Cervical Artery Dissections

Abstract

Cervical artery dissection (CAD) accounts for up to one fifth of ischemic strokes occurring before 45 years. Their increasing recognition is probably due to an increased clinical awareness of this condition in patients with painful ischemic events. The internal carotid artery is the most commonly affected vessel. Cerebral ischemia is the most serious consequence of a CAD. It may be due to hemodynamic factors or emboli. The enlargement of the artery may lead to a direct compression of the lower cranial nerves. CAD typically occurs in young adults with a mean age of 40 years with a male:female ratio of 1.5. After exclusion of traumatic cases, the average annual incidence rate of CAD is 2.6 per 100,000, but the reported incidence figures in the literature are likely to be an underestimation of the incidence of CAD. A spontaneous dissection is assumed when no or only minor trauma preceded the onset. However, the differentiation between spontaneous and traumatic dissections is artificial because of a continuum between both forms. The pathogenesis of dissections remains unknown in most cases. However, traumas and primary diseases of the arterial wall are the main predisposing factors. The clinical presentation of spontaneous dissections of the internal carotid artery includes cerebral ischemia, cervical or cranial pain, Homer’s syndrome and cranial nerve palsy; CAD may also be silent. Brainstem ischemic deficits and occipital pain are the most common findings in vertebral artery dissections, but these features may be biased because the most benign and the most severe cases may escape detection. The favorable natural history of CAD emphasizes the need for a noninvasive approach to the detection, monitoring and follow-up. This noninvasive approach can be obtained by means of CT scan, MRI, magnetic resonance angiography and ultrasonography, although angiography remains the gold standard for the diagnosis of arterial dissections. Follow-up studies suggest a fairly good overall prognosis in adults and in children. In many centers, CAD are treated by heparin at the acute stage, although the benefit of such a potentially dangerous treatment has never been proven by a randomized trial.

Extracranial traumatic carotid artery dissections in children: a review of current diagnosis and treatment options

“…58,63 Treatment with Coumadin for 6 months-1 year has traditionally been advocated, with a target international normalized ratio of 2-3. 33,55 In a study on the treatment of blunt CA injury, anticoagulation was suggested to be the treatment of choice when dissection or pseudoaneurysm was diagnosed. 61 There are no data from controlled studies on the safety of heparin, although several consecutive series have shown no significant side effects.…”

Spontaneous Dissection of Internal Carotid Artery Masquerading as Angioedema

“…Most cases of ICA dissections present within hours; however, some develop over weeks as evolving symptoms leading patients to seek medical attention 17 . Symptoms of ICA dissection include headache, anterior neck pain, scalp tenderness, transient ischemic attack, cerebral infarction, amaurosis fugax, cranial nerve palsies, tinnitus and Horner's syndrome [18][19][20] . Sturzenegger et al 21 20 .…”

Treatment of Acute Ischemic Stroke: Beyond Thrombolysis and Supportive Care

“…As the most common cause of stroke from dissection is thromboembolism, and because the risk of stroke seems to be greatest in the first day after the onset of the vascular injury, early anticoagulation has long been considered the first-line treatment [27][28][29][30][31]. However, only observational data exist and they are conflicting.…”