Rutherford CH93 – Carotid Artery Dissection

- 2% of all ischemic strokes

- 10-20% of strokes in young people
- No gender predilection but females affected 5 years earlier than males on avg
- RFs for dissection
o Chiropractic manipulation
o CTD
 EDS
 FMS
 Osteogenesis imperfecta type I
 Cystic medial necrosis
 Autosomal dominant polycystic kidney disease
o HTN
o Migraine like disorder
o Recent infection
o Winter months

Clinical Presentation

- Headache
- Partial Horners syndrome
- Nausea (VA dissections)
- Hemispheric symptoms (CA dissections)
- Neck pain
- Amaurosis Fugax
- Anisocoria
- Pulsatile tinnitus
- CN palsy (IX, X, XI, XII. In particular, hypoglossal nerve involvement)

- Classic triad = ipsilateral head or neck pain, cerebral or retinal ischemia, ipsilateral
oculosympathetic palsy

- Oculosympathetic palsy
o Miosis and ptosis caused by involvement of sympathetic fibers accompanying
ICA.
o No facial anhydrosis since these fibers accompany the ECA

- Mandatory imaging in the following trauma patients to r/o cervical artery dissection
o Active bleeding in the head or neck
o Expanding neck hematoma
o Cervical bruit in patients 50yr or older
o Imaging suggesting acute brain infarction
o Central or lateralizing neurological deficits
o Horner syndrome
Rutherford CH93 – Carotid Artery Dissection

o Head or neck pain

o Cervical spine fracture
o GCS < 6
o Petrous bone #
o Diffuse axonal injury
o Basilar skull #
o Lefort II or III #

Diagnostic Evaluation

- Gold standard – 4 vessel cerebral angiography

o Intimal flap or double lumen sign = pathognomonic
o ICA stenosis caused by dissection is usually irregular and 2-4cm distal to the bulb
with a long tapering stenosis that usually ends before the ICA enters the petrous
portion of the temporal bone
o Occlusions = tapered and flame-like appearance
o Aneurysms = develop later in a fusiform fashion in the distal subcranial segment

Natural History

Spontaneous carotid dissections

- Cerebral infarction in 42%
- Persistent neurological deficit in 58%
- In patients managed medically, recurrent dissection rate = 0.3-1.4%. More common in
1st month, CTD or family history. Annual risk of recurrent stroke = 0.3-3.4%
- Dissection = most common cause of ICA aneurysms  2/3rd RESOLVE***

Traumatic carotid dissections

- Worse prognosis
- More likely to develop aneurysms and grow to occlusions

Treatment

- Spontaneous or traumatic dissection  heparin infusion then transition to VKA for 3-6
months. No evidence based
- CADISS Trial
o RCT in acute (<7days) dissection of carotid and vertebral. Intracranial dissection
excluded.
o Randomized to antiplatelet (ASA, dipyramidol or Plavix) alone or in combination
vs anticoag with heparin infusion  VKA INR 2-3 for at least 3 months
o Primary endpoint = ipsilateral stroke or death within 3 months. Secondary
endpoint any TIA/stroke, major bleed or residual stenosis.
Rutherford CH93 – Carotid Artery Dissection

o No difference between antiplatelet or anticoagulant at preventing stroke/death

in patients with symptomatic carotid and vertebral dissection. Stroke rare in
both groups, questioning use of anticoagulant treatment to begin with. Some
observational studies suggest a higher bleeding rate with anticoagulants vs
antiplatelets.
- Open Surgery
o Indications ACUTE
 Fluctuating or deteriorating clinical neurologic symptoms despite medical
treatment
 Compromised cerebral blood flow
 Contraindications to antithrombotic therapy
 Symptomatic or enlarging aneurysm
 Cerebral embolus in the asymptomatic patient
o Indications for surgery >6 months out
 Persistent high grade stenosis
 New or persistent aneurysm >2x normal ICA diameter
- Options for repair
o Ligation (only safe if systolic stump pressure >70mmHg
o Interposition saphenous vein graft
o Patch angioplasty
o ECA to ICA transposition
- Endovascular therapy
o Same indications as open
o Options
 Intraarterial or IV thrombolysis for dissections with ischemic symptoms
secondary to thromboembolism – CI in traumatic dissection therefore
only for spontaneous dissection
 CADISP trial = thrombolysis not associated with unfavorable
outcomes or with an increased rate of symptomatic bleeding.
 Stenting dissection with BM or CS
 Coiling of dissecting aneurysms
 Stent-assisted coiling
 Embolization or occlusion of dissected vessel
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