Vertebral and carotid artery dissection - Revision history

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Ostermayer: /* Disposition */

2026-03-19T16:20:07Z

Disposition

← Older revision		Revision as of 16:20, 19 March 2026
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	**Annual recurrence risk ~1% after initial episode; higher with [[Connective tissue disease\|connective tissue disorders]]		**Annual recurrence risk ~1% after initial episode; higher with [[Connective tissue disease\|connective tissue disorders]]
	*Return precautions: any new weakness, numbness, [[Dysarthria\|speech difficulty]], [[Vertigo\|dizziness]], [[Ataxia\|imbalance]], visual changes, severe worsening headache		*Return precautions: any new weakness, numbness, [[Dysarthria\|speech difficulty]], [[Vertigo\|dizziness]], [[Ataxia\|imbalance]], visual changes, severe worsening headache

	~~{{Stroke Syndromes}}~~

	==See Also==		==See Also==

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2026-03-19T16:17:43Z

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Ostermayer at 03:07, 18 March 2026

2026-03-18T03:07:09Z

Ostermayer at 03:03, 18 March 2026

2026-03-18T03:03:35Z

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Patricklin at 05:21, 7 December 2023

2023-12-07T05:21:45Z

← Older revision		Revision as of 05:21, 7 December 2023
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	==Background==		==Background==
	*Primarily categorized as Spontaneous vs. Traumatic		*Primarily categorized as Spontaneous vs. Traumatic/mechanical
	*Most frequent cause of [[CVA]] in young and middle-aged patients (median age - 40yrs)		*Most frequent cause of [[CVA]] in young and middle-aged patients (median age - 40yrs)
	*Symptoms may be transient or persistent		*History pearls
	*Consider in trauma patient who has neurologic deficits despite normal head CT		**Symptoms may be transient or persistent
	*Consider in patient with CVA + [[neck pain]]		**Consider in trauma patient who has neurologic deficits despite normal head CT
			**Consider in patient with CVA + [[neck pain]]
			*Pathophysiology: Dissection of arterial vessel wall results in false lumen formation, leading to lumen stenosis and exposure of platelet aggregation factors ---> local thrombus formation ---> possible thromboembolism to intracranial vessels
			**Less commonly, dissection of thinner intracranial arteries may lead to SAH through vessel rupture

	[[File:Carotid_dissection.jpg\|thumb\|CTA brain showing filling defect in the right carotid artery (circled)]]		[[File:Carotid_dissection.jpg\|thumb\|CTA brain showing filling defect in the right carotid artery (circled)]]
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	===Risk Factors===		===Risk Factors===
	*[[Neck trauma]] (often minor)		*Any mechanical event involving neck; symptoms typically occur 2-3 days after event
	**Symptoms typically occur 2-3 days after event		**[[Neck trauma]] (often minor)
	*Cervical manipulation		**Cervical manipulation
	*Coughing		**Coughing/sneezing, vigorous exercise, weightlifting, intercourse, etc
	*[[Connective tissue disease]]		*[[Connective tissue disease]]
	*History of [[migraine]]<ref>De Giuli V et al. Association Between Migraine and Cervical Artery Dissection: The Italian Project on Stroke in Young Adults. JAMA Neurol. Published online March 6, 2017. doi:10.1001/jamaneurol.2016.5704</ref>		*History of [[migraine]]<ref>De Giuli V et al. Association Between Migraine and Cervical Artery Dissection: The Italian Project on Stroke in Young Adults. JAMA Neurol. Published online March 6, 2017. doi:10.1001/jamaneurol.2016.5704</ref>
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	**Pain can precede other symptoms by hours-days (median 4d)		**Pain can precede other symptoms by hours-days (median 4d)
	**Headache most commonly is frontotemporal; severity may mimic SAH or preexisting migraine		**Headache most commonly is frontotemporal; severity may mimic SAH or preexisting migraine
			*[[Cranial nerve palsies]]
			*Vision loss
	*Partial [[Horner syndrome]] (miosis and ptosis) in 50% of cases		*Partial [[Horner syndrome]] (miosis and ptosis) in 50% of cases
	*[[~~Cranial nerve palsies~~]]		*Symptoms of [[Stroke]], [[Transient ischemic attack]]

