Vertebral and carotid artery dissection

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

Risk Factors

  • Neck trauma (often minor)
  • Coughing
  • Connective tissue disease
  • History of migraine

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)
  • Cranial nerve 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

Diagnosis

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[1][2][3]

If positive, CTA or MRA

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

Management

Anti-coagulation followed by vascular repair is the generally accepted treatment. Anti-coagulation prevents clot propagation along the dissecting lumen[4]

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

  1. ↑ 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
  2. ↑ 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
  3. ↑ 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
  4. ↑ 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.
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