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

• Denver Screening Criteria
  • If positive, CTA or MRA

Differential Diagnosis

Neck Trauma

• Penetrating neck trauma
• Blunt neck trauma
  • Vertebral and carotid artery dissection
  • Strangulation
  • Whiplash injury
• Cervical injury
  • Cervical fractures and dislocations
  • Cervical injury (peds)
  • Cervical spine clearance
• Neurogenic shock
• Spinal cord injury

Treatment

Anti-coagulation followed by vascular repair is the generally accepted treatment. Anti-coagulation prevents clot propagation along the dissecting lumen

tPA

• Do not give if dissection enters the skull (ie Intracranial)
• Do not give if aorta is involved
• Otherwise, give according to same guidelines as for ischemic CVA (see CVA (tPA))

Antiplatelet vs Anticoagulation Therapy

Very controversial with poor data

• Heparin: If dissection causes neuro deficits and is EXTRACRANIAL
• Aspirin: If dissection is INTRACRANIAL
• Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thrombo-embolic event
• If tPA was given, wait 24hr before starting antiplatelet therapy
• Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)

Endovascular Therapy

• Emergent consultation with vascular surgery.
• tPA use does not exclude patients from endovascular therapy

Complications

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

See Also

• Blunt neck trauma

Sources

• 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

• UpToDate: 'Spontaneous cerebral and cervical artery dissection: Treatment and prognosis'