Carotid Artery Dissection

Subscribe to Resus

Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. And it's FREE!

  • We respect your privacy
  • This field is for validation purposes and should be left unchanged.

Register Now:

Sorry, we couldn't find any posts. Please try a different search.

Patients can present to us with a sudden severe headache, also known as a thunderclap headache. Although there are several potential causes of sudden headache(shown below), the main aetiology we try to exclude in the emergency department, is aneurysmal rupture. When we do rule this out, we still need to consider the other possible causes of a thunderclap headache. These can include Cerebral Venous Thrombosis and carotid Artery Dissection.

Causes of Sudden Headache

  • Cerebral aneurysmal rupture
  • Arterial Dissection
  • Venous Sinus Thrombosis
  • Reversible Vasoconstriction Syndrome
  • Rarer causes including
    • Spontaneous intracranial hypotension
    • Pituitary apoplexy
    • Pheochromocytoma
    • AMI

Spontaneous dissection of the carotid artery occurs in 3 per 100,000 of the population annually(1). Dissection of the vertebral artery occurs in 1 per 100,000 of the population, however it makes up about 25% of all cerebral events in those less than 40 year of age(2). It can manifest as headache(the most common early symptom(3))  with or without neck pain.

Clinical Presentation

Internal Carotid Artery Dissection.

There is a classic triad of symptoms and signs, but these only occur in 30% of cases(1). Two of the three can assist us in making the diagnosis:

  1. Pain to one side of the head, face or neck
    1. Ipsilateral neck pain occurs in 25% of cases(4)
    2. Ipsilateral facial or orbital pain is present in about 50% of cases(5)
    3. Headache can involve the whole head, the front-temporal area or the occipital area(5)
    4. In most cases the headache is gradual, but it can be ‘thunderclap’ in nature.
  2. Partial Horner’s Syndrome (oculosympathetic palsy)
    1. Miosis and Ptosis occurs in < 50% of cases(50)

      Horner’s Syndrome. Source mrcophth.com

  3. Cerebral or Retinal ischaemia signs, which manifest days to weeks later.
    1. 20% have an ischaemic stroke without warning(7)
    2. Up to 90% of patients will have transient ischemic attacks with transient monocular blindness

Note that other cranial nerves may be involved, especially hypoglossal(CN12) Cranial nerves III, IV and VII, including taste sensation may be affected. 25% of patients report pulsatile tinnitus(6).

Vertebral Artery Dissection

The initial presentation is pain in the posterior neck or head followed by ischaemic symptoms.

  1. Neck Pain(7)
    1. This is usually posterior neck pain in 50% of patients.
  2. Headache(7)
    1. It occurs in 60% of patients
    2. It is almost always occipital.
  3. Ischaemia
    1. Transient ischaemic attacks do not occur as often as with carotid artery dissections.
    2. 90% will have ischaemic symptoms
      1. These will be of the brain stem (lateral medulla), thalamus, cerebral or cerebellar hemispheres
      2. Lateral Medullary Syndrome known as Wallenberg’s syndrome will involve:
        1. Sensory Symptoms
          1. Ipsilateral pain and temperature Deficits of the face and cranial nerves
          2. Contralateral pain and temperature deficits of the torso. This crossing of pain and temperature loss, helps in making the diagnosis
        2. Vestibulo-cerebellar Symptoms
          1. Multidirectional nystagmus
          2. Diplopia
          3. Vertigo
        3. Autonomic Dysfunction
          1. Ipsilateral Horner’s Syndrome
        4. Ipsilateral Bulbar muscle weakness
          1. Dyspohonia
          2. Dysphagia
          3. Dysarthria

Note that although rare, unilateral arm pain or weakness(usually C5-C6) can result from cervical root involvement, or spinal epidural hematomas(8).

Investigations

Making this diagnosis is all about the imaging. CT angiography is probably the test to do, being almost as good as MRI/MRA. The use of ultrasound may be useful in the first instance, as it identifies an abnormal flow patterns.

Treatment

90% of ischaemic symptoms are due to thromboembolic sources.

  • Antiplatelets
    • Preferred in intracranial dissections
  • Anticoagulants
    • Only in extra cranial dissections
    • Only in small infarctions
  • Surgical or endovascular treatment is reserved for those with ongoing symptoms.

Prognosis

The mortality rate from Carotid and Vertebral Artery dissection is less than 5%(4), with more than 75% of those having a stroke, progressing to a good functional recovery.

Most dissections will heal spontaneously and about 90% of stenoses resolve within 3 to 6 months, either by recanalisation or reduction of aneurysm size.

Conclusion

The initial discussion of carotid and vertebral artery dissection, resulted from a discussion of differentials of sudden headache. Internal carotid Artery dissection can present with thunderclap headache. When this occurs, look for:

  • Oculosympathetic Palsy(Horner’s Syndrome)
  • Look for other cranial nerve involvement, especially III,IV,VII and XII.

References

  1. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001;344(12):898-906
  2. Kratz SN, Butke KH. Vertebreal artery dissection presenting as acute cerebrovascular accident. J Emerg Med. 2011;40(2):151-7.
  3. Flis CM, Jäger HR, Sidhu PS. Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol. 2007;17(3):820-34.
  4. Biousse V, D’Anglejan-Chatillon J, Massiou H, Bousser M-G. Head pain in non-traumatic carotid artery dissection: a series of 65 patients. Cephalalgia 1994;14:33-6
  5. Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spon- taneous internal carotid and vertebral artery dissections. Neurology 1995; 45:1517-22.
  6. Mokri B, Silbert PL, Schievink WI, Piepgras DG. Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery. Neu- rology 1996;46:356-9
  7. Biousse V, D’Anglejan-Chatillon J, Touboul PJ, Amarenco P, Bousser MG. Time course of symptoms in extracranial carotid artery dissections: a series of 80 patients. Stroke 1995;26:235-9
  8. Crum B, Mokri B, Fulgham J. Spinal manifestations of vertebral artery dissection. Neurology 2000;55:304-6

Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator resus.com.au.

