Dissection Syndromes Workup

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

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.
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Imaging Studies

  • Historically, catheter angiography has been considered the criterion standard for diagnosing cervicocephalic dissections. A variety of abnormal patterns may be seen (see image below). The diagnosis is confirmed if an intimal flap or double-barrel lumen (secondary to a dissecting aneurysm) is seen. Cerebral angiogram of a left internal carotid dissCerebral angiogram of a left internal carotid dissection showing gradual vessel tapering to occlusion.
  • 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 image below). Axial T1-weighted MRI demonstrating a crescent sigAxial T1-weighted MRI demonstrating a crescent sign (arrow) in a patient with a left internal carotid artery dissection.
  • 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.
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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.
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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.

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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

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  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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