Cervical Artery Dissection

Aka: Cervical Artery Dissection, Cervicocerebral Arterial Dissection, Dissecting Aneurysm of Precerebral Artery, Cerebroarterial Dissection

II. Definitions

  1. Cervical Artery Dissection (Cervicocerebral Arterial Dissection)
    1. Extracranial Arterial Dissection includes carotid dissection and Vertebral Dissection

III. Epidemiology

  1. Cervical Artery Dissection (Carotid Artery and Vertebral Artery) are uncommon overall
    1. Overall: <2% of ischemic Cerebrovascular Accidents
    2. Young Patients: 10-25% of ischemic Cerebrovascular Accidents

IV. Pathophysiology

  1. Vessel intima tear or vasa vasorum rupture
  2. Vessel wall media develops localized bleeding
  3. Blood within vessel wall separates layers resulting in a false lumen
  4. Aneurysm may form if vessel wall hematoma expands toward adventitia (sub-adventitial dissection)
  5. Vessel lumen may be narrowed if vessel wall expands towards intima

V. Types

  1. Carotid Artery Dissection
  2. Vertebral Artery Dissection

VI. Causes

  1. Genetic Predisposition, Typically Connective Tissue Disorder (spontaneous dissection)
    1. Ehlers-Danlos Syndrome Type IV
    2. Marfan's Syndrome
    3. Autosomal Dominant Polycystic Kidney Disease
    4. Osteogenesis Imperfecta Type 1
  2. Hypertension or rotation of the neck (esp. if sudden)
    1. Yoga
    2. Painting ceiling
    3. Coughing, Sneezing or Vomiting
    4. Procedural Sedation
  3. Trauma
    1. See Vertebral Artery Injury in Blunt Neck Trauma
    2. See Traumatic Carotid Dissection
    3. Whiplash
    4. Rollercoasters
    5. Chiropractic Manipulation (1 in 20,000 Spinal Manipulations)
      1. Hufnagel (1999) Neurol 246: 683-88 [PubMed]
    6. Motor Vehicle Accidents (e.g. Seat Belt Sign)
    7. Strangulation Injury
  4. Respiratory infection
    1. Autumn peak in dissection Incidence also may suggest infectious contributing factors
  5. Other possible risk factors
    1. Coronary Artery Disease Risk Factors
    2. Migraine Headache with aura

VII. Findings

  1. See Carotid Artery Dissection
  2. See Vertebral Artery Dissection
  3. Findings are specific to distribution of dissection

VIII. Differential Diagnosis

  1. See Headache Causes
  2. Subarachnoid Hemorrhage
  3. Cerebral Venous Thrombosis
  4. Reversible Cerebral Vasoconstriction Syndrome (RCBS)
  5. Spontaneous Intracranial Hypotension
  6. Pituitary Apoplexy
  7. Pheochromocytoma
  8. Cerebrovascular Accident

IX. Imaging

  1. CT Angiogram Head and Neck
    1. Optimal in Vertebral Artery Dissection
    2. Double lumen sign (false and true lumen)
    3. Flame-like taper of vessel lumen
  2. MRI/MRA Head and Neck (T1 axial cervical with fat saturation)
    1. Overall preferred dissection imaging, esp. in Carotid Artery Dissection
    2. Able to identify intramural hematoma

X. Complications

  1. Cerebrovascular Infarction (up to 70% of cases)
    1. Typically occurs in the first 2 weeks of Cervical Artery Dissection
    2. Functional independence at 3 months in 75% of Cerebrovascular Accident cases
  2. Cerebral Vessel Stenosis (e.g. Carotid Artery Stenosis)
    1. Initially may be symptomatic
    2. Typically resolves in first 6 months
    3. Not associated with significant increased Cerebrovascular Accident risk after initial dissection
  3. Pseudoaneurysm
    1. Typically persists despite vessel otherwise healing
    2. Pseudoaneurysm risk of future rupture 1% (esp. intracranial vessels lacking external elastic lamina)
  4. Recurrent Cervical Artery Dissection
    1. Occurs in up to 7% of patients within 7 years

XI. Management

  1. Consult Neurology and Neurosurgery
  2. Cerebrovascular Accident
    1. Systemic or directed Thrombolysis may be recommended by stroke neurology
    2. Patients may be candidates for intervention (Angioplasty, stenting)
  3. Antiplatelet Agents or Anticoagulation
    1. Management is controversial
    2. Aspirin may be as effective as Anticoagulation in Cervical Artery Dissection
      1. Markus (2015) Lancet 14:361-7 +PMID:25684164 [PubMed]

XII. References

  1. Marcolini and Swaminathan in Herbert (2021) EM:Rap 21(3): 9-11
  2. Blum (2015) Arch Neurosci 2(4) +PMID:26478890 [PubMed]

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Related Studies

Ontology: Cervicocerebral arterial dissection (C0338584)

Concepts Finding (T033)
SnomedCT 230728003
English Cervicocerebral art dissectn, Cervicocerebral arterial dissection, Cervicocerebral arterial dissection (disorder), Dissection of cervicocerebral artery
Spanish disección arterial cervicocerebral (trastorno), disección arterial cervicocerebral, disección de arteria cervicocerebral
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Cerebrovascular aneurysms and dissections (C0949012)

Concepts Disease or Syndrome (T047)
Italian Aneurismi e dissezioni cerebrovascolari
Japanese 脳血管瘤および解離, ﾉｳｹｯｶﾝﾘｭｳｵﾖﾋﾞｶｲﾘ
Czech Aneurysmata a disekce mozkových cév
Hungarian Cerebrovascularis aneurysmák és dissectiók
English Cerebrovascular aneurysms and dissections
Portuguese Aneurismas e dissecções cerebrovasculares
Spanish Aneurismas y disecciones cerebrovasculares
Dutch cerebrovasculaire aneurysmata en -dissecans
French Anévrysmes et dissections cérébro-vasculaires
German Zerebrovaskulaere Aneurysmen und Dissektionen
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Dissecting aneurysm of precerebral artery (C2919595)

Concepts Disease or Syndrome (T047)
SnomedCT 444935005
English Dissecting aneurysm of precerebral artery (disorder), Dissecting aneurysm of precerebral artery, Aneurysm and dissection of precerebral artery
Spanish aneurisma disecante de arteria precerebral, aneurisma disecante de arteria precerebral (trastorno)
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Cardiovascular Medicine

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