• Clinical science

Dissection of the carotid and the vertebral artery (Cervical artery dissection)

Abstract

Carotid or vertebral artery dissection describes the separation of the tunica media and tunica intima of a vessel. This can lead to thrombosis of the false lumen, which can, in turn, lead to stenoses or embolisms with the risk of stroke. Dissections of the carotid and vertebral artery primarily affect young adults and may occur spontaneously or as a result of a major trauma (e.g., car accidents). The initial symptoms are usually headaches (temporal and occipital for carotid and vertebral artery dissection respectively), which may be followed by features of ischemia (e.g., stroke) a few hours or days later. Duplex ultrasonography may provide a rapid diagnosis, but definitive diagnosis requires CT angiography or MR angiography. Treatment is primarily conservative and involves blood thinners, anticoagulants, and antiplatelet therapy. Severe cases may require surgery.

Epidemiology

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

References:[1]

Clinical features

Dissection of the carotid artery

Dissection of the vertebral artery

Carotid or vertebral artery dissection is the separation of the tunica media and tunica intima of a vessel. This can lead to thrombosis of the false lumen, which can, in turn, lead to stenoses or embolisms with the risk of stroke!

References:[3][1][2]

Diagnostics

  • Duplex ultrasonography: high resistance flow or complete absence of flow in affected artery
  • Helical CT angiography (replacing MRI as diagnostic modality of choice ;)
    • Changed caliber of vessel
    • Oval or slit-like crosssection of vessel
  • MR angiography
    • Intramural blood
    • Mural expansion
    • Irregular vessel margins
    • Filling defects
    • Extravasation of contrast
    • Caliber changes of vessel
  • Conventional angiography

Baseline monitoring parameters (e.g., INR, PT, aPPT) should be performed before administering anticoagulant therapy!
References:[1][2]

Treatment

  • Treatment should be initiated after an intracerebral hemorrhage has been ruled out
    • Heparin therapy followed by oral anticoagulation for 3–6 months and/or
    • Antiplatelet agents for 1 year
  • Possibly angioplasty/stenting or surgical intervention may be warranted in severe cases

Asymptomatic pseudoaneurysms do not usually require treatment and most dissections heal spontaneously!
References:[2][4]