44 Comments

  1. pwrqnmjpeg on 13/09/2021 at 7:33 pm

    Carotid Artery Dissection – Resus
    apwrqnmjpeg
    [url=http://www.gth1srwm8xg986ct7nf07y31860yt030s.org/]upwrqnmjpeg[/url]
    pwrqnmjpeg http://www.gth1srwm8xg986ct7nf07y31860yt030s.org/

  2. https://blackbeargolfcomplex.com on 18/09/2021 at 11:57 am

    I’d like to find out more? I’d want to find out some additional information.

  3. Erectesto XL Male Enhancement on 18/09/2021 at 11:58 am

    Ridiculous story there. What happened after? Thanks!

    Also visit my website … Erectesto XL Male Enhancement

  4. Bioneo Farms CBD Oil on 18/09/2021 at 12:00 pm

    Hello, you used to write fantastic, but the last few posts have
    been kinda boring? I miss your super writings.
    Past few posts are just a bit out of track! come on!

    my web site Bioneo Farms CBD Oil

  5. Max Melt Keto Ingredients on 18/09/2021 at 12:27 pm

    After exploring a few of the blog posts on your web site, I honestly appreciate your technique of writing a
    blog. I added it to my bookmark webpage list and will be checking back soon. Please check out my web
    site too and tell me what you think.

    my website: Max Melt Keto Ingredients

  6. Extreme Keto EFX Review on 18/09/2021 at 12:40 pm

    Wow! Thank you! I continually needed to write on my blog something like that.
    Can I implement a portion of your post to my blog?

    My blog :: Extreme Keto EFX Review

  7. A1 Keto BHB Review on 18/09/2021 at 12:54 pm

    Great blog! Is your theme custom made or did you download it from somewhere?
    A theme like yours with a few simple tweeks would really make my blog stand out.
    Please let me know where you got your theme.
    Thanks

    My site :: A1 Keto BHB Review

  8. Pure CBD Softgels Review on 18/09/2021 at 1:15 pm

    Hello, i feel that i saw you visited my website
    thus i got here to return the want?.I am trying to
    to find issues to enhance my web site!I assume its ok to
    make use of some of your concepts!!

    Also visit my web blog; Pure CBD Softgels Review

  9. GrownMD CBD Review on 18/09/2021 at 1:40 pm

    I was wondering if you ever considered changing the structure of your
    site? Its very well written; I love what youve got to say.
    But maybe you could a little more in the way of content so people could
    connect with it better. Youve got an awful lot of text for only having one or two pictures.
    Maybe you could space it out better?

    Visit my homepage :: GrownMD CBD Review

  10. www.fotosombra.com.br on 18/09/2021 at 2:10 pm

    Wow! Thank you! I always needed to write on my blog something like that.
    Can I take a part of your post to my blog?

    Also visit my homepage :: Testo X Men (http://www.fotosombra.com.br)

  11. Ultra Quick Keto Burn Reviews on 18/09/2021 at 2:30 pm

    I’m impressed, I have to admit. Rarely do I
    come across a blog that’s both educative and entertaining, and let me tell you,
    you have hit the nail on the head. The issue is something too few people are speaking intelligently about.

    I am very happy that I stumbled across this during my hunt for something regarding this.

    My web-site Ultra Quick Keto Burn Reviews

  12. Renew Brite Review on 18/09/2021 at 3:07 pm

    I?m amazed, I must say. Seldom do I encounter a
    blog that?s both educative and interesting, and let me tell you, you’ve hit the nail
    on the head. The issue is something which too few men and women are speaking intelligently
    about. I’m very happy that I came across this in my search
    for something regarding this.

    My blog: Renew Brite Review

  13. http://www.fotosombra.com.br/ on 18/09/2021 at 3:18 pm

    I’m still learning from you, as I’m trying to achieve my goals.
    I certainly love reading everything that is written on your website.Keep
    the stories coming. I loved it!

    My web-site – Mega Male Enhancement Review (http://www.fotosombra.com.br/)

  14. Quick Keto Trim Review on 18/09/2021 at 3:37 pm

    Good post. I learn something totally new and challenging on sites I stumbleupon everyday.
    It will always be useful to read through content from other authors and use something from their web
    sites.

    Here is my page :: Quick Keto Trim Review

  15. Nelson on 20/09/2021 at 1:20 am

    Can you tell us more about this? I’d care to find out some additional information.

  16. Alyssa on 20/09/2021 at 1:53 am

    Hey there! I’m at work surfing around your blog from my
    new apple iphone! Just wanted to say I love reading your blog
    and look forward to all your posts! Keep up the excellent work!

  17. Giuseppe on 20/09/2021 at 5:15 am

    all the time i used to read smaller articles or reviews which also clear
    their motive, and that is also happening with this post
    which I am reading here.

  18. Reyna on 20/09/2021 at 7:00 am

    I know this site provides quality depending posts and extra material, is
    there any other site which presents these kinds of stuff
    in quality?

Leave a Comment