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 patient who has neurologic deficits despite normal head CT
• Consider in patient with CVA + neck pain

Risk Factors

• Neck trauma (often minor)
• Cervical manipulation
• Coughing
• Connective tissue disease
• History of migraine

Clinical Features

Internal Carotid Dissection

• Unilateral headache, face pain, anterior neck pain
  • Pain can precede other symptoms by hours-days (median 4d)
  • Headache most commonly is frontotemporal; severity may mimic SAH or preexisting migraine
• Partial Horner syndrome (miosis and ptosis) in 50% of cases
• Cranial nerve palsies

Vertebral Artery Dissection

• Posterior neck pain, headache
  • May be unilateral or bilateral
  • Headache is typically occipital
• Unilateral facial paresthesia
• Dizziness
• Vertigo
• Nausea/vomiting
• Diplopia and other visual disturbances
• Ataxia
• Lateral Medullary Syndrome seen in up to 20% of cases of VAD

Differential Diagnosis

Blunt Neck Trauma

• Spinal cord trauma
• Vertebral and carotid artery dissection
• Whiplash injury
• Cervical spine fractures and dislocations
• Strangulation

Evaluation

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

Signs and Symptoms

• Focal neurologic deficit
• Arterial Hemorrhage
• Cervical Bruit or Thrill (<50yo)
• Infarct on Head CT
• Expanding Neck Hematoma
• Neuro exam inconsistent with Head CT

Risk Factors

• Midface Fractures
• Cervical Spine Injuries
• Basilar Skull Fracture
• GCS<8
• 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

If Denver Criteria positive, CTA or MRA

• CTA has been shows to be equivalent to MRA

• 

  CTA brain showing filling defect in the right carotid artery (circled)

Management

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

References

Authors

Jordan Swartz, Daniel Ostermayer, Daniel Eggeman, Neil Young, James Cunningham, Kevin Lu, Ross Donaldson, Nicole Zadzilka, Claire