Vertebral and carotid artery dissection: Difference between revisions
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{{Blunt neck trauma DDX}}
{{Blunt neck trauma DDX}}


==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>==
==Treatment==
*tPA
Anti-coagulation followed by vascular repair is the generally accepted treatment. Anti-coagulation prevents clot propagation along the dissecting lumen<ref><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></ref>
**Do not give if dissection enters the skull (ie Intracranial)
===tPA===
**Do not give if aorta is involved
*Do not give if dissection enters the skull (ie Intracranial)
**Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])
*Do not give if aorta is involved
*Antiplatelet vs Anticoagulation Therapy (Very controversial with poor data)
*Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])
**Heparin: If dissection causes neuro deficits and is EXTRACRANIAL
===Antiplatelet vs Anticoagulation Therapy===
**Aspirin: If dissection is INTRACRANIAL
''Very controversial with poor data''
**Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thrombo-embolic event
*Heparin: If dissection causes neuro deficits and is EXTRACRANIAL
**If tPA was given, wait 24hr before starting antiplatelet therapy
*Aspirin: If dissection is INTRACRANIAL
**Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)
*Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thrombo-embolic event
*Endovascular Therapy
*If tPA was given, wait 24hr before starting antiplatelet therapy
**Option for pts who have contraindication to lytic therapy
*Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)
**tPA use does not exclude pts from endovascular therapy
===Endovascular Therapy===
*Emergent consulation with vascular surgery.
*tPA use does not exclude patients from endovascular therapy


==Complications==
==Complications==

Revision as of 00:15, 16 October 2015

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

Differential Diagnosis

Neck Trauma

Treatment

Anti-coagulation followed by vascular repair is the generally accepted treatment. Anti-coagulation prevents clot propagation along the dissecting lumenCite error: Closing </ref> missing for <ref> tag</ref>

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 consulation 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

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'
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