Vertebral and carotid artery dissection: Difference between revisions
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==Background==
==Background==
*Primarily categorized as Spontaneous vs. Traumatic/mechanical
*Most frequent cause of [[CVA]] in young and middle-aged patients (median age - 40yrs)
*Most frequent cause of [[CVA]] in young and middle-aged patients (median age - 40yrs)
*Symptoms may be transient or persistent
*History pearls
*Consider in trauma pt who has neurologic deficits despite normal head CT
**Symptoms may be transient or persistent
*Consider in pt w/ CVA + neck pain
**Consider in trauma patient who has neurologic deficits despite normal head CT
**Consider in patient with CVA + [[neck pain]]
*Pathophysiology: Dissection of arterial vessel wall results in false lumen formation, leading to lumen stenosis and exposure of platelet aggregation factors ---> local thrombus formation ---> possible thromboembolism to intracranial vessels
**Less commonly, dissection of thinner intracranial arteries may lead to SAH through vessel rupture
 
[[File:Carotid_dissection.jpg|thumb|CTA brain showing filling defect in the right carotid artery (circled)]]
 
===Anatomy===
*Vertebral artery comes off the subclavian and runs upward through the formina in the transverses processes of C6 to C2.


===Risk Factors===
===Risk Factors===
#Neck trauma (often minor)
*Any mechanical event involving neck; symptoms typically occur 2-3 days after event
#Coughing
**[[Neck trauma]] (often minor)
#Connective tissue disease
**Cervical manipulation
#History of migraine
**Coughing/sneezing, vigorous exercise, weightlifting, intercourse, etc
*[[Connective tissue disease]]
*History of [[migraine]]<ref>De Giuli V et al. Association Between Migraine and Cervical Artery Dissection: The Italian Project on Stroke in Young Adults. JAMA Neurol. Published online March 6, 2017. doi:10.1001/jamaneurol.2016.5704</ref>


==Clinical Features==
==Clinical Features==
===Internal Carotid Dissection===
===Internal Carotid Dissection===
*Unilateral HA, face pain, anterior neck pain
*Unilateral [[headache]], face pain, anterior [[neck pain]]
**Pain can precede other symptoms by hours-days (median 4d)
**Pain can precede other symptoms by hours-days (median 4d)
**HA most commonly is frontotemporal; severity may mimic SAH or preexisting migraine
**Headache most commonly is frontotemporal; severity may mimic SAH or preexisting migraine
*Partial Horner syndrome (miosis and ptosis)
*[[Cranial nerve palsies]]
*CN palsies
*Vision loss
*Partial [[Horner syndrome]] (miosis and ptosis) in 50% of cases
*Symptoms of [[Stroke]], [[Transient ischemic attack]]
 
===Vertebral Artery Dissection===
===Vertebral Artery Dissection===
*Posterior neck pain, HA
*Posterior [[neck pain]], [[headache]]
**May be unilateral or bilateral
**May be unilateral or bilateral
**HA is typically occipital
**Headache is typically occipital
*Unilateral facial paresthesia
*Unilateral facial [[paresthesia]]
*Dizziness
*[[Dizziness]] or [[Vertigo]]
*Vertigo
*[[Nausea/vomiting]]
*N/V
*[[Diplopia]], [[nystagmus]], and other visual disturbances
*[[Diplopia]] and other visual disturbances
*[[Ataxia]]
*Ataxia
*[[Lateral Medullary Syndrome]] seen in up to 20% of cases of VAD<ref>Lee MJ, Park YG, Kim SJ, Lee JJ, Bang OY, Kim JS. Characteristics of stroke mechanisms in patients with medullary infarction. Eur J Neurol. 2012;19(11):1433-1439.</ref><ref>Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-1872.</ref>
 
