See also: [[Neck and spine trauma#Cerebrovascular trauma|Cerebrovascular trauma]] , [[Cervical spine trauma radiology#Blunt Cerebrovascular injury - Denver Criteria|Blunt Cerebrovascular injury - Denver Criteria]] see [dunn - carotid and vertebral artery dissection](x-devonthink-item://78A5FED4-5371-41AF-A891-8290524921DD), [Rosen Carotid and vertebral artery dissection](x-devonthink-item://1781B09F-B327-4348-AA6F-F427FF97CA97?page=9) > in pts <50 years old, cervical artery dissection is the most frequent cause of ischaemic stroke - Risk factors: - Ehlers danlos - autosomal dominant polycystic kidneys - FMx - hyperextension - yoga - chiropractic # internal carotid dissection - ==abrupt onset of pain in the head or neck, often a/w sx resulting from ischaemic consequences of the dissection and emboli== - pain on side of head, face, neck, or orbit - unilateral facial or orbital pain - unilateral headache, usually frontotemporal - pulsitile tinnitus sometimes - partial Horner's syndrome - [[Cranial nerve palsies]], usually lower cranial nerves, especially hypoglossal nerve - impairment in taste, tongue deviations > 1. unilateral headache or neck pain, sometimes radiating to the ipsilateral eye > 2. ipsilateral ptosis and miosis (partial [[pupil exam#Horner Syndrome|horner's syndrome]]) > 3. blindness due to retinal ischemia or contralateral motor deficits caused by cerebral ischaemia # vertebral dissection - pain in back of neck or head - usually *occipital headache* - signs of ==posterior circulation ischaemia== in > 90% - [[vertigo#occlusion of posterior inferior cerebellar artery (wallenberg syndrome)]] - occipital, cerebellar, and brain stem signs # investigations - MRI/MRI replaces conventional angiography as gold standard - irregular vessel margins - filling defects - extravasation of contrast - calibre changes - vascular occlusion - intimal flaps - CT angiography - similar results to MRI; sensitivity approaches 100% - ultrasound - may be useful initially - ==dissection is NOT usually seen; but abnormal flow pattern present in >90% of pts with dissection== (usually high resistance flow pattern) - rarely shows itimal flap, but pathognomonic when present # management **medical** - anticoagulation with heparin and warfarin recommended for all acute dissections - contraindicated if dissection extends intracranially - not much evidence - antiplatelet agents (aspirin, clopidogrel) generally comparably effective at reducing stroke risk, which is [relatively uncommon](cubox://card?id=7165718274485783689) **surgical** - reserved for pts with persistent ischaemia despite adequate anticoagulation - ligation of carotid or vertebral artery, bypass procedure - +/- endovascular stenting # outcomes - can progress to stroke → risks related to severaty of initial ischaemic insult and collateral circulation - 75% of those that stroke have good neurological outcomes - 90% of infarcts following dissection are thromboembolic rather than haemodynamic