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Cervical Artery Dissection
Aka: Cervical Artery Dissection, Cervicocerebral Arterial Dissection, Dissecting Aneurysm of Precerebral Artery, Cerebroarterial Dissection
- See Also
- Carotid Artery Dissection
- Traumatic Carotid Dissection
- Vertebral Artery Dissection
- Vertebral Artery Injury in Blunt Neck Trauma
- Definitions
- Cervical Artery Dissection (Cervicocerebral Arterial Dissection)
- Extracranial Arterial Dissection includes carotid dissection and Vertebral Dissection
- Epidemiology
- Cervical Artery Dissection (Carotid Artery and Vertebral Artery) are uncommon overall
- Overall: <2% of ischemic Cerebrovascular Accidents
- Young Patients: 10-25% of ischemic Cerebrovascular Accidents
- Pathophysiology
- Vessel intima tear or vasa vasorum rupture
- Vessel wall media develops localized bleeding
- Blood within vessel wall separates layers resulting in a false lumen
- Aneurysm may form if vessel wall Hematoma expands toward adventitia (sub-adventitial dissection)
- Vessel lumen may be narrowed if vessel wall expands towards intima
- Types
- Carotid Artery Dissection
- Vertebral Artery Dissection
- Causes
- Genetic Predisposition, Typically Connective Tissue Disorder (spontaneous dissection)
- Ehlers-Danlos Syndrome Type IV
- Marfan's Syndrome
- Autosomal Dominant Polycystic Kidney Disease
- Osteogenesis Imperfecta Type 1
- Hypertension or rotation of the neck (esp. if sudden)
- Yoga
- Painting ceiling
- Coughing, Sneezing or Vomiting
- Procedural Sedation
- Trauma
- See Vertebral Artery Injury in Blunt Neck Trauma
- See Traumatic Carotid Dissection
- Whiplash
- Rollercoasters
- Chiropractic Manipulation (1 in 20,000 Spinal Manipulations)
- Hufnagel (1999) Neurol 246: 683-88 [PubMed]
- Motor Vehicle Accidents (e.g. Seat Belt Sign)
- Strangulation Injury
- Respiratory infection
- Autumn peak in dissection Incidence also may suggest infectious contributing factors
- Other possible risk factors
- Coronary Artery Disease Risk Factors
- Migraine Headache with aura
- Findings
- See Carotid Artery Dissection
- See Vertebral Artery Dissection
- Findings are specific to distribution of dissection
- Differential Diagnosis
- See Headache Causes
- Subarachnoid Hemorrhage
- Cerebral Venous Thrombosis
- Reversible Cerebral Vasoconstriction Syndrome (RCBS)
- Spontaneous Intracranial Hypotension
- Pituitary Apoplexy
- Pheochromocytoma
- Cerebrovascular Accident
- Imaging
- CT Angiogram Head and Neck
- Optimal in Vertebral Artery Dissection
- Double lumen sign (false and true lumen)
- Flame-like taper of vessel lumen
- MRI/MRA Head and Neck (T1 axial cervical with fat saturation)
- Overall preferred dissection imaging, esp. in Carotid Artery Dissection
- Able to identify intramural Hematoma
- Complications
- Cerebrovascular Infarction (up to 70% of cases)
- Typically occurs in the first 2 weeks of Cervical Artery Dissection
- Functional independence at 3 months in 75% of Cerebrovascular Accident cases
- Cerebral Vessel Stenosis (e.g. Carotid Artery Stenosis)
- Initially may be symptomatic
- Typically resolves in first 6 months
- Not associated with significant increased Cerebrovascular Accident risk after initial dissection
- Pseudoaneurysm
- Typically persists despite vessel otherwise healing
- Pseudoaneurysm risk of future rupture 1% (esp. intracranial vessels lacking external elastic lamina)
- Recurrent Cervical Artery Dissection
- Occurs in up to 7% of patients within 7 years
- Management
- Consult Neurology and Neurosurgery
- Cerebrovascular Accident
- Systemic or directed Thrombolysis may be recommended by stroke neurology
- Patients may be candidates for intervention (Angioplasty, stenting)
- Antiplatelet Agents or Anticoagulation
- Management is controversial
- Aspirin may be as effective as Anticoagulation in Cervical Artery Dissection
- Markus (2015) Lancet 14:361-7 +PMID:25684164 [PubMed]
- References
- Marcolini and Swaminathan in Herbert (2021) EM:Rap 21(3): 9-11
- Blum (2015) Arch Neurosci 2(4) +PMID:26478890 [PubMed]