Vertebral and carotid artery dissection

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  • 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


  • 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)

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

Signs and Symptoms

  • Focal neurologic deficit
  • Arterial Hemorrhage
  • Cervical Bruit or Thrill (<50yo)
  • Infarct on Head CT
  • Expanding Neck Hematoma
  • Neuro exam inconsistent with Head CT

Risk Factors

  • Midface Fractures
  • Cervical Spine Injuries
  • Basilar Skull Fracture
  • GCS<8
  • 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]
Algorithm for evaluation of BCVI with high risk criteria based on Memphis and Denver Screening Criteria


  • Anti-coagulation (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted treatment.[6]
  • Obtain emergent vascular surgery consult for possible endovascular intervention


  • 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)


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

See Also


  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. 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.