Here's a fun one for you trauma addicts out there- something we maybe don't think of enough but see quite often during our Shock Trauma rotation (especially when it's actively being looked for).
Cervical Artery DISSECTION:
* Who, when?
- Spontaneous vs Traumatic: likely all are traumatic just unrecognized
= Any and all physical activity may be implicated
= Usually 2-3d after trauma
- Carotid > Vertebral dissection rates; traumatic dissections 1/1000 trauma patients
- 20% of strokes in patients <45yo
- Consider it especially in young patients with recent trauma, high risk activity, intense sneezing (!), spinal manipulation or hx of collagen dz
= pain to head/face/neck is present in 80% of cases
= carotid bruit in only 30% of cases
* What? This says it all to me.
- Carotid: most commonly 2cm below carotid bifurcation at skull base (C2-3)
- Vertebral: at the foramen magnum 2/2 compression (C1-2)
= Prior to screening, had 50% mortality rate with 50% of the survivors having severe morbidity
= Now mortality 10-15% with 30% morbidity
- No RCTs to assess safety of TPA on these patients;
- No agreement on exact treatment; usually anticoagulation followed by antiplatelet med andendovascular intervention; d/c home 6months anticoagulation w/ follow up imaging; usually follows EAST recommendations (below)