Dissection Syndromes Clinical Presentation

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

History

The most frequent presenting complaints with cervicocephalic dissections are ischemic symptoms that include transient ischemic attack (TIA) or stroke (cerebrovascular accident).

Up to two thirds of patients complain of ipsilateral neck, scalp, or head pain, occurring in both carotid and vertebral artery dissections.

Up to one fourth of patients report pulsatile tinnitus or a subjective bruit, particularly with carotid artery dissections.

In a large, pooled, observational study of 982 patients with cervical artery dissections, significant differences were observed in patients with internal carotid artery dissections (ICAD) compared to vertebral artery dissections (VAD). Most notably, patients with ICAD were older, more often men, more frequently had a recent infection, and less frequently had cerebral ischemia. In contrast, patients with VAD more frequently reported a history of neck trauma and cervical pain and less frequently presented with headache. Of those patients with cerebral ischemia, ICAD patients had more severe baseline National Institutes of Health Stroke Scale scores. [1]

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Physical

Extracranial carotid artery

Cerebral ischemia occurs in at least 75% of reported cases (TIAs in 30%, infarcts in 45-50%).

Neurologic deficits reflect the ultimate site of ischemia in the ipsilateral anterior circulation.

In extracranial carotid dissections, local symptoms may occur as the intramural hematoma expands outward, compressing local structures.

Examination findings may include the following:

  • Ipsilateral partial Horner syndrome (32-82% of patients in various series)
  • Ipsilateral cranial nerve palsies, particularly cranial nerves IX, X, XI, and XII (5-12% of patients in various series)
  • Audible bruit (up to 20% of patients)

Intracranial carotid artery

Patients with intracranial carotid dissections usually present with headache followed by a major ischemic stroke.

Some patients initially may present with a seizure, syncope, or altered level of consciousness.

One fifth of patients develop subarachnoid hemorrhage.

Extracranial vertebral artery

  • This dissection is characterized by headache (often occipital) or neck pain and signs of ischemia in the posterior circulation.
  • Infarcts in the territory of the posterior inferior cerebral artery (commonly with a lateral medullary syndrome) are frequent.

Intracranial vertebrobasilar dissection

This dissection may present with symptoms of posterior circulation ischemia (particularly brainstem), subarachnoid hemorrhage (occurs in one half of patients), or both.

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Causes

Major blunt trauma to the head and neck can produce cervicocephalic dissection. In spontaneous dissections (dissection in absence of major trauma), a history of minor trauma is a precipitating factor in at least 25% of dissections. The CADISP study group reported that 40.5% of cervical artery dissection patients had prior cervical trauma, which was mild in 88% of cases.

Types of trauma associated with cervicocephalic dissections include chiropractic neck manipulations [2] , sporting activities, coughing, sneezing, sexual activity, and more intense forms of blunt trauma (eg, motor vehicle accidents, falls, strangulation, hanging).

Arteriopathies have been associated with cervicocephalic dissections.

  • Fibromuscular dysplasia (the most common underlying arteriopathy, found in as many as 15% of patients)
  • Extreme vessel tortuosity
  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • Alpha-1-antitrypsin deficiency
  • Cystic medial necrosis
  • Type 1 collagen point mutation
  • Other connective tissue disorders
  • Moyamoya disease
  • Meningovascular syphilis

Associations also have been reported with systemic infections, hypertension, migraine, elevated homocysteine levels, alcohol use, and oral contraceptive use. Hypercholesterolemia and obesity have been reported to be inversely associated with cervical artery dissection.

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