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Dissection Syndromes Treatment & Management

  • Author: Chelsea S Kidwell, MD; Chief Editor: Helmi L Lutsep, MD  more...
 
Updated: Dec 08, 2015
 

Medical Care

Patients with symptoms of cerebral ischemia generally should be admitted to a monitored bed and provided supportive stroke care (eg, intravenous fluids, prevention of hyperglycemia).

Patients presenting within 3-4 1/2 hours of stroke symptom onset may be considered for treatment with intravenous tissue plasminogen activator. A growing number of studies have suggested that there is not an increased rate of symptomatic hemorrhage or unfavorable outcomes in this population. However, the CADISP co-investigators also failed to find any trend towards benefit in dissection patients treated with thrombolysis compared with those not treated.[3] Thus, the role of thrombolysis in patients with acute infarction secondary to dissection is unproven.[4]

No randomized controlled trials have been performed to determine the optimum antithrombotic treatment regimen. Current options include anticoagulants[5] , 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 from a randomized, controlled trial are available to determine if antiplatelet therapy is as effective as or superior to anticoagulation. In the nonrandomized arm of the Cervical Artery Dissection Stroke Study (CADISS-NR), there was no evidence for superiority of anticoagulation or antiplatelet therapy in prevention of stroke.[6] However, mean time to treatment from symptom onset in this study was 10.8 days, which may have been beyond the window of highest risk.

Anticoagulation is contraindicated in intracranial dissections complicated by subarachnoid hemorrhage.

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, University of Arizona College of Medicine

Chelsea S Kidwell, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Society of Neuroimaging, National Stroke Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Additional Contributors

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, Biomedical Engineering Society, American Clinical Neurophysiology Society, American Epilepsy Society, EEG and Clinical Neuroscience Society, American Medical Informatics Association

Disclosure: Nothing to disclose.

Acknowledgements

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.

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. 2011 Sep 7. [Medline].

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

  3. Engelter ST, Dallongeville J, Kloss M, Metso TM, Leys D, Brandt T, et al. Thrombolysis in cervical artery dissection--data from the Cervical Artery Dissection and Ischaemic Stroke Patients (CADISP) database. Eur J Neurol. 2012 Sep. 19(9):1199-206. [Medline].

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

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

  6. Kennedy F, Lanfranconi S, Hicks C, Reid J, Gompertz P, Price C, et al. Antiplatelets vs anticoagulation for dissection: CADISS nonrandomized arm and meta-analysis. Neurology. 2012 Aug 14. 79(7):686-9. [Medline].

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

  8. 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. 2010 Apr. 41(4):802-4. [Medline].

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

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

  11. 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. 2009 May 26. 72(21):1810-5. [Medline].

  12. Schwartz NE, Vertinsky AT, Hirsch KG, Albers GW. Clinical and radiographic natural history of cervical artery dissections. J Stroke Cerebrovasc Dis. 2009 Nov-Dec. 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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