Cervical artery dissection

Question 1

Definition

Answer 1

Where there’s a tear in a carotid or vertebral artery within your neck.

It is not fully cut through, so blood doesn’t move out into your neck and brain

A dissection makes it possible for clots to form

Common cause of stroke in young and middle-aged adults

It may track back to the pericardium

So the blood starts to run into the tear between the vessel wall

Question 2

Aetiology

Answer 2

Injury to your head and neck (most common cause)
– neck sprain
– whiplash from a car accident
– extreme head positions for long periods (painting a ceiling)
– rapid movements of the head (rollercoaster, chiropractic neck manipulation)

– GI upset causing frequent vomiting
– upper respiratory infection which causes persistent coughing

Predisposition to a weakened aortic wall:
– marfans syndrome
– Ehlers-Danlos syndrome

Question 3

Epidemiology

Answer 3

Common cause of stroke in young adults

Prevalence of up to 20% in this population

Annual incidence rate of 2.6-2.9 per 100’000
– true incidence is likely to be higher as many causes of dissection may go undiagnosed due to minor self-limited clinical symptoms

Question 4

Pathophysiology

Answer 4

Results from a tear in the intima, resulting in a separation of the vessel wall layers and the formation of a false lumen
– creating an intramural haematoma inside the false lumen
– true lumen becomes smaller meaning less blood can get through

Vessel wall weakness is thought to be present in patients with spontaneous dissection

Genetic predisposition to the occurrence of the disease seen as skin biopsies have shown a disruption in the morphology of the extracellular matrix in patients with cervical artery dissection

Acquired conditions such as minor trauma, hypertension, or a recent infection that may cause vessel wall weakness or injury are also predisposing factors

Talk about atherosclerosis and hypertension pathophysiology as well

Question 5

Risk factors

Answer 5

Atherosclerosis

Hypertension (most significant risk factor)

Smoking

Question 6

Clinical presentation

Answer 6

Severe, sudden head pain (particularly behind one eye) or neck pain

Patient may be very distressed

Stroke-like symptoms:
— ataxia
— balance problems
— blurred vision
— dizziness
— double vision
— limb weakness
— speech difficulty
— vertigo

Head and neck pain:
– comes on suddenly and doesn’t go away
– one side of the head especially behind the eye or neck

Horners syndrome:
– affects the involuntary function of your eyes and face
– symptoms include:
—- drooping eyelids (ptosis)
—- smaller pupil in one eye and a lack of sweating
—- usually impacts on the side of your head

Question 7

Investigations

Answer 7

CT angiogram or MRI- good for detecting, takes specific pictures of your blood vessels

Question 8

Treatment

Answer 8

Often heal on their own
Medical therapies can lower your risk of blood clots that can lead to stroke

You may need:
– anti platelet therapy- aspirin or clopidogrel. Prevent blood from clotting and clumping together to reduce strokes

– anticoagulant medications (blood thinners)- heparin infusion or warfarin tablets

Surgical stenting can be used to reinforce and expand the blood vessel walls if other treatments do not work