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:
- Pain to one side of the head, face or neck
- Ipsilateral neck pain occurs in 25% of cases(4)
- Ipsilateral facial or orbital pain is present in about 50% of cases(5)
- Headache can involve the whole head, the front-temporal area or the occipital area(5)
- In most cases the headache is gradual, but it can be ‘thunderclap’ in nature.
- Partial Horner’s Syndrome (oculosympathetic palsy)
- Miosis and Ptosis occurs in < 50% of cases(50)
Horner’s Syndrome. Source mrcophth.com
- Miosis and Ptosis occurs in < 50% of cases(50)
- Cerebral or Retinal ischaemia signs, which manifest days to weeks later.
- 20% have an ischaemic stroke without warning(7)
- 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.
- Neck Pain(7)
- This is usually posterior neck pain in 50% of patients.
- Headache(7)
- It occurs in 60% of patients
- It is almost always occipital.
- Ischaemia
- Transient ischaemic attacks do not occur as often as with carotid artery dissections.
- 90% will have ischaemic symptoms
- These will be of the brain stem (lateral medulla), thalamus, cerebral or cerebellar hemispheres
- Lateral Medullary Syndrome known as Wallenberg’s syndrome will involve:
- Sensory Symptoms
- Ipsilateral pain and temperature Deficits of the face and cranial nerves
- Contralateral pain and temperature deficits of the torso. This crossing of pain and temperature loss, helps in making the diagnosis
- Vestibulo-cerebellar Symptoms
- Multidirectional nystagmus
- Diplopia
- Vertigo
- Autonomic Dysfunction
- Ipsilateral Horner’s Syndrome
- Ipsilateral Bulbar muscle weakness
- Dyspohonia
- Dysphagia
- Dysarthria
- Sensory Symptoms
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
- Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001;344(12):898-906
- Kratz SN, Butke KH. Vertebreal artery dissection presenting as acute cerebrovascular accident. J Emerg Med. 2011;40(2):151-7.
- 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.
- 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
- Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spon- taneous internal carotid and vertebral artery dissections. Neurology 1995; 45:1517-22.
- 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
- 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
- Crum B, Mokri B, Fulgham J. Spinal manifestations of vertebral artery dissection. Neurology 2000;55:304-6
Carotid Artery Dissection – Resus
apwrqnmjpeg
[url=http://www.gth1srwm8xg986ct7nf07y31860yt030s.org/]upwrqnmjpeg[/url]
pwrqnmjpeg http://www.gth1srwm8xg986ct7nf07y31860yt030s.org/
Tiffanyティファニースーパーコピー
Epdm Rubber
Gucciグッチ財布コピー
Box Lunch Bags
I’d like to find out more? I’d want to find out some additional information.
Ridiculous story there. What happened after? Thanks!
Also visit my website … Erectesto XL Male Enhancement
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
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
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
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
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
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
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)
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
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
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/)
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
スーパーコピーブランド
30 Egg Tray
ブランド財布コピー
Highway Road Marking Machine
ブランドコピー代引き
Abs Plastic Injection Molding
Can you tell us more about this? I’d care to find out some additional information.
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!
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.
I know this site provides quality depending posts and extra material, is
there any other site which presents these kinds of stuff
in quality?
22-year-old charged in seizure of 77,000 THC-loaded vape cartridges – StarTribune.com
スーパーコピーバッグ
ブランドコピー専門店
Electric Bikes For Adults
ブランドバッグコピー
Isolation Gown Aami Level 3
コピー時計
Stainless Steel Trim Strips
Automatic snack Machine
BottegaVenetaボッテガヴェネタバッグコピー
Pradaプラダ靴コピー
Axyprep Dna Gel Extraction Kit
Chinese Quartz
Fendiフェンディバッグスーパーコピー
4 Inch Concrete Core Bit
スーパーコピーブランド
ブランドDIORディオール指輪コピー代引き
10kg Dumbbell
ブランドコピーPaneraiパネライN級品
Diaphragm Pump
ブランドChanelシャネル靴コピー代引き
Portable Induction Heater
portalet for sale
LouisVuittonルイヴィトン指輪販売店
ブランドFendiフェンディバッグコピーN級品
3d curved wire mesh fence
Bullshooter Dart Machine For Sale
ブランドネックレススーパーコピー
LouisVuittonルイヴィトンサングラスコピー
Hip Hop Cap Monster
ブランドGucciグッチベルトコピーN級品
Melt Blown Production Machine
Hermesエルメスマフラースーパーコピー
Angel Monument
bandstop filter
コピー時計
スーパーコピーバッグ
Metal Beveling Machine
Large Biodegradable Plant Pots
0798007880
スーパーコピーバッグ
22448-2Y000
ブランド財布コピー
6 Well Casing