Arterial Dissection

Pitfalls (1)

“I have a pain in my neck and

(or) head unlike anything I have

ever had before.”

Pain referral common to Vertebral Pain referral common to Internal Carotid

Pitfalls (2)

The pain was described as

throbbing, steady or sharp as

the “thunderclap” headache.

Diagnosing VAD/CAD CT or MRI are not sensitive enough to detect

arterial dissections.– MRA, carotid ultrasound, or DSA are more sensitive.

• Rarely administered unless physician suspects CAD/VAD

Accurate diagnosis of CAD/VAD in younger stroke patients is rare.– Physicians and patients are relatively unaware of the

link between precipitating events and presenting signs/ symptoms

Treatment Aimed at preventing CVA.

– Anticoagulation and antiplatelet therapy.– Surgery required in very few cases.

• Bypass

• Stenting Patient prognosis is dependent on the timeline of

diagnosis and subsequent treatment. If the dissection is discovered early, patients have a excellent prognosis for recovery from symptoms.

Can J Neurol Sci. 2000; 27(4): 292-6.

1. Recurrent stroke after dissection:10.7%(1st yr); 14.0%(3rd yr)

2. Recurrent stroke within 6m with anti-coagulation 2% comparedto anti-platelet 16.7%. (P=0.02)

3. Long term benefit remained uncertain.

(JNNP.2010; 81: 869-873.)

Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients.

1. No significant difference.

2. Aspirin may be better.

(NEUROLOGY, 2009; 72: 1810-5.)

Preventive measures Avoid trauma to the head and neck. Wear seatbelts when driving or riding in

vehicles. (*) Take appropriate safety precautions for

sporting events– Helmet.– Padding.

Be aware that extended or extreme neck extension or cervical manipulation may increase risk for arterial dissection.

*(cases report of dissection with seatbelt use…)

The following might suggest: headache is due to dissection of a carotid artery

Sudden severe, unilateral pain (70% of cases) New onset bilateral headache (20% , not necessarily

explosive at onset) New onset unilateral upper neck pain (under the jaw or

mandible) - 6% of cases. New onset facial pain - 17% of cases. New onset pulsatile tinnitus- 7% of cases. Thunderclap headache- occurred in one of 65 cases

(1.5%) of dissection.

(www.severe-headache-expert.com)

Conclusion

Dissections accounts for 10-25% of all ischemic strokes in young/middle aged persons.

Median time from onset of headache to neurological symptoms is 4 days with carotid artery dissection, and 14.5 hours of vertebral artery dissection.

Highly suspicion of dissection in patients of TIA’s or stroke with a history of trauma or chiropractic manipulation.

Conclusion Most common associated with a headache of subacute

onset. 15-20% of patients presented with a thunderclap

headache. Headache reported by 60-95% of patients with carotid

artery dissection and 70% of patients with vertebral artery dissection.

Headache generally occurred ipsilateral to the dissection area, involved the face, jaw, ears, periorbital, frontal and temporal regions, with neck pain in 30-40 % of patients.

(Postgrad Med J. 2005;81: 383-388.)

Blessing Taiwan

( 部分內容圖片摘自網路僅供參考 )