==Differential Diagnosis==
{{Blunt neck trauma DDX}}
 
==Evaluation==
*Consider noncontrast CTH to assess for concomitant SAH
*Denver screening criteria is one way to evaluate for blunt cerebrovascular injury (BCVI)
**If positive findings on screening → obtain CTA or MRA (CTA has been shown to be equivalent to MRA)<ref>Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol. 2009 Oct;193(4):1167-74. doi: 10.2214/AJR.08.1688. PMID: 19770343.</ref>
 
{{Denver Screening Criteria}}


==Diagnosis==
[[File:BCVI-Algorithm.png|thumb|Algorithm for evaluation of BCVI with high risk criteria based on Memphis and Denver Screening Criteria]]
#CTA/MRA
#Angiography
##Gold standard
##Consider if diagnosis still strongly suspected despite negative CTA/MRA


==Treatment<ref>Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–2520.</ref>==
==Management==
*tPA
*'''[[Anticoagulation]] (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted treatment.'''<ref>Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–2520.</ref>
**Do not give if dissection enters the skull (ie Intracranial)
*Obtain emergent vascular surgery or neuro-interventionalist consult for possible endovascular intervention, including mechanical thrombectomy and/or angioplasty or stenting of dissected artery
**Do not give if aorta is involved
 
**Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])
===[[tPA]]===
*Antiplatelet vs Anticoagulation Therapy (Very controversial with poor data)
*Do not give if dissection enters the skull (ie Intracranial), due to risk of SAH or ICH
**Heparin: If dissection causes neuro deficits and is EXTRACRANIAL
*Do not give if aorta is involved; may worsen dissection
**Aspirin: If dissection is INTRACRANIAL
*Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])
**Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thrombo-embolic event
**In a limited meta-analysis, thrombolytics appear equally efficacious in patients presenting with ischemic stroke due to cervical artery dissection vs ischemic stroke from other causes<ref>Zinkstok SM, Vergouwen MD, Engelter ST, Lyrer PA, Bonati LH, Arnold M, Mattle HP, Fischer U, Sarikaya H, Baumgartner RW, Georgiadis D, Odier C, Michel P, Putaala J, Griebe M, Wahlgren N, Ahmed N, van Geloven N, de Haan RJ, Nederkoorn PJ. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011 Sep;42(9):2515-20. doi: 10.1161/STROKEAHA.111.617282. Epub 2011 Jul 28. PMID: 21799165.</ref>
**If tPA was given, wait 24hr before starting antiplatelet therapy
 
**Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)
===[[Antiplatelet]] vs [[Anticoagulation]] Therapy===
*Endovascular Therapy
''Very controversial with poor data''
**Option for pts who have contraindication to lytic therapy
*Specific anticoagulation vs antiplatelet therapy is listed below based on expert consensus and theoretical risks
**tPA use does not exclude pts from endovascular therapy
**[[Heparin]]: If dissection causes neuro deficits and is EXTRACRANIAL<ref>Vasc Med. 2011 Feb;16(1):35-77. doi: 10.1177/1358863X11399328. Erratum in: Vasc Med. 2011 Aug;16(4):317. PMID: 21471149.</ref>
**[[Aspirin]]: If dissection is INTRACRANIAL<ref>Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J. 2021 Sep;6(3):XXXIX-LXXXVIII. doi: 10.1177/23969873211046475. Epub 2021 Oct 13. Erratum in: Eur Stroke J. 2023 Mar;8(1):399. PMID: 34746432; PMCID: PMC8564160.</ref>
***Anticoagulants are avoided due to the weaker medial walls of intracranial vessels that have a higher theoretical risk for bleeding
**Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thromboembolic event
**In a small RCT study, there is no significant difference between antiplatelets vs anticoagulation in preventing subsequent stroke/death due to carotid/vertebral dissection<ref>CADISS trial investigators; Markus HS, Hayter E, Levi C, Feldman A, Venables G, Norris J. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015 Apr;14(4):361-7. doi: 10.1016/S1474-4422(15)70018-9. Epub 2015 Feb 12. Erratum in: Lancet Neurol. 2015 Jun;14(6):566. PMID: 25684164.</ref>
*If tPA was given, wait 24hr before starting antiplatelet therapy
*Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)


==Complications==
==Complications==
*CVA  
*[[CVA]]
*Risk of stroke or recurrent stroke is highest in the first 24hr after dissection
**Risk of stroke or recurrent stroke is highest in the first 24hr after dissection
 
*[[SAH]] (if dissection extends intracranially)
*SAH (if dissection extends intracranially)


==See Also==
==See Also==
*[[Blunt neck trauma]]
*[[Blunt neck trauma]]


==Sources==
==References==
*Patel RR, Adam R, et al. Cervical carotid artery dissection: current review of diagnosis and treatment Cardiology in Review. 2012 May-Jun; 20(3):145-52.
*Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcomes. Lancet Neurol 2009; 8:668.
*Engelter, ST, Brandt, T, et al. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke. 2007;38:2605-2611
<references/>
<references/>
*UpToDate: 'Spontaneous cerebral and cervical artery dissection: Treatment and prognosis'
 
[[Category:Neuro]]
[[Category:Neurology]]
[[Category:Vascular]]

Latest revision as of 05:21, 7 December 2023

Background

  • Primarily categorized as Spontaneous vs. Traumatic/mechanical
  • Most frequent cause of CVA in young and middle-aged patients (median age - 40yrs)
  • History pearls
    • Symptoms may be transient or persistent
    • Consider in trauma patient who has neurologic deficits despite normal head CT
    • Consider in patient with CVA + neck pain
  • Pathophysiology: Dissection of arterial vessel wall results in false lumen formation, leading to lumen stenosis and exposure of platelet aggregation factors ---> local thrombus formation ---> possible thromboembolism to intracranial vessels
    • Less commonly, dissection of thinner intracranial arteries may lead to SAH through vessel rupture
CTA brain showing filling defect in the right carotid artery (circled)

Anatomy

  • Vertebral artery comes off the subclavian and runs upward through the formina in the transverses processes of C6 to C2.

Risk Factors

  • Any mechanical event involving neck; symptoms typically occur 2-3 days after event
    • Neck trauma (often minor)
    • Cervical manipulation
    • Coughing/sneezing, vigorous exercise, weightlifting, intercourse, etc
  • Connective tissue disease
  • History of migraine[1]

Clinical Features

Internal Carotid Dissection

Vertebral Artery Dissection

Differential Diagnosis

Neck Trauma

Evaluation

  • Consider noncontrast CTH to assess for concomitant SAH
  • Denver screening criteria is one way to evaluate for blunt cerebrovascular injury (BCVI)
    • If positive findings on screening → obtain CTA or MRA (CTA has been shown to be equivalent to MRA)[4]

Denver screening criteria for blunt cerebrovascular injury

The Denver Screening Criteria are divided into risk factors and signs and symptoms

Signs and Symptoms

  • Arterial hemorrhage
  • Cervical bruit
  • Expanding neck hematoma
  • Focal neurologic deficit
  • Neuro exam inconsistent with head CT
  • Stroke on head CT

Risk Factors

  • Midface Fractures (Le Fort II or III)
  • Basilar Skull Fracture with carotid canal involvement
  • Diffuse axonal injury with GCS<6
  • Cervical spine fracture
  • Hanging with anoxic brain injury
  • Seat belt abrasion or other soft tissue injury of the anterior neck resulting in significant swelling or altered mental status
    • Isolated seatbelt sign without other neurologic symptoms has not been identified as a risk factor[5][6][7]
Algorithm for evaluation of BCVI with high risk criteria based on Memphis and Denver Screening Criteria

Management

  • Anticoagulation (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted treatment.[8]
  • Obtain emergent vascular surgery or neuro-interventionalist consult for possible endovascular intervention, including mechanical thrombectomy and/or angioplasty or stenting of dissected artery

tPA

  • Do not give if dissection enters the skull (ie Intracranial), due to risk of SAH or ICH
  • Do not give if aorta is involved; may worsen dissection
  • Otherwise, give according to same guidelines as for ischemic CVA (see CVA (tPA))
    • In a limited meta-analysis, thrombolytics appear equally efficacious in patients presenting with ischemic stroke due to cervical artery dissection vs ischemic stroke from other causes[9]

Antiplatelet vs Anticoagulation Therapy

Very controversial with poor data

  • Specific anticoagulation vs antiplatelet therapy is listed below based on expert consensus and theoretical risks
    • Heparin: If dissection causes neuro deficits and is EXTRACRANIAL[10]
    • Aspirin: If dissection is INTRACRANIAL[11]
      • Anticoagulants are avoided due to the weaker medial walls of intracranial vessels that have a higher theoretical risk for bleeding
    • Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thromboembolic event
    • In a small RCT study, there is no significant difference between antiplatelets vs anticoagulation in preventing subsequent stroke/death due to carotid/vertebral dissection[12]
  • If tPA was given, wait 24hr before starting antiplatelet therapy
  • Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)

Complications

  • CVA
    • Risk of stroke or recurrent stroke is highest in the first 24hr after dissection
  • SAH (if dissection extends intracranially)

See Also

References

  1. ↑ De Giuli V et al. Association Between Migraine and Cervical Artery Dissection: The Italian Project on Stroke in Young Adults. JAMA Neurol. Published online March 6, 2017. doi:10.1001/jamaneurol.2016.5704
  2. ↑ Lee MJ, Park YG, Kim SJ, Lee JJ, Bang OY, Kim JS. Characteristics of stroke mechanisms in patients with medullary infarction. Eur J Neurol. 2012;19(11):1433-1439.
  3. ↑ Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-1872.
  4. ↑ Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol. 2009 Oct;193(4):1167-74. doi: 10.2214/AJR.08.1688. PMID: 19770343.
  5. ↑ DiPerna CA, Rowe VL, Terramani TT, et al. Clinical importance of the “seat belt sign” in blunt trauma to the neck. Am Surg. 2002;68:441–445
  6. ↑ Rozycki GS, Tremblay L, Feliciano DV, et al. A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. J Trauma. 2002;52:618–623; discussion 623–624
  7. ↑ Sherbaf FG, Chen B, Pomeranz T, et al. Value of emergent neurovascular imaging for “Seat belt injury”: A multi-institutional study. American Journal of Neuroradiology. 2021;42(4):743-748
  8. ↑ Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–2520.
  9. ↑ Zinkstok SM, Vergouwen MD, Engelter ST, Lyrer PA, Bonati LH, Arnold M, Mattle HP, Fischer U, Sarikaya H, Baumgartner RW, Georgiadis D, Odier C, Michel P, Putaala J, Griebe M, Wahlgren N, Ahmed N, van Geloven N, de Haan RJ, Nederkoorn PJ. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011 Sep;42(9):2515-20. doi: 10.1161/STROKEAHA.111.617282. Epub 2011 Jul 28. PMID: 21799165.
  10. ↑ Vasc Med. 2011 Feb;16(1):35-77. doi: 10.1177/1358863X11399328. Erratum in: Vasc Med. 2011 Aug;16(4):317. PMID: 21471149.
  11. ↑ Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J. 2021 Sep;6(3):XXXIX-LXXXVIII. doi: 10.1177/23969873211046475. Epub 2021 Oct 13. Erratum in: Eur Stroke J. 2023 Mar;8(1):399. PMID: 34746432; PMCID: PMC8564160.
  12. ↑ CADISS trial investigators; Markus HS, Hayter E, Levi C, Feldman A, Venables G, Norris J. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015 Apr;14(4):361-7. doi: 10.1016/S1474-4422(15)70018-9. Epub 2015 Feb 12. Erratum in: Lancet Neurol. 2015 Jun;14(6):566. PMID: 25684164.
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