Vertebral and carotid artery dissection

Background

• Most frequent cause of CVA in young and middle-aged patients (median age - 40yrs)
• Symptoms may be transient or persistent
• Consider in trauma pt who has neurologic deficits despite normal head CT
• Consider in pt w/ CVA + neck pain

Risk Factors

1. Neck trauma (often minor)
2. Coughing
3. Connective tissue disease
4. History of migraine

Clinical Features

Internal Carotid Dissection

• Unilateral HA, face pain, anterior neck pain
  • Pain can precede other symptoms by hours-days (median 4d)
  • HA most commonly is frontotemporal; severity may mimic SAH or preexisting migraine
• Partial Horner syndrome (miosis and ptosis)
• CN palsies

Vertebral Artery Dissection

• Posterior neck pain, HA
  • May be unilateral or bilateral
  • HA is typically occipital
• Unilateral facial paresthesia
• Dizziness
• Vertigo
• N/V
• Diplopia and other visual disturbances
• Ataxia

Diagnosis

1. CTA/MRA
2. Angiography
   1. Gold standard
   2. Consider if diagnosis still strongly suspected despite negative CTA/MRA

Treatment

• tPA
  • Do not give if dissection enters the skull
  • Do not give if aorta is involved
  • Otherwise, give according to same guidelines as for ischemic CVA (see CVA (tPA))
• Antiplatelet/Anticoagulation Therapy
  • If tPA was given, wait 24hr before starting antiplatelet therapy
  • Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)
  • Otherwise, give ASA or warfarin (have similar outcomes)
• Endovascular Therapy
  • Option for pts who have contraindication to lytic therapy
  • tPA use does not exclude pts from endovascular therapy

Complications

• CVA
• Risk of stroke or recurrent stroke is highest in the first 24hr after dissection

• SAH (if dissection extends intracranially)

Source

• EB Medicine vol 14, number 4, 04/2012
• Tintinalli