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carotid artery dissection

Etiology: - spontaneous: - connective tissues disease - Ehlers-Danlos syndrome type-4 - fibromuscular dysplasia - pseudoxanthoma elasticum - cystic medial necrosis - Marfan syndrome - polycystic kidney disease (autosomal dominant) - osteogenesis imperfecta type-1 - syphilitic arteritis - oral contraceptives - smoking - drug abuse - traumatic: - mostly from high-speed motor vehicle accidents (Whiplash) - chiropractic cervical spinal manipulation or strain - blunt trauma (high impact) - pentrating trauma Epidemiology: - accounts for 25% of strokes in young & middle-age patients - occurs most frequently in the fifth decade of life - annual incidence of spontaneous dissection 0.003% - incidence of traumatic dissection < 1-3% [2] Pathology: - extracranial dissection more common than intracranial dissection - dissection begins as a tear in the tunica intima or between the tunica media & tunica adventitia - it is suggested that pathology may originate in the vasa vasorum [2] - arterial pressure dissects the artery to create an intramural hematoma, which may result in carotid stenosis or formation of an aneurysm - thromboemboli can result in ischemic stroke - aneurysm may put pressure lower cranial nerves - transient retinal ischemia or retinal infarction may occur - cerebral hemispheric dysfunction Clinical manifestations: - non-specific complaints of headache, neck pain or facial pain - thunderclap headache in 20% [5] - pain is generally in the ipsilateral neck, face, orbit, or frontotemporal cranium - may present as Horner's syndrome; ipsilateral Horner's syndrome may occur (acute onset) - combination of abrupt onset cervical pain with Horner's syndrome - patients may or may not have defined episode of head trauma - generally a delay of hours from a traumatic event to development of stroke caused by a dissected carotid artery - retromandibular pain is often the presenting symptom - contralateral hemiparesis & hemisensory deficit may occur - other variable manifestations - amaurosis fugax - pulsatile tinnitus - diplopia - Broca's aphasia [10] - symptoms may fluctuate in severity - patients >= 60 years of age less likely to present with cervical pain (RR=0.47), headache (RR=0.58), or history of mechanical triggers (RR=0.53) [8] Laboratory: - in general not helpful, unless surgery is contemplated - complete blood count - coagulation profile - prothrombin - activated partial thromboplastin time Special laboratory: - electrocardiogram may be useful for identifying atrial fibrillation, a source of emboli - echocardiogram may identify atrial thrombus or other risk factors for embolic stroke - electroencephalogram may identify primary CNS pathology contributing to patient status - carotid ultrasound (doppler) screening may identify carotid artery dissection Radiology: - magnetic resonance angiography - CT angiography - pathognomonic 'intimal flap' may be noted with angiography - computed tomography or MRI of brain may identify CNS pathology contributing to patient status Complications: - embolic stroke - thrombus formation at the site of dissection - arterial thromboembolism [5] - stroke 2% with aspirin therapy - risk of recurrent stroke is 2.5% at 1 year [9] - mortality with spontaneous dissection is < 5% Management: - aspirin 81-325 mg PO QD for platelet inhibition better than heparin followed by warfarin; [1,5,7] - pediatrics: aspirin 10-15 mg/kg/dose PO every 4-6 hours; not to exceed 60-80 mg/kg/day [2] - patients with angiographically documented thrombus may benefit from anticoagulation [7] - aspirin is not non-inferior to vitamin K antagonist (warfarin) [11] - no evidence that antiplatelet agents or anticoagulants of benefit in reducing risk of recurrent stroke [9] - consider consultation with neurology, neurosurgery, interventional radiology - carotid artery stenting is risky & of unproven benefit [5]

Related

internal carotid artery (ICA) vertebral artery dissection

General

carotid artery disease arterial dissection

References

  1. Georgiadis D et al Aspirin vs anticoagulation in carotid artery dissection: A study of 298 patients. Neurology 2009 May 26; 72:1810. PMID: 19321846 - Kasner SE and Dreier JP. A fresh twist on carotid artery dissections. Neurology 2009 May 26; 72:1800. PMID: 19321842
  2. Zohrabian D and Leber MD Dissection, Carotid Artery eMedicine: Emergency Medicine http://emedicine.medscape.com/article/757906-overview
  3. Kidwell CS and Burgess RE Dissection Syndromes eMedicine: Neurology http://emedicine.medscape.com/article/1160482-overview
  4. Wikipedia: Carotid artery dissection http://en.wikipedia.org/wiki/Carotid_artery_dissection
  5. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021.
  6. Caplan LR. Dissections of brain-supplying arteries. Nat Clin Pract Neurol. 2008 Jan;4(1):34-42 PMID: 18199995
  7. The CADISS trial investigators. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): A randomised trial. Lancet Neurol 2015 Feb 12 PMID: 25684164 http://www.thelancet.com/journals/laneur/article/PIIS1474-4422%2815%2970018-9/abstract
  8. Traenka C, Dougoud D, Simonetti BG et al. Cervical artery dissection in patients >= 60 years: Often painless, few mechanical triggers. Neurology 2017 Apr 4; 88:1313 PMID: 28258079 http://www.neurology.org/content/88/14/1313
  9. Markus HS, Levi C, King A et al Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection. The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA Neurol. Published online February 25, 2019 PMID: 3080162 https://jamanetwork.com/journals/jamaneurology/fullarticle/2725385
  10. NEJM Knowledge+ Question of the Week Feb 18, 2020 https://knowledgeplus.nejm.org/question-of-week/1356/ - Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001 Mar 22; 344:898. https://www.nejm.org/doi/full/10.1056/NEJM200103223441206 - Baumgartner R, Bogousslavsky J. Clinical manifestations of carotid dissection. Front Neurol Neurosci. 2005;20:70-76. doi: 10.1159/000088151. Review. PMID: 17290113
  11. Engelter ST et al. Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): An open-label, randomised, non-inferiority trial. Lancet Neurol 2021 Mar 22; [e-pub]. PMID: 33765420 https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(21)00044-2/fulltext