Carotid artