Carotid calcifications on panoramic radiography identify an asymptomatic male patient at risk for stroke A case report Laurie C. Carter, DDS, MA, PhD, a Kelly Tsimidis, DDS, b and Jude Fabiano, DDS, c Buffalo, N.Y. STATEUNIVERSITYOF NEW YORK AT BUFFALOSCHOOL OF DENTALMEDICINE Although stroke may be preventable, a major challenge is to find effective methods of detection of stroke-prone patients. Most noncardiogenic strokes occur as a result of atherosclerosis involving the proximal internal carotid artery, calcifications of which can be detected on dental panoramic radiography. This report describes the case of an asymptomatic patient whose dental radiographic findings led to carotid endarterectomy. Calcifications were viewed bilaterally in the soft tissues of the neck in the area of the carotid bifurcation on a screening panoramic radiograph of an asymptomatic 75-year-old man. Subsequent duplex Doppler ultrasound revealed extensive atherosclerotic changes bilaterally with critical stenosis (90%+) in the right internal carotid artery. Carotid digital subtraction angiography revealed a 95%+ stenosis at the origin of the right internal carotid artery. The patient underwent right carotid endarterectomy involving the internal, external, and common carotid arteries. Twelve months later the patient was alive and well. Dental panoramic radiography represents a useful imaging modality for detection of some asymptomatic stroke-prone patients. Identification of calcifications in the area of a patient's carotid vasculature should prompt expeditious referral to a physician for a cerebrovascular and cardiovascular work-up as part of an active stroke prevention strategy. (Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 1998585:119-22)
There is no doubt that carotid calcifications can be detected in the extracranial carotid vasculature on dental panoramic radiography.t However, although calcification of the coronary arteries is a well-established marker for significant cardiovascular disease, the relation of carotid calcification to clinical cerebrovascular events is as yet undefined. 2 Fortunately, calcified extracranial carotid arteries are amenable to further noninvasive investigation by duplex Doppler and Bmode ultrasound imaging. What follows is the case history of an asymptomatic individual who initially appeared at the dental clinic with carotid calcifications, as revealed on dental radiography.
CASE REPORT A 75-year-old man came to the clinics of the School of Dental Medicine for fabrication of complete dentures. A screening panoramic radiograph on January 5, 1996, revealed the presence of multiple punctate and irregular heterogeneous radiopacities. They were arranged in a verticolinear This project was supported in part by a grant from the National Institutefor Dental Research (5T35 DE07106-15). aAssociateProfessor and Director, Oral and MaxillofacialDiagnostic Imaging Clinic. bFormerly senior dental student; currentlygeneral practice resident, Strong Memorial Hospital, Rochester, N.Y. cClinicalAssistant Professor, Oral Diagnostic Sciences, and private practice, Amherst, New York. Received for publication Apr. 14, 1997; accepted for publication May 28, 1997. Copyright Š 1998 by Mosby, Inc. 1079-2104/98/$5.00 + 0 7/16185782
fashion bilaterally in the soft tissues of the neck, inferior to the angle of the mandible, and adjacent to the hyoid bone and the C3 and C4 vertebral bodies (Fig. 1). The radiographic impression was consistent with calcification of the carotid vasculature bilaterally in the area of the bifurcation and the internal carotid artery (ICA). Physical examination was negative for neck bruits, and the patient denied any history of overt transient ischemic attacks (TIAs). He did, however, suffer from lightheadedness on standing and from vertigo, for which he took meclizine (12.5 mg/day). Risk factors for cerebrovascular disease included a history of smoking, a myocardial infarction after a 1-month history of unstable angina (in February of 1993), and a subsequent quadruple coronary bypass and marginal endarterectomy. At the time of the bypass, it was noted that the patient's coronary vessels were highly calcified. On March 13, 1996, the patient was referred to his internist for cerebrovascular assessment. On March 29, 1996, sonographic examination of the bilateral carotid vasculature was performed by means of the duplex scanner with imaging and Doppler evaluation, including color Doppler. Extensive atherosclerotic changes containing calcium were observed at the right carotid bifurcation. Peak velocities were 430 cm/sec in the right proximal ICA and 276 crrdsec in the right external carotid artery (ECA). On the left side, the atherosclerotic changes were somewhat less pronounced. Peak velocities were 188 cm/sec in the left proximal ICA and 133 cm/sec in the proximal ECA. Carotid sonography identified carotid stenosis bilaterally with a critical stenosis (90%+) in the right ICA (Fig. 2). Stenosis was determined to be 90% in the right ECA, 70% in the left ICA, and 55% in the left ECA. On April 19, 1996, carotid digital subtraction angiography revealed a stenosis greater than 95% at the origin of the right ICA for a 2.5-cm 119