Vertebral and carotid artery dissection: Difference between revisions
Ostermayer (talk | contribs) |
Ostermayer (talk | contribs) |
||
Line 35: | Line 35: | ||
##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 | ||
Line 47: | Line 47: | ||
**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
- 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
Diagnosis
- CTA/MRA
- Angiography
- Gold standard
- 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
- ↑ 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.