	===Vertebral Artery Dissection===		===Vertebral Artery Dissection===
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	**Headache is typically occipital		**Headache is typically occipital
	*Unilateral facial [[paresthesia]]		*Unilateral facial [[paresthesia]]
	*[[Dizziness]]		*[[Dizziness]] or [[Vertigo]]
	*[[Vertigo]]
	*[[Nausea/vomiting]]		*[[Nausea/vomiting]]
	*[[Diplopia]] and other visual disturbances		*[[Diplopia]], [[nystagmus]], and other visual disturbances
	*[[Ataxia]]		*[[Ataxia]]
	*[[Lateral Medullary Syndrome]] seen in up to 20% of cases of VAD<ref>Lee MJ, Park YG, Kim SJ, Lee JJ, Bang OY, Kim JS. Characteristics of stroke mechanisms in patients with medullary infarction. Eur J Neurol. 2012;19(11):1433-1439.</ref><ref>Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-1872.</ref>		*[[Lateral Medullary Syndrome]] seen in up to 20% of cases of VAD<ref>Lee MJ, Park YG, Kim SJ, Lee JJ, Bang OY, Kim JS. Characteristics of stroke mechanisms in patients with medullary infarction. Eur J Neurol. 2012;19(11):1433-1439.</ref><ref>Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-1872.</ref>
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	==Evaluation==		==Evaluation==
			*Consider noncontrast CTH to assess for concomitant SAH
	*Denver screening criteria is one way to evaluate for blunt cerebrovascular injury (BCVI)		*Denver screening criteria is one way to evaluate for blunt cerebrovascular injury (BCVI)
	*If positive findings on screening → obtain CTA or MRA (CTA has been shown to be equivalent to MRA)		**If positive findings on screening → obtain CTA or MRA (CTA has been shown to be equivalent to MRA)<ref>Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol. 2009 Oct;193(4):1167-74. doi: 10.2214/AJR.08.1688. PMID: 19770343.</ref>

	{{Denver Screening Criteria}}		{{Denver Screening Criteria}}
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	==Management==		==Management==
	*'''[[Anticoagulation]] (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted treatment.'''<ref>Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–2520.</ref>		*'''[[Anticoagulation]] (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted treatment.'''<ref>Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–2520.</ref>
	*Obtain emergent vascular surgery consult for possible endovascular intervention		*Obtain emergent vascular surgery or neuro-interventionalist consult for possible endovascular intervention, including mechanical thrombectomy and/or angioplasty or stenting of dissected artery

	===[[tPA]]===		===[[tPA]]===
	*Do not give if dissection enters the skull (ie Intracranial)		*Do not give if dissection enters the skull (ie Intracranial), due to risk of SAH or ICH
	*Do not give if aorta is involved		*Do not give if aorta is involved; may worsen dissection
	*Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])		*Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])
			**In a limited meta-analysis, thrombolytics appear equally efficacious in patients presenting with ischemic stroke due to cervical artery dissection vs ischemic stroke from other causes<ref>Zinkstok SM, Vergouwen MD, Engelter ST, Lyrer PA, Bonati LH, Arnold M, Mattle HP, Fischer U, Sarikaya H, Baumgartner RW, Georgiadis D, Odier C, Michel P, Putaala J, Griebe M, Wahlgren N, Ahmed N, van Geloven N, de Haan RJ, Nederkoorn PJ. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011 Sep;42(9):2515-20. doi: 10.1161/STROKEAHA.111.617282. Epub 2011 Jul 28. PMID: 21799165.</ref>

	===[[Antiplatelet]] vs [[Anticoagulation]] Therapy===		===[[Antiplatelet]] vs [[Anticoagulation]] Therapy===
	''Very controversial with poor data''		''Very controversial with poor data''
	*[[Heparin]]: If dissection causes neuro deficits and is EXTRACRANIAL		*Specific anticoagulation vs antiplatelet therapy is listed below based on expert consensus and theoretical risks
	*[[Aspirin]]: If dissection is INTRACRANIAL		**[[Heparin]]: If dissection causes neuro deficits and is EXTRACRANIAL<ref>Vasc Med. 2011 Feb;16(1):35-77. doi: 10.1177/1358863X11399328. Erratum in: Vasc Med. 2011 Aug;16(4):317. PMID: 21471149.</ref>
	*Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thromboembolic event		**[[Aspirin]]: If dissection is INTRACRANIAL<ref>Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J. 2021 Sep;6(3):XXXIX-LXXXVIII. doi: 10.1177/23969873211046475. Epub 2021 Oct 13. Erratum in: Eur Stroke J. 2023 Mar;8(1):399. PMID: 34746432; PMCID: PMC8564160.</ref>
			***Anticoagulants are avoided due to the weaker medial walls of intracranial vessels that have a higher theoretical risk for bleeding
			**Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thromboembolic event
			**In a small RCT study, there is no significant difference between antiplatelets vs anticoagulation in preventing subsequent stroke/death due to carotid/vertebral dissection<ref>CADISS trial investigators; Markus HS, Hayter E, Levi C, Feldman A, Venables G, Norris J. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015 Apr;14(4):361-7. doi: 10.1016/S1474-4422(15)70018-9. Epub 2015 Feb 12. Erratum in: Lancet Neurol. 2015 Jun;14(6):566. PMID: 25684164.</ref>
	*If tPA was given, wait 24hr before starting antiplatelet therapy		*If tPA was given, wait 24hr before starting antiplatelet therapy
	*Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)		*Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)

