Medical Care
Medical therapy should be started immediately for cervicocephalic dissections except in cases of associated with intracranial hemorrhage, large ischemic stroke, or traumatic injuries contraindicating anticoagulation. Anticoagulation therapy typically consists of a heparin drip in the acute period followed by transition to oral agents such as coumadin. Antiplatelet therapy can also be effective. [5]
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. [6] Thus, the role of thrombolysis in patients with acute infarction secondary to dissection is unproven. [7]
No randomized controlled trials have been performed to determine the optimum antithrombotic treatment regimen. Current options include anticoagulants [8] , 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. [9] 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.
Surgical Care
In rare patients with symptoms refractory to medical management, patients with subarachnoid hemorrhage, and those with expanding dissecting aneurysms, or intradural dissections, endovascular therapy or surgical procedures may be indicated. Endovascular procedures include angioplasty and stenting, vessel occlusion by embolization or coiling. In cases where endovascular techniques are not an option, open surgical treatments include vessel occlusion by clipping, vessel clipping followed by bypass, and clipping or wrapping of associated aneurysms.
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Cerebral angiogram of a left internal carotid dissection showing gradual vessel tapering to occlusion.
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Axial T1-weighted MRI demonstrating a crescent sign (arrow) in a patient with a left internal carotid artery dissection.
