Vertebral and carotid artery dissection: Difference between revisions
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*[[Diplopia]] and other visual disturbances | *[[Diplopia]] and other visual disturbances | ||
*Ataxia | *Ataxia | ||
==Differential Diagnosis== | |||
{{Blunt neck trauma DDX}} | |||
==Diagnosis== | ==Diagnosis== | ||
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**If positive, CTA or MRA | **If positive, CTA or MRA | ||
== | ==Management== | ||
Anti-coagulation followed by vascular repair is the generally accepted treatment. Anti-coagulation prevents clot propagation along the dissecting lumen<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> | Anti-coagulation followed by vascular repair is the generally accepted treatment. Anti-coagulation prevents clot propagation along the dissecting lumen<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> | ||
===tPA=== | ===tPA=== | ||
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*[[Blunt neck trauma]] | *[[Blunt neck trauma]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Neuro]] | [[Category:Neuro]] | ||
[[Category:Vascular]] | |||
Revision as of 14:31, 18 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
- Neck trauma (often minor)
- Coughing
- Connective tissue disease
- 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
Differential Diagnosis
Neck Trauma
- Penetrating neck trauma
- Blunt neck trauma
- Cervical injury
- Neurogenic shock
- Spinal cord injury
Diagnosis
- Denver Screening Criteria
- If positive, CTA or MRA
Management
Anti-coagulation followed by vascular repair is the generally accepted treatment. Anti-coagulation prevents clot propagation along the dissecting lumen[1]
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
References
- ↑ 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.