A 25-year-old woman presents with neck pain, headache, nausea, left-sided facial numbness, and an unsteady gait. She says the headache began 7 days earlier shortly after a chiropractic treatment for chronic neck pain. Vital signs are normal; the unsteady gait is noted on ambulation. Noncontrast head CT findings are normal.
Which of these tests should be ordered next?
A. CT angiography of the neck with contrast
B. CT of the neck without contrast
C. Duplex ultrasonography of the carotid arteries
D. Duplex ultrasonography of the vertebral arteries.
The answer is A.
Cervical Artery Dissection
What is it?
Cervical artery dissections is the collective term for dissections of the carotid or vertebral arteries
internal carotid artery is most commonly affected
vertebral artery dissections are uncommon
Dissection of the cervical arteries is a common cause of stroke among young and middle-aged persons.
~ 20% of strokes in the young are caused by carotid artery or vertebral artery dissections in the neck, compared to only 2.5% in older patients
Caused by minor trauma in the setting of neck manipulation (e.g. by a chiropractor) or a minor sports injury. There are some case reports of these injuries occurring from riding roller coasters.
Seen more commonly in patients with connective tissue disorders or vascular pathologies (e.g. HTN, Marfan’s syndrome, fibrocystic dysplasia, etc)
Classic presentations include neck pain and headache that might precede development of neurologic symptoms (hemiplegia, hemisensory loss) by hours or up to 14 days.
Vascular bruits (absence does not exclude dissection, e.g. present in only about 1/3 of carotid dissections)
carotid dissection tends to present with some or all of the following:
anterior neck pain
eye, ear, or face pain
Ipsilateral Horner’s syndrome (due to expansion of the internal carotid artery with compression of sympathetic nerve fibers)
vertebral artery dissectiontends to present with some or all of the following:
posterior neck pain
unilateral facial numbness, dizziness, ataxia, vision disturbances (diplopia), and nausea or vomiting
Diagnosis is via CT angiography of the neck. Although it might take longer to obtain, MRA is also an acceptable diagnostic test.
Anticoagulation with heparin intravenously followed by warfarin.
tPA may be considered in some patients with stroke due to spontaneous extracranial dissection
Endovascular therapies include stenting
usually used for extracranial carotid or vertebral artery dissection when medical management fails or is contraindicated
improved outcomes are associated with reconstitution of flow within 6 hours