Teaching NeuroImages: An aTIPICal cause of acute neck pain

A healthy 54-year-old woman developed spontaneous acute onset of sharp left-sided neck and facial pain and odynophagia following a brief flu-like illness. CT angiography revealed eccentric perivascular infiltration at the left carotid bifurcation (figure 1) with corresponding enhancement on MRI (figure 2). She was empirically treated with prednisone and had clinical and imaging improvement at follow-up.

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Figure 1 Initial imaging

(A) Sagittal and (B) axial CT angiography images demonstrate eccentric low-attenuation plaque along the posterior wall of the distal left common carotid artery (long arrow) without significant luminal narrowing. Surrounding soft tissue and fat stranding (short arrows) are consistent with perivascular inflammation.

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Figure 2 Follow-up imaging at 3 weeks

(A) Noncontrast T1-weighted axial MRI at 3 weeks post-CT showing minimally hyperintense plaque at the posterior aspect of the distal left common carotid artery (CCA), which enhances post IV contrast on (B) postgadolinium T1 fat-saturation imaging axial MRI (long arrows). There is a clear fat plane at the posterior margin of the left CCA (short arrows) consistent with resolution of perivascular inflammation, which was identified on CT at the time of initial presentation.

Transient perivascular inflammation of the carotid artery (TIPIC) is a rare, self-limited entity distinguishable on vascular imaging from extracranial dissection by lack of luminal narrowing and marked perivascular inflammation.¹ Reported treatments include nonsteroidal anti-inflammatory drugs, antiplatelet agents, and steroids. There is no known associated risk of stroke. Pain typically resolves within 2 weeks, with radiologic improvement by 3 months.²

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