ClaireLewis at 17:02, 3 October 2019

2019-10-03T17:02:34Z

← Older revision		Revision as of 17:02, 3 October 2019
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	*Symptoms may be transient or persistent		*Symptoms may be transient or persistent
	*Consider in trauma patient who has neurologic deficits despite normal head CT		*Consider in trauma patient who has neurologic deficits despite normal head CT
	*Consider in patient with CVA + neck pain		*Consider in patient with CVA + [[neck pain]]

	[[File:Carotid_dissection.jpg\|thumb\|CTA brain showing filling defect in the right carotid artery (circled)]]		[[File:Carotid_dissection.jpg\|thumb\|CTA brain showing filling defect in the right carotid artery (circled)]]
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	**Pain can precede other symptoms by hours-days (median 4d)		**Pain can precede other symptoms by hours-days (median 4d)
	**Headache most commonly is frontotemporal; severity may mimic SAH or preexisting migraine		**Headache most commonly is frontotemporal; severity may mimic SAH or preexisting migraine
	*Partial Horner syndrome (miosis and ptosis) in 50% of cases		*Partial [[Horner syndrome]] (miosis and ptosis) in 50% of cases
	*[[Cranial nerve palsies]]		*[[Cranial nerve palsies]]

	===Vertebral Artery Dissection===		===Vertebral Artery Dissection===
	*Posterior neck pain, headache		*Posterior [[neck pain]], [[headache]]
	**May be unilateral or bilateral		**May be unilateral or bilateral
	**Headache is typically occipital		**Headache is typically occipital
	*Unilateral facial paresthesia		*Unilateral facial [[paresthesia]]
	*Dizziness		*[[Dizziness]]
	*[[Vertigo]]		*[[Vertigo]]
	*Nausea/vomiting		*[[Nausea/vomiting]]
	*[[Diplopia]] and other visual disturbances		*[[Diplopia]] and other visual disturbances
	*Ataxia		*[[Ataxia]]
	*[[Lateral Medullary Syndrome]] seen in up to 20% of cases of VAD<ref>Lee MJ, Park YG, Kim SJ, Lee JJ, Bang OY, Kim JS. Characteristics of stroke mechanisms in patients with medullary infarction. Eur J Neurol. 2012;19(11):1433-1439.</ref><ref>Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-1872.</ref>		*[[Lateral Medullary Syndrome]] seen in up to 20% of cases of VAD<ref>Lee MJ, Park YG, Kim SJ, Lee JJ, Bang OY, Kim JS. Characteristics of stroke mechanisms in patients with medullary infarction. Eur J Neurol. 2012;19(11):1433-1439.</ref><ref>Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-1872.</ref>

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	==Management==		==Management==
	*'''~~Anti-coagulation~~ (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted treatment.'''<ref>Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–2520.</ref>		*'''[[Anticoagulation]] (prevents clot propagation along dissecting lumen) followed by vascular repair is the generally accepted treatment.'''<ref>Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–2520.</ref>
	*Obtain emergent vascular surgery consult for possible endovascular intervention		*Obtain emergent vascular surgery consult for possible endovascular intervention

	===tPA===		===[[tPA]]===
	*Do not give if dissection enters the skull (ie Intracranial)		*Do not give if dissection enters the skull (ie Intracranial)
	*Do not give if aorta is involved		*Do not give if aorta is involved
	*Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])		*Otherwise, give according to same guidelines as for ischemic CVA (see [[CVA (tPA)]])

