eMedicine Specialties > Neurology > Neuro-vascular Diseases

Dissection Syndromes: Differential Diagnoses & Workup

Author: Chelsea S Kidwell, MD, Associate Professor, Department of Neurology, Georgetown University; Medical Director, Washington Hospital Center Stroke Center
Coauthor(s): Richard E Burgess, MD, PhD, Consulting Staff, Department of Neurology, Georgetown University Hospital, Consulting Staff, Suburban Hospital and Washington Hospital Center
Contributor Information and Disclosures

Updated: Dec 15, 2008

Differential Diagnoses

Acute Stroke Management
Migraine Variants
Anterior Circulation Stroke
Moyamoya Disease
Aphasia
Polyarteritis Nodosa
Apraxia and Related Syndromes
Posterior Cerebral Artery Stroke
Cluster Headache
Stroke Anticoagulation and Prophylaxis
Fibromuscular Dysplasia
Syncope and Related Paroxysmal Spells
Frontal Lobe Syndromes
Migraine Headache
Migraine Headache: Neuro-Ophthalmic Perspective

Other Problems to Be Considered

Brainstem syndromes
Giant cell arteritis
Hypertension and stroke
Vertigo
Carotid disease and stroke

Workup

Laboratory Studies

  • Laboratory studies are primarily used to exclude an underlying connective tissue disorder.
  • Studies may include erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), alpha 1-antitrypsin, and homocysteine level.

Imaging Studies

  • Historically, catheter angiography has been considered the criterion standard for diagnosing cervicocephalic dissections. A variety of abnormal patterns may be seen (see Media file 1). The diagnosis is confirmed if an intimal flap or double-barrel lumen (secondary to a dissecting aneurysm) is seen.
  • Frequently, only irregular vessel narrowing may be found, often with a string sign, gradual vessel tapering, and/or distal embolic occlusions. While these findings may suggest an underlying dissection, in some patients they may not be diagnostic. Evidence of fibromuscular dysplasia or vessel tortuosity also may be found, suggesting an underlying predisposing condition.
  • Brain magnetic resonance imaging (MRI) may be normal or show evidence of infarction related to the dissection. Magnetic resonance angiography (MRA) may show patterns similar to those on catheter angiography, but this study is frequently not as sensitive. Axial T1 sequences through the vessel lumen may be particularly helpful in confirming diagnosis, especially if a crescent sign (elliptical bright signal within a vessel wall that surrounds a signal flow void) is visualized (see Media file 2).
  • Computed tomography angiography (CTA) may show patterns similar to those seen on MRA or catheter angiography.
  • In proximal carotid dissections, carotid duplex ultrasonography most commonly shows evidence of a distal severe stenosis or occlusion. Occasionally, a double lumen may be visualized on B mode imaging.
  • Transcranial Doppler studies may demonstrate collateral flow patterns or evidence of microemboli.

Procedures

  • Lumbar puncture may be performed in selected patients with intracranial vessel dissections to exclude subarachnoid hemorrhage.
  • Connective tissue biopsy may be performed in patients in whom an underlying connective tissue disorder is suspected.

Histologic Findings

Pathologic specimens commonly demonstrate evidence of an intramural hematoma. In some patients, evidence of an underlying connective tissue disorder or arteriopathy may be identified.

More on Dissection Syndromes

Overview: Dissection Syndromes
Differential Diagnoses & Workup: Dissection Syndromes
Treatment & Medication: Dissection Syndromes
Follow-up: Dissection Syndromes
Multimedia: Dissection Syndromes
References
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References

  1. Arnold M, Kappeler L, Georgiadis D, et al. Gender differences in spontaneous cervical artery dissection. Neurology. Sep 26 2006;67(6):1050-2. [Medline].

  2. Arnold M, Bousser MG, Fahrni G, et al. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke. Oct 2006;37(10):2499-503. [Medline].

  3. Beletsky V, Nadareishvili Z, Lynch J, et al. Cervical arterial dissection: time for a therapeutic trial?. Stroke. Dec 2003;34(12):2856-60. [Medline].

