eMedicine Specialties > Neurology > Neuro-vascular Diseases
Dissection Syndromes: Treatment & Medication
Updated: Dec 15, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Patients with symptoms of cerebral ischemia generally should be admitted to a monitored bed. Provide supportive stroke care (eg, intravenous fluids, prevention of hyperglycemia).
- Patients presenting within 3 hours of stroke symptom onset may be considered for treatment with intravenous tissue plasminogen activator. Several case series have reported that local complications such as extension of the wall hematoma did not occur. Prospective studies are needed to determine the safety and efficacy of thrombolytic therapy in the setting of cervicocephalic dissection.
- No randomized controlled trials have been performed to determine optimum treatment. Current options include anticoagulants, antiplatelet agents, and surgical and/or endovascular treatment.
- Since most ischemic strokes caused by dissections are likely to be due to emboli originating from a thrombus at the site of dissection, many experts recommend anticoagulation for the first 3-6 months. This practice is supported by several small case series demonstrating good outcome with low complication rates in patients receiving anticoagulation. However, no data are available to determine if antiplatelet therapy is as effective as or superior to anticoagulation, and a clinical trial that sufficiently answers this question is unlikely due to the low rate of recurrent ischemic events in patients with dissection.
- Anticoagulation is contraindicated in intracranial dissections complicated by subarachnoid hemorrhage.
- The role of thrombolysis in patients with acute infarction secondary to dissection is unproven.
- In patients with hemodynamically significant dissections, hypertensive and/or hypervolemic therapy may be initiated.
- Some experts recommend avoidance of oral contraception and hormonal replacement therapy in patients with cervicocephalic dissections, since these agents may promote intimal proliferation.
- Repeat imaging (angiography, MRA, CTA) generally is recommended at 3-6 months. In most patients, the vessel wall is fully healed at that time; thus, patients may be switched to aspirin. Alternatively, all therapy may be discontinued.
Surgical Care
In rare patients with symptoms refractory to medical management, patients with subarachnoid hemorrhage, and those with expanding dissecting aneurysms, endovascular therapy or surgical procedures may be indicated. These procedures include angioplasty and stenting, vessel occlusion by embolization, vessel coiling or ligations, and bypass procedures.
Medication
The goals of pharmacotherapy are to prevent complications and to reduce morbidity.
Anticoagulants
These agents are used to prevent thromboembolisms.
Heparin
Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin; does not actively lyse but is able to inhibit further thrombogenesis; prevents reaccumulation of a clot after spontaneous fibrinolysis.
Adult
Adjusted for goal aPTT 1.5-2.0 X control; administered IV
Pediatric
Administer as in adults
Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; conversely, NSAIDs, aspirin, dextran, dipyridamole, warfarin, and hydroxychloroquine may increase toxicity
Documented hypersensitivity; subacute bacterial endocarditis; coagulopathy; active bleeding; history of heparin-induced thrombocytopenia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Some preparations contain benzyl alcohol as a preservative and when used in large amounts may be associated with fetal toxicity (gasping syndrome); use of preservative-free heparin is recommended in neonates; caution in patients with shock or severe hypotension
Warfarin (Coumadin)
Interferes with hepatic synthesis of vitamin K–dependent coagulation factors; used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders.
Adult
Adjusted for goal INR of 2-3; administered PO
Pediatric
Administer as in adults
Many medications may impact warfarin activity; those that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate; some medications that may increase anticoagulant effects include oral antibiotics, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen, and sulindac
Documented hypersensitivity; severe liver or kidney disease; open wounds; GI ulcers
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Do not switch brands after achieving therapeutic response; caution with active tuberculosis or diabetes; patients with protein C or S deficiency are also at risk of developing skin necrosis
Antiplatelet agents
These agents prevent thromboembolism.
Aspirin (Anacin, Ascriptin, Bayer Aspirin, Bayer Buffered Aspirin)
Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A-2.
Adult
81-1300 mg/d PO; standard adult dose is 325 mg
Pediatric
81 mg/d PO
Antacids and urinary alkalinizers can decrease effects; conversely, corticosteroids increase clearance and decrease serum levels; when administered concurrently with other anticoagulants, can have additive hypoprothrombinemic effect and may increase bleeding time; also may antagonize probenecid's uricosuric effects and increase free phenytoin and valproic acid levels, increasing their toxicity; in doses > 2 g/d, may alter pancreatic beta-cell function and potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; caution with liver damage, hypoprothrombinemia, coagulopathy, vitamin K deficiency, bleeding disorders, and asthma; because of association of aspirin with Reye syndrome, do not use in children who have the flu and are younger than 16 y
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution with chronic renal insufficiency, since may cause transient decrease in renal function and may aggravate chronic kidney diseases; extreme caution in patients with severe anemia, those with a history of blood coagulation defects, and those on anticoagulants
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
Arnold M, Kappeler L, Georgiadis D, et al. Gender differences in spontaneous cervical artery dissection. Neurology. Sep 26 2006;67(6):1050-2. [Medline].
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].
Beletsky V, Nadareishvili Z, Lynch J, et al. Cervical arterial dissection: time for a therapeutic trial?. Stroke. Dec 2003;34(12):2856-60. [Medline].
Benninger DH, Georgiadis D, Kremer C, et al. Mechanism of ischemic infarct in spontaneous carotid dissection. Stroke. Feb 2004;35(2):482-5. [Medline].
Bogousslavsky J. Dissections of the cerebral arteries: clinical effects. Curr Opin Neurol Neurosurg. 1988;1:63-8.
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].
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].
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].
Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev. 2003;CD000255. [Medline].
Provenzale JM. Dissection of the internal carotid and vertebral arteries: imaging features. AJR Am J Roentgenol. Nov 1995;165(5):1099-104. [Medline].
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].
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].
Schievink WI, Mokri B, O'Fallon WM. Recurrent spontaneous cervical-artery dissection. N Engl J Med. Feb 10 1994;330(6):393-7. [Medline].
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].
Zweifler RM, Silverbord G. Arterial Dissections. In: Stroke: Pathophysiology, Diagnosis, and Management. 4th ed. Netherlands: Elsevier Health Sciences; 2004:549-73.
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].
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].
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].
Further Reading
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