	===Antiplatelet vs Anticoagulation Therapy===		===[[Antiplatelet]] vs [[Anticoagulation]] Therapy===
	''Very controversial with poor data''		''Very controversial with poor data''
	*Heparin: If dissection causes neuro deficits and is EXTRACRANIAL		*[[Heparin]]: If dissection causes neuro deficits and is EXTRACRANIAL
	*Aspirin: If dissection is INTRACRANIAL		*[[Aspirin]]: If dissection is INTRACRANIAL
	*Aspirin: If dissection is extracranial but no neuro deficit, for prevention of ~~thrombo-embolic~~ event		*Aspirin: If dissection is extracranial but no neuro deficit, for prevention of thromboembolic event
	*If tPA was given, wait 24hr before starting antiplatelet therapy		*If tPA was given, wait 24hr before starting antiplatelet therapy
	*Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)		*Do not give if NIHSS score ≥ 15 (risk of hemorrhagic transformation)

Kearny89: /* Background */

2019-06-15T02:37:27Z

Background

← Older revision		Revision as of 02:37, 15 June 2019
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	===Risk Factors===		===Risk Factors===
	*[[Neck trauma]] (often minor)		*[[Neck trauma]] (often minor)
			**Symptoms typically occur 2-3 days after event
	*Cervical manipulation		*Cervical manipulation
	*Coughing		*Coughing

Dteoli: /* Background */

2018-04-17T01:04:42Z

Background

← Older revision		Revision as of 01:04, 17 April 2018
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	==Background==		==Background==
			*Primarily categorized as Spontaneous vs. Traumatic
	*Most frequent cause of [[CVA]] in young and middle-aged patients (median age - 40yrs)		*Most frequent cause of [[CVA]] in young and middle-aged patients (median age - 40yrs)
	*Symptoms may be transient or persistent		*Symptoms may be transient or persistent

Dteoli: /* Background */

2018-04-17T01:03:08Z

Background

← Older revision		Revision as of 01:03, 17 April 2018
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	[[File:Carotid_dissection.jpg\|thumb\|CTA brain showing filling defect in the right carotid artery (circled)]]		[[File:Carotid_dissection.jpg\|thumb\|CTA brain showing filling defect in the right carotid artery (circled)]]

			===Anatomy===
			*Vertebral artery comes off the subclavian and runs upward through the formina in the transverses processes of C6 to C2.

	===Risk Factors===		===Risk Factors===

← Older revision		Revision as of 03:07, 18 March 2026
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	==Clinical Features==		==Clinical Features==
	===Internal Carotid Dissection===		===Internal Carotid Dissection===
	*Unilateral ~~[[Headache (differential)\|~~headache]], face pain, anterior [[Neck pain\|neck pain]]		*Unilateral headache, face pain, anterior [[Neck pain\|neck pain]]
	**Pain can precede other symptoms by hours-days (median 4 days)		**Pain can precede other symptoms by hours-days (median 4 days)
	**Headache most commonly is frontotemporal; severity may mimic [[Subarachnoid hemorrhage\|SAH]] or preexisting [[Migraine\|migraine]]		**Headache most commonly is frontotemporal; severity may mimic [[Subarachnoid hemorrhage\|SAH]] or preexisting [[Migraine\|migraine]]
	*Partial '''[[Horner syndrome]]''' (miosis and ptosis without anhidrosis) in ~50% — sympathetic fibers run along the ICA		*Partial '''[[Horner syndrome]]''' (miosis and ptosis without anhidrosis) in ~50% — sympathetic fibers run along the ICA
	*[[Cranial nerve palsies]] — especially CN XII (hypoglossal); also CN IX, X, XI (lower cranial nerves compressed by expanding vessel wall)		*[[Cranial nerve palsies]] — especially CN XII (hypoglossal); also CN IX, X, XI (lower cranial nerves compressed by expanding vessel wall)
	*[[Pulsatile tinnitus]] — ipsilateral; from turbulent flow through stenosed artery
	*Vision loss ([[Amaurosis fugax\|amaurosis fugax]], retinal artery occlusion)		*Vision loss ([[Amaurosis fugax\|amaurosis fugax]], retinal artery occlusion)
	*Symptoms of anterior circulation [[Ischemic stroke\|stroke]] or [[Transient ischemic attack\|TIA]]		*Symptoms of anterior circulation [[Ischemic stroke\|stroke]] or [[Transient ischemic attack\|TIA]]

