Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment

Abstract

Extracranial arterial dissections are a recognised cause of stroke, particularly in young adults. Clinical diagnosis may be difficult, and the classical triad of symptoms is uncommon. Imaging plays a pivotal role in the diagnosis of extracranial arterial dissections, and this review provides a detailed discussion of the relative merits and limitations of currently available imaging modalities. Conventional arteriography has been the reference standard for demonstrating an intimal flap and double lumen, which are the hallmarks of a dissection, and for detecting complications such as stenosis, occlusion or pseudoaneurysm. Noninvasive vascular imaging methods, such as ultrasound (US), magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are increasingly replacing conventional angiography for the diagnosis of carotid and vertebral dissections. Ultrasound provides dynamic and "real-time" information regarding blood flow. Source data of MRA and CTA and additional cross-sectional images can provide direct visualisation of the mural haematoma and information about the vessel lumen. Anticoagulation to prevent strokes is the mainstay of medical treatment, but randomised trials to define the optimal treatment regime are lacking. Surgery has a limited role in management of dissections, but endovascular procedures are gaining importance for treatment of complications and if medical management fails.

Recognition of Spontaneous Vertebral Artery Dissection Preempting Spinal Manipulative Therapy: A Patient Presenting With Neck Pain and Headache for Chiropractic Care

“…Risk factors for arterial dissection include connective tissue disorders, hypertension, diabetes mellitus, smoking, hyperlipidemia, oral contraception, and others. 5,17 One study found fibromuscular dysplasia (FMD) in 15% of cases of spontaneous dissection of the carotid or vertebral arteries. 18 Our patient had imaging findings suggestive of FMD, but not associated with either of the vertebral arteries.…”

“…Ischemia or infarction may occur distal to the territory of the occluded vasculature. 5 A complication of VAD includes ischemia in the vertebro-basilar artery (VBA) distribution, but stroke in young adults secondary to VAD is far less common than those secondary to dissection of the internal carotid artery. 2,19 A literature review that combined carotid and vertebral artery (cervical artery) dissections indicated that a minority of dissections (6%) were associated with SMT.…”

“…2 CTA may demonstrate a narrowed lumen surrounded by mural thickening, which may enhance at its outermost aspect as seen in our patient. 5 Most clinicians, whether medical or practitioners using SMT, when faced with VAD in progress aren't aware that non-specific symptoms such as neck pain and headache may be the only symptoms. 1 Examination findings may be non-contributory and the history may be more helpful, as was true in our case.…”

“…The clinical diagnosis of a VAD is difficult when stroke or transient ischemic attack have not occurred, as it may be asymptomatic or present with only symptoms of neck pain. 5 The most common clinical manifestations of VAD are neck pain and headache, which may or may not be followed by posterior circulation ischemia. 3,6 Neck pain and headache in such a case could easily be mistaken as musculoskeletal in origin, such as the myofascial pain syndrome.…”

Extracranial traumatic carotid artery dissections in children

“…6,7 Appropriate imaging studies should be performed urgently when a neurological finding is obvious and, more importantly, even if one has only a suspicion based on the mechanism of the traumatic event. 5 In this review, disease was diagnosed in all 34 patients only after the onset of ischemic symptomatology. In patients involved in accidents resulting in polytrauma, routine imaging of the spine is often performed, and based on this evaluation, MR and/or CT dissection protocols should be part of the evaluation.…”