Cervical Artery Dissection

Question 1

Explain Cervical Artery Dissection (CAD) as an Outside-In Phenomenon:

Answer 1

Degenerative changes start at the medial-adventitial border, capillary leakage, microhematomata along the medial-adventitia
further degeneration and ultimately rupture of the wall of the artery

Question 2

Incidence of Vertebral artery dissection

Answer 2

incidence is difficult to estimate as only those that progress to stroke are reported

~2% of all strokes (VAD)

up to 25% of all strokes in people under 55

Question 3

Prognosis of VAD

Answer 3

good functional recovery in 67%
headache resolves 1 week 90%
artery stenosis resolves in 90%
death in less than 5%
10 year survival rate 95.5%

Question 4

Recurrence of VAD

Answer 4

2% 1 month
1% 1 year
3.7% 2+ years
5% 5+ years
11.9% 10+ years
younger patients increased risk
ALL recurrent dissections in different cervical vessles

Question 5

Most Common Symptoms VAD

Answer 5

INITIAL:
vertigo 58% (stroke)
headache 51% (dissection)
neck pain 46% (dissection)

VAD patients: occipital or neck pain
ICAD patients: frontal or retro-orbital

Question 6

“Causes” of VAD

Answer 6

• all based on case reports
• less than 1/2 are associated with a mechanical event

childbirth, calistehnics, yoga, hanging laundry, neck extension for bloody nose, seizure, dental work, sneezing/nose blowing/coughing, star gazing, watching aircraft, break dancing, beauty/barber chair, sexual intercourse, atheltics, overhead work/painting wall, archery, neck extension for radiography, neck turn while driving, amusement rides, wrestling, CPR, sleeping position, football, tai chi, swimming

Question 7

Recognizing vertebral artery dissection

Answer 7

sudden, severe, sustained neck pain and/or headache

-VAD: occipital and/or suboccipital
-sharp or throbbing
in migraine patients, RARELY mistaken for typical migraine

-onset of stroke symptoms can develop hours, days, or at times, weeks after neck/head pain

-some patients will have transient visual disturbance, dizziness, imbalance, or other ischemic symptoms and might not spontaneously report them

• median time between onset of neck pain and neuro sx = 2 weeks
• median time between HA and neuro sx = 15 hours
  -mean time from pain (HA or NP) to stroke DX: 3-8 days, longer in pts with intermittent pain, sorter in pts with constant pain
  -many patient swill have transient neuro symptoms in the month prior and may not connect with the Np/HA

Question 8

Conditions that predispose to CAD

Answer 8

-connective tissue disease
-autosomal dominant polycystic kidney disease
-ehlers-danlos type IV
-marfan syndrome
-fibromuscular dystrophy

though only about 8% of VAD pts have a known connective tissue disorder.

pts. with migraine have 2x the risk compared to non-migraine.
HOWEVER, the vast majority will never have CAD

Question 9

5 D’s And 3 N’s

Answer 9

diplopia
dizziness
drop attacks
dysarthria
dysphagia

Ataxia

nausea
numbness
nystagmus

Question 10

VAD or Migraine?

Answer 10

VAD: Sudden, Severe, Sustained!

Migraine: gradual onset and disappearance within 14-48 hours

Question 11

Internal Carotid Dissection

Answer 11

Partial Horner’s: ptosis and cormiosis WITHOUT anhydrosis

Amaurosis fugax: transient monocular blindness

Sudden onset Horner’s syndrome PARTICULARLY with HA or NP and ipsilateral neuro symptoms should lead to URGENT INVESTIGATION

Question 12

Ask about symptoms in the preceding month

Answer 12

unusual HA or NP
balance problem
visual disturbance
dizziness
extremity weakness or paresthesia
pulsatile tinnitus

Question 13

Tests to order if dissection is suspected

Answer 13

Doppler US

MRA: better as it will show dissection in teh wall

Question 14

Spontaneous Coronary Artery Dissection:

Answer 14

mean age 43yrs
higher prevalence in females
pain most common initial symptom
CT disease risk factors: EDS, fibromuscular dysplasia

• believed to be inherent arterial weakness