Vertebral and carotid artery dissection: Difference between revisions

No edit summary
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*Consider in trauma patient who has neurologic deficits despite normal head CT
*Consider in trauma patient who has neurologic deficits despite normal head CT
*Consider in patient with CVA + neck pain
*Consider in patient with CVA + neck pain
[[File:Carotid_dissection.jpg|thumb|CTA brain showing filling defect in the right carotid artery (circled)]]


===Risk Factors===
===Risk Factors===
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==Evaluation==
==Evaluation==
*Denver screening criteria is one way to evaluate for blunt cerebrovascular injury (BCVI)
*If positive findings on screening → obtain CTA or MRA (CTA has been shown to be equivalent to MRA)
{{Denver Screening Criteria}}
{{Denver Screening Criteria}}
====If Denver Criteria positive, CTA or MRA====
 
*CTA has been shows to be equivalent to MRA
[[File:BCVI-Algorithm.png|thumb|Algorithm for evaluation of BCVI with high risk criteria based on Memphis and Denver Screening Criteria]]
<gallery>
File:Carotid_dissection.jpg|CTA brain showing filling defect in the right carotid artery (circled)
</gallery>


==Management==
==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 (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted 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>
*Obtain emergent vascular surgery consult for possible endovascular intervention
 
===tPA===
===tPA===
*Do not give if dissection enters the skull (ie Intracranial)
*Do not give if dissection enters the skull (ie Intracranial)
*Do not give if aorta is involved
*Do not give if aorta is involved
*Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])
*Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])
===Antiplatelet vs Anticoagulation Therapy===
===Antiplatelet vs Anticoagulation Therapy===
''Very controversial with poor data''
''Very controversial with poor data''
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*If tPA was given, wait 24hr before starting antiplatelet therapy
*If tPA was given, wait 24hr before starting antiplatelet therapy
*Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)
*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==
==Complications==

Revision as of 17:37, 28 June 2017

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

Risk Factors

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[2][3]

Differential Diagnosis

Neck Trauma

Evaluation

  • Denver screening criteria is one way to evaluate for blunt cerebrovascular injury (BCVI)
  • If positive findings on screening → obtain CTA or MRA (CTA has been shown to be equivalent to MRA)

Denver screening criteria for blunt cerebrovascular injury

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

Signs and Symptoms

  • Arterial hemorrhage
  • Cervical bruit
  • Expanding neck hematoma
  • Focal neurologic deficit
  • Neuro exam inconsistent with head CT
  • Stroke on head CT

Risk Factors

  • Midface Fractures (Le Fort II or III)
  • Basilar Skull Fracture with carotid canal involvement
  • Diffuse axonal injury with GCS<6
  • Cervical spine fracture
  • 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[4][5][6]
Algorithm for evaluation of BCVI with high risk criteria based on Memphis and Denver Screening Criteria

Management

  • Anti-coagulation (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted treatment.[7]
  • Obtain emergent vascular surgery consult for possible endovascular intervention

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)

Complications

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

See Also

References

  1. De Giuli V et al. Association Between Migraine and Cervical Artery Dissection: The Italian Project on Stroke in Young Adults. JAMA Neurol. Published online March 6, 2017. doi:10.1001/jamaneurol.2016.5704
  2. Lee MJ, Park YG, Kim SJ, Lee JJ, Bang OY, Kim JS. Characteristics of stroke mechanisms in patients with medullary infarction. Eur J Neurol. 2012;19(11):1433-1439.
  3. Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-1872.
  4. DiPerna CA, Rowe VL, Terramani TT, et al. Clinical importance of the “seat belt sign” in blunt trauma to the neck. Am Surg. 2002;68:441–445
  5. Rozycki GS, Tremblay L, Feliciano DV, et al. A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs. J Trauma. 2002;52:618–623; discussion 623–624
  6. Sherbaf FG, Chen B, Pomeranz T, et al. Value of emergent neurovascular imaging for “Seat belt injury”: A multi-institutional study. American Journal of Neuroradiology. 2021;42(4):743-748
  7. 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.