Cervical artery dissection

Cervical artery dissection can occur both intracranially and extracranially, with intracranial dissections being more serious.

Causes

• Traumatic: Direct or minor trauma (e.g., whiplash, cervical manipulation)
• Spontaneous: Often related to underlying vascular pathology such as:
  • Marfan’s syndrome
  • Fibromuscular dysplasia
  • Arteritis/connective tissue diseases
  • Hypertension

Investigation of Choice

• 4-vessel cervical CT angiography

Treatment Options

• Antiplatelet therapy
• Anticoagulation (e.g., heparin)
• tPA (in selected cases)
• Endovascular interventions

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Epidemiology

• Occurs in all age groups
• Important cause of stroke in patients < 45 years
• Carotid artery dissection is more common than vertebral artery dissection
• ~20% of young strokes due to CAD vs. 2.5% in older patients

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Pathophysiology

Dissection results from an intimal tear allowing blood to create an intramural hematoma (false lumen). Subintimal dissection causes stenosis of the arterial lumen; subadventitial can cause aneurysmal dilation.

Complications:

• Vessel occlusion (stroke)
• Thromboembolism
• Vessel rupture (SAH if intracranial)
• Pseudoaneurysm formation

Prognosis:

• Better for extracranial than intracranial dissections
• Good with spontaneous extracranial dissections (often recanalize in 7-30 days)

Clinical Features

History

• Pain: Headache, facial pain, neck pain (ipsilateral to dissection)
  • Carotid: Frontal headache, anterior neck pain
  • Vertebral: Occipital headache, posterior neck pain
  • Eye/ear/facial pain suggests carotid involvement
• Neurological symptoms: Hemiparesis, monocular vision loss
• History of trauma: Especially trivial trauma like neck manipulation

Examination

• Neurological deficits
• Carotid/cranial bruits (only in ~1/3 of cases)
• Ipsilateral neck tenderness
• Horner’s syndrome with ipsilateral neck pain
• Lucid interval followed by deteriorating consciousness (especially in trauma)

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Investigations

Blood Tests

• FBE, U&Es, glucose
• ESR, CRP (if vasculitis suspected)
• Coagulation profile

Imaging

• ECG: Rule out AF
• Carotid Doppler: Limited utility
• CT Brain + 4-vessel CTA: Best initial investigation
• MRI/MRA: Alternative if contrast contraindicated
• Digital Subtraction Angiography (DSA): Gold standard, rarely needed unless CTA is equivocal

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Management

General Principles

Management varies by:

• Cause (traumatic vs. spontaneous)
• Location (carotid vs. vertebral, intracranial vs. extracranial)
• Presence of complications (e.g., hemorrhage)

Medical Treatment

• Antiplatelet or anticoagulation therapy: Equal efficacy in stroke prevention post-dissection
• Antiplatelets often preferred for simplicity and perceived safety

Endovascular Interventions

• Consider when medical therapy fails or contraindicated
• Includes stenting, coiling of aneurysms
• Initiating medical therapy does not preclude later endovascular intervention

Trauma Protocol

• Screening should be proactive in high-risk trauma cases
• Do not wait for neurologic signs to perform imaging

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Disposition

Refer potential endovascular cases to Vascular Surgery

Trauma-related dissections: Admit under Trauma with Vascular input

Spontaneous dissections: Admit under Stroke Unit

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References

Publications

• Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906.
• Shea K, Stahmer S. Carotid and vertebral arterial dissections in the emergency department. Emerg Med Pract. 2012 Apr;14(4):1-23; quiz 23-4. 

FOAMed

• Nickson C. Cervical artery dissection. LITFL