	===Vertebral Artery Dissection===		===Vertebral Artery Dissection===
	*Posterior [[Neck pain\|neck pain]], occipital ~~[[Headache (differential)\|~~headache]]		*Posterior [[Neck pain\|neck pain]], occipital headache
	**May be unilateral or bilateral		**May be unilateral or bilateral
	*Unilateral facial [[Paresthesia\|paresthesia]]		*Unilateral facial [[Paresthesia\|paresthesia]]
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	Other considerations:		Other considerations:
	*'''[[Migraine]]''' — most common misdiagnosis; but new-type headache in a patient without migraine history warrants imaging		*'''[[Migraine]]''' — most common misdiagnosis; but new-type headache in a patient without migraine history warrants imaging
	*'''[[Cervical strain]]''' / musculoskeletal neck pain — absence of neurologic symptoms does NOT exclude early dissection		*'''Cervical strain''' / musculoskeletal neck pain — absence of neurologic symptoms does NOT exclude early dissection
	*'''[[Subarachnoid hemorrhage]]''' — ~~[[Thunderclap headache\|~~thunderclap headache]]; intracranial dissection can cause SAH		*'''[[Subarachnoid hemorrhage]]''' — thunderclap headache; intracranial dissection can cause SAH
	*'''[[Cerebellar stroke]]''' from other embolic sources		*'''[[Cerebellar stroke]]''' from other embolic sources
	*'''[[Vertebrobasilar insufficiency]]'''		*'''[[Vertebrobasilar insufficiency]]'''
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	*'''MRI/MRA with fat-suppressed T1:''' shows intramural hematoma as hyperintense crescent; preferred if already obtaining MRI for [[Ischemic stroke\|stroke]] workup; better for follow-up imaging		*'''MRI/MRA with fat-suppressed T1:''' shows intramural hematoma as hyperintense crescent; preferred if already obtaining MRI for [[Ischemic stroke\|stroke]] workup; better for follow-up imaging
	*'''MRI brain (DWI):''' most sensitive for acute posterior fossa [[Ischemic stroke\|ischemia]] (CT misses many small [[Cerebellar stroke\|cerebellar]]/brainstem strokes)		*'''MRI brain (DWI):''' most sensitive for acute posterior fossa [[Ischemic stroke\|ischemia]] (CT misses many small [[Cerebellar stroke\|cerebellar]]/brainstem strokes)
	*'''[[HINTS exam]]:''' in patients presenting with acute [[Vertigo\|vertigo]] and [[Nystagmus\|nystagmus]], a central HINTS pattern should raise suspicion for posterior circulation [[Ischemic stroke\|stroke]] from VAD		*'''Labs:''' [[CBC]], [[BMP]], [[Coagulation studies\|coags]], [[Troponin\|troponin]], glucose, type and screen
	*'''Labs:''' [[CBC]], [[BMP]], [[Coagulation studies\|coags]], [[Troponin\|troponin]], ~~[[Blood glucose\|~~glucose]], type and screen
	*'''[[ECG]]:''' baseline; stroke can cause ECG changes (deep TWI, prolonged QT)		*'''[[ECG]]:''' baseline; stroke can cause ECG changes (deep TWI, prolonged QT)
	*Doppler ultrasound: insufficient — misses skull base segments; '''a negative ultrasound does NOT exclude dissection'''		*Doppler ultrasound: insufficient — misses skull base segments; '''a negative ultrasound does NOT exclude dissection'''
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	\| '''II''' \|\| Dissection/intramural hematoma with ≥25% luminal narrowing, intraluminal thrombus, or raised intimal flap \|\| ATT; follow-up imaging at 7-10 days; endovascular if progresses		\| '''II''' \|\| Dissection/intramural hematoma with ≥25% luminal narrowing, intraluminal thrombus, or raised intimal flap \|\| ATT; follow-up imaging at 7-10 days; endovascular if progresses
	\|-		\|-
	\| '''III''' \|\| [[Pseudoaneurysm]] \|\| ATT ± endovascular repair		\| '''III''' \|\| Pseudoaneurysm \|\| ATT ± endovascular repair
	\|-		\|-
	\| '''IV''' \|\| Complete occlusion \|\| ATT ± endovascular repair		\| '''IV''' \|\| Complete occlusion \|\| ATT ± endovascular repair
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	*'''[[Subarachnoid hemorrhage\|SAH]]:''' if dissection extends intracranially (especially vertebral V4 segment)		*'''[[Subarachnoid hemorrhage\|SAH]]:''' if dissection extends intracranially (especially vertebral V4 segment)
	*'''Recurrent dissection:''' ~1% annual risk; higher in those with [[Connective tissue disease\|connective tissue disorders]] or family history		*'''Recurrent dissection:''' ~1% annual risk; higher in those with [[Connective tissue disease\|connective tissue disorders]] or family history
	*'''[[Pseudoaneurysm]] formation:''' may require long-term follow-up and possible intervention		*'''Pseudoaneurysm formation:''' may require long-term follow-up and possible intervention

	==Disposition==		==Disposition==