorly understood syndrome. In 1988, the International Headache Society accepted acute idiopathic carotidynia as a valid entity and defined a set of four criteria2: A. At least one of the following overlying the carotid artery: 1. tenderness, 2. swelling, or 3. increased pulsations; B. Appropriate investigations not revealing a structural abnormality; C. Pain over the affected side of the neck; may project to the ipsilateral side of the head; D. A self-limiting syndrome of less than two weeks duration. Explicit to these original criteria is the understanding that other organic diseases in the differential diagnosis have been ruled out. This includes a variety of vascular, inflammatory, neoplastic, neurologic and musculoskeletal conditions, including vascular injury and dissection. In 2004, carotidynia was removed from this society’s diagnostic criteria after cases were reported with imaging findings3. The current understanding of carotidynia as a clinical syndrome has been criticized for its lack of attention to imaging characteristics. There have been case reports demonstrating imaging findings on ultrasound, computed tomography (CT), computed tomography angiography (CTA), magnetic resonance (MR), magnetic resonance angiography (MRA), and positron emission tomography (PET). In effect, carotidynia by definition is a symptom of pain, yet it is also the name for the specific diagnosis of an inflammatory carotid wall disease that is the subject of this report. In the following case study, we describe clinical findings of a patient diagnosed with carotidynia who presented with neck pain, and demonstrate the CTA, MR, and MRA imaging including follow-up imaging.