Arterial Dissections

FACTS

Epidemiology

M > F, median age 45

Pathophysiology of stroke

Most commonly: embolization 2/2 platelet aggregation: nick in arterial wall --> creates prothrombogenic area that produces embolus

tear is big enough that flap narrows artery, so not just embolic, but produces hemodynamic, flow-limiting stenosis

pseudoaneurysm

if extracranial (petrous, cervical): low-risk, just treat with aspirin, rarely intervene unless mass effect
if intracranial (rare, can be spontaneous or due to trauma): generally, do NOT put on AC, you worry if they get a pseudoaneurysm that they rupture

tx is coil off artery if have good contralateral, or reconstruct with pipeline (treats dissection and covers the whole)

HPI

Any neck manipulations (chiropractor, yoga, pilates)

Any connective tissue disease

fibromuscular dysplasia
Marfan syndrome
EDS
atherosclerosis
Takayasu's disease
syphillitic arteritis
Moya moya disease

Strenuous physical activity (body builder, elite athlete)

Any contrast allergies? hives vs. anaphylaxis?

Spontaneous VA dissections: FMD, migraine, OCPs

Any trauma, including trivial

simple neck turning, violent coughing, nose blowing (esp. if young women)

PHYSICAL EXAM

Complete stroke exam, include speech

ICA:

ipsilateral HA (orbital/periorbital vs. auricular/mastoid)

carotidynia

incomplete Horner's (oculosympathetic palsy): ptosis and miosis w/o anhyidrosis (plexus around ECA = facial sweat glands is spared)

neck swelling

scalp tenderness

syncope

amaurosis fugax

Vertebral

neck pain (over occiput/posterior cervical region)

TIAs/stroke

IMAGING

CTH: evaluate for SAH, more common in posterior circulation > anterior circulation dissections

A/P

CTA H&N to eval lesion

MRI Brain w/o to eval for strokes

MRA also option to eval lesion - this is a noncontrast study, just a time of flight technique so may as well get while pt in scanner

Stroke c/s - usually manage spontaneous dissections

#1 medical therapy: Likely ASA81 vs. Heparinization --> warfarin/DOAC (if pending procedures)

DSA not necessarily indicated - injection can even worsen flap; endovascular treatment w/ balloons/stents can be done

Monitor for re-rupture (0-3 weeks is highest risk)

Tx paradigm:

1. embolus: typically, antiplatelet is adequate, if active thrombus in lumen: high risk emboli = anticoagulation

2. hemodynamic and symptomatic: need stent

Associated Syndromes

PCKD, Marfan Syndrome