Dissection Syndromes Treatment & Management

  • Author: Chelsea S Kidwell, MD; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: Sep 19, 2011
 

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[3] , 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.[4]
  • 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.
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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.

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Contributor Information and Disclosures
Author

Chelsea S Kidwell, MD  Professor, Department of Neurology, Georgetown University; Medical Director, Georgetown University 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  Assistant Professor, Department of Neurology, Georgetown University Hospital; Medical Director, Clinical Stroke Service

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.

Specialty Editor Board

William J Nowack, MD  Associate Professor, Epilepsy Center, Department of Neurology, 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD  Professor, Department of Neurology, Oregon Health and Science University School of Medicine; 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; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

Additional Contributors

I would like to thank Jeffrey L. Saver, MD, for his thoughtful review of this article.

References

  1. Debette S, Grond-Ginsbach C, Bodenant M, Kloss M, Engelter S, Metso T, et al. Differential features of carotid and vertebral artery dissections: The CADISP Study. Neurology. Sep 7 2011;[Medline].

  2. Paciaroni M, Bogousslavsky J. Cerebrovascular complications of neck manipulation. Eur Neurol. 2009;61(2):112-8. [Medline].

  3. Kim YK, Schulman S. Cervical artery dissection: pathology, epidemiology and management. Thromb Res. Apr 2009;123(6):810-21. [Medline].

  4. Engelter ST, Rutgers MP, Hatz F, Georgiadis D, Fluri F, Sekoranja L. Intravenous thrombolysis in stroke attributable to cervical artery dissection. Stroke. Dec 2009;40(12):3772-6. [Medline].

  5. Arauz A, Márquez JM, Artigas C, Balderrama J, Orrego H. Recanalization of vertebral artery dissection. Stroke. Apr 2010;41(4):717-21. [Medline].

  6. Arnold M, Kurmann R, Galimanis A, Sarikaya H, Stapf C, Gralla J, et al. Differences in demographic characteristics and risk factors in patients with spontaneous vertebral artery dissections with and without ischemic events. Stroke. Apr 2010;41(4):802-4. [Medline].

  7. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. Jul 2009;8(7):668-78. [Medline].

  8. Debette S, Markus HS. The genetics of cervical artery dissection: a systematic review. Stroke. Jun 2009;40(6):e459-66. [Medline].

  9. Georgiadis D, Arnold M, von Buedingen HC, Valko P, Sarikaya H, Rousson V. Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients. Neurology. May 26 2009;72(21):1810-5. [Medline].

  10. Schwartz NE, Vertinsky AT, Hirsch KG, Albers GW. Clinical and radiographic natural history of cervical artery dissections. J Stroke Cerebrovasc Dis. Nov-Dec 2009;18(6):416-23. [Medline].

 
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Cerebral angiogram of a left internal carotid dissection showing gradual vessel tapering to occlusion.
Axial T1-weighted MRI demonstrating a crescent sign (arrow) in a patient with a left internal carotid artery dissection.
 
 
 
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