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vertebral artery dissection

see carotid artery dissection Clinical manifestations: - balance impairment & visual loss common [2] - Wallenberg syndrome via lateral medullary infarction [2] - 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) [5] - does not cause hemispheric stroke [7] Complications: - distal embolization - posterior-circulation stroke - brainstem or cerebellar injury - dysarthria, dysphagia, dizziness, & diplopia [7] - embolic stroke risk is low [4] - thrombus formation at the site of dissection - arterial thromboembolism [2] - risk of recurrent stroke is 2.5% at 1 year [6] Management: - see carotid artery dissection - aspirin 81-325 mg PO QD for platelet inhibition better than heparin followed by warfarin [2] - aspirin is not non-inferior to vitamin K antagonist (warfarin) [8] - no evidence that antiplatelet agents or anticoagulants of benefit in reducing risk of recurrent stroke [6]

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carotid artery dissection vertebral artery

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arterial dissection

References

  1. Kidwell CS and Burgess RE Dissection Syndromes eMedicine: Neurology http://en.wikipedia.org/wiki/Carotid_artery_dissection
  2. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021
  3. Caplan LR. Dissections of brain-supplying arteries. Nat Clin Pract Neurol. 2008 Jan;4(1):34-42 PMID: 18199995
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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