  4. Benninger DH, Georgiadis D, Kremer C, et al. Mechanism of ischemic infarct in spontaneous carotid dissection. Stroke. Feb 2004;35(2):482-5. [Medline].

  5. Bogousslavsky J. Dissections of the cerebral arteries: clinical effects. Curr Opin Neurol Neurosurg. 1988;1:63-8.

  6. Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. Oct 2003;250(10):1179-84. [Medline].

  7. Georgiadis D, Caso V, Baumgartner RW. Acute therapy and prevention of stroke in spontaneous carotid dissection. Clin Exp Hypertens. Apr-May 2006;28(3-4):365-70. [Medline].

  8. Georgiadis D, Lanczik O, Schwab S. IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection. Neurology. May 10 2005;64(9):1612-4. [Medline].

  9. Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev. 2003;CD000255. [Medline].

  10. Provenzale JM. Dissection of the internal carotid and vertebral arteries: imaging features. AJR Am J Roentgenol. Nov 1995;165(5):1099-104. [Medline].

  11. Rubinstein SM, Peerdeman SM, van Tulder MW, et al. A systematic review of the risk factors for cervical artery dissection. Stroke. Jul 2005;36(7):1575-80. [Medline].

  12. Schievink WI, Mokri B, Whisnant JP. Internal carotid artery dissection in a community. Rochester, Minnesota, 1987-1992. Stroke. Nov 1993;24(11):1678-80. [Medline].

  13. Schievink WI, Mokri B, O'Fallon WM. Recurrent spontaneous cervical-artery dissection. N Engl J Med. Feb 10 1994;330(6):393-7. [Medline].

  14. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. May 13 2003;60(9):1424-8. [Medline].

  15. Zweifler RM, Silverbord G. Arterial Dissections. In: Stroke: Pathophysiology, Diagnosis, and Management. 4th ed. Netherlands: Elsevier Health Sciences; 2004:549-73.

  16. Vertinsky AT, Schwartz NE, Fischbein NJ, Rosenberg J, Albers GW, Zaharchuk G. Comparison of multidetector CT angiography and MR imaging of cervical artery dissection. AJNR Am J Neuroradiol. Oct 2008;29(9):1753-60. [Medline].

  17. Menon R, Kerry S, Norris JW, Markus HS. Treatment of cervical artery dissection: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. Oct 2008;79(10):1122-7. [Medline].

  18. Menon RK, Markus HS, Norris JW. Results of a UK questionnaire of diagnosis and treatment in cervical artery dissection. J Neurol Neurosurg Psychiatry. May 2008;79(5):612. [Medline].

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Further Reading

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Keywords

alpha-1-antitrypsin deficiency, basilar artery dissection, cervical dissection, connective tissue disorders, cystic medial necrosis, Ehlers-Danlos syndrome, extracranial internal carotid artery dissection, extracranial vertebral artery dissection, intracranial internal carotid artery dissection, intracranial vertebral artery dissection, Marfan syndrome, meningovascular syphilis, middle cerebral artery dissection, moyamoya disease, type 1 collagen point mutation, dissection syndromes

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Contributor Information and Disclosures

Author

Chelsea S Kidwell, MD, Associate Professor, Department of Neurology, Georgetown University; Medical Director, Washington Hospital Center Stroke Center
Chelsea S Kidwell, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Society of Neuroimaging, and National Stroke Association
Disclosure: Nothing to disclose.

Coauthor(s)

Richard E Burgess, MD, PhD, Consulting Staff, Department of Neurology, Georgetown University Hospital, Consulting Staff, Suburban Hospital and Washington Hospital Center
Richard E Burgess, MD, PhD is a member of the following medical societies: American Academy of Neurology and American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

William J Nowack, MD, Associate Professor, Department of Neurology, Epilepsy Center, University of Kansas Medical Center
William J Nowack, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Electroencephalographic Association, American Medical Informatics Association, and Biomedical Engineering Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Novartis Consulting fee Review panel membership

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Boston Scientific Honoraria Speaking and teaching; Concentric Medical None Review panel membership; Northstar Neuroscience  Review panel membership; ev3 Consulting fee Review panel membership

 
 
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