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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% compared
to 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
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