Spontaneous Cervical and Intracranial Arterial Dissections

26 Apr

(scroll to bottom for quick hits)

Background
-Arterial dissections can cause stroke in both young in old populations, and is the most common cause of stroke in the young

-Extracranial dissection is more common than intracranial dissection

-Stroke is generally caused by either diminished blood flow from intraluminal thrombus or embolized clot

Pathogenesis (stick with it)
-Dissection are believed to begin with a tear in the media of the vessel wall, leading to bleeding in the wall itself

-partially coagulated intramural blood can enter the lumen which activates platelets and
the coagulation cascade leading to intraluminal thrombus.

-Intramural blood can accumulate leading to compression of the lumen



Risk Factors
Connective tissue and vascular disorders are thought to be main risk factors:
(e.g. Ehlers-Danlos Syndrome (type IV), Marfan Syndrome, Polycystic kidney disease, cystic medial necrosis, Fibromuscular dysplasia)

-many are caused by trauma




Diagnosis
-based on radiologic criteria taken from the Strategies Against Stroke Study for Young Adults in Japan (SASSY) using CTA or MRI/MRA

-Primary rules are based on finding an intimal flap or double lumen on Angiogram or MRI/MRA, or repeated non-specific findings associated with dissection on multiple studies.



Symptoms
Head or neck pain

Horner Syndrome occurs when the sympathetic fibers on the ICA are stretched. It is usually just partial with ptosis and miosis but no anhidrosis.

Difference between Carotid and Vertebral Dissections
-Transient monocular blindness occurred only with internal carotid dissection

-Ischemic stroke is more common in vertebral dissections

Neck pain and recent minor cervical trauma are more common in vertebral dissections

-Proportion of men and a recent infection are more common in ICA

Treatment
Antithrombotic therapy (antiplatelet or anticoagulation) is the primary initial treatment for ischemic stroke and TIA caused by arterial dissection

-For intracranial dissection, antiplatelet therapy is often the treatment of choice

-For extracranial dissection, anticoagulation initially followed by 6 months of warfarin therapy as opposed to antiplatet therapy is often chosen

Endovascular and surgical therapy are generally only reserved for recurrent ischemic events

BOTTOM LINE:
arterial dissection is more common cause of stroke in the young
extracranial (vertebral, carotid) more common than intracranial dissection
-sx: headache, neck pain, stroke-like symptoms, Horner’s syndrome (for ICA)
-risk factors: connective tissue disorders, trauma
-dx: angiography, MRI/MRA
-tx: antithrombotics/anticoagulation (aspirin, heparin, coumadin, etc.); surgical/endovascular for recurrent events

Submitted by J. Grover.


Reference(s): Caplan, LR and Biousse V. “Cervicocranial Artery Dissections.” J Neuro-Opthalmol. 2004; 24:299-305. Maruyama, H et al. “Spontaneous Cervicocephalic Arterial Dissection with Headache and Neck Pain as the Only Symptom.” J Headache Pain (2012) 13: 247-253. “Spontaneous Cerebral and Cervical Artery Dissection: Treatment and Prognosis”. Uptodate.  “Spontaneous Cerebral and Cervical Artery Dissection: Clinical Features and Diagnosis”. Uptodate., picture

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