Vertebral and carotid artery dissection: Difference between revisions

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##Consider if diagnosis still strongly suspected despite negative CTA/MRA
##Consider if diagnosis still strongly suspected despite negative CTA/MRA


==Treatment==
==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>==
*tPA
*tPA
**Do not give if dissection enters the skull
**Do not give if dissection enters the skull
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**Option for pts who have contraindication to lytic therapy
**Option for pts who have contraindication to lytic therapy
**tPA use does not exclude pts from endovascular therapy
**tPA use does not exclude pts from endovascular therapy
 
==Complications==
==Complications==
*CVA  
*CVA  

Revision as of 01:59, 14 February 2014

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

  1. CTA/MRA
  2. Angiography
    1. Gold standard
    2. Consider if diagnosis still strongly suspected despite negative CTA/MRA

Treatment[1]

  • tPA
    • Do not give if dissection enters the skull
    • Do not give if aorta is involved
    • Otherwise, give according to same guidelines as for ischemic CVA (see CVA (tPA))
  • Antiplatelet/Anticoagulation Therapy
    • If tPA was given, wait 24hr before starting antiplatelet therapy
    • Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)
    • Otherwise, give ASA or warfarin (have similar outcomes)
  • Endovascular Therapy
    • Option for pts who have contraindication to lytic therapy
    • tPA use does not exclude pts from endovascular therapy

Complications

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

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
  1. 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.