Updated: 6/19/2018

Carotid Dissection

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  • A 34-year-old woman presents to the emergency department with constant and severe right-sided headaches. One day prior to presentation, she was in a minor motor vehicle accident where her head jerked forward. She has also noticed mild eye-lid drooping earlier in the day. She smokes approximately 2-3 cigarettes per day. On physical exam, she has right-sided ptosis and miosis without anhydrosis. A non-contrast CT scan and CT angiography is performed, which demonstrates a tapered stenosis of the internal carotid artery and an intimal flap.
  • Definition
    • intimal tear of a cervical artery
      • cervical arteries include
        • carotid and vertebral arteries
  • Epidemiology
    • risk factors
      • trauma to the neck
  • Pathogenesis
    • an intimal tear of a cervical artery leads to an intramural hematoma, which results in 
      • stenosis
      • occlusion
      • aneurysm
  • Prognosis
    • unfavorable factors
      • cerebral ischemia
      • increased age
      • arterial occlusion
  • Classic triad
    • one-sided head, neck, or facial pain (most common)
    • partial Horner syndrome with internal carotid involvement
      • which leads to miosis and ptosis
        • there is no anhydrosis because the sympathetic fibers that are involved in facial sweating and vasodilation branch off of the oculosympathetic pathway at the superior cervical ganglion to course with the external carotid artery
    • cerebral or retinal ischemia
  • Symptoms
    • symptoms secondary to stroke such as
      • numbness
      • weakness
      • transient monocular blindness (amaurosis fugax)
    • pulsatile tinnitus
  • Physical exam
    • physical exam findings secondary to stroke such as
      • ataxia
      • weakness
      • aphasia
  • Magnetic resonance angiography
    • indication
      • preferred imaging modality in the evaluation of cervical artery dissection
        • CT angiography can also be used with relatively similar sensitivity and specificity
    • findings
      • hyperintense crescent-shaped rim and decreased lumen 
      • tapered stenosis or occlusion
      • dissecting aneurysm
  • Migraine
    • differentiating factor
      • motor deficits are not typically seen in migraine headaches
  • Medical 
    • tPA
      • indication
        • used in the acute ischemic stroke period in patients with extracranial cervical artery dissection
    • antithrombotic or antiplatelet therapy
      • indication
        • depends on the type of cervical dissection
  • Operative
    • endovascular or surgical repair
      • indication
        • typically used in patients with recurrent ischemia even though they were treated with appropriate medical therapy
  •  Ischemic stroke

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