Cervical Artery Dissection

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

1. See Also
   1. Carotid Artery Dissection
   2. Traumatic Carotid Dissection
   3. Vertebral Artery Dissection
   4. Vertebral Artery Injury in Blunt Neck Trauma
2. Definitions
   1. Cervical Artery Dissection (Cervicocerebral Arterial Dissection)
      1. Extracranial Arterial Dissection includes carotid dissection and Vertebral Dissection
3. 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
4. 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
5. Types
   1. Carotid Artery Dissection
   2. Vertebral Artery Dissection
6. 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
7. Findings
   1. See Carotid Artery Dissection
   2. See Vertebral Artery Dissection
   3. Findings are specific to distribution of dissection
8. 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
9. 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
10. 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
11. 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]
12. References
    1. Marcolini and Swaminathan in Herbert (2021) EM:Rap 21(3): 9-11
    2. Blum (2015) Arch Neurosci 2(4) +PMID:26478890 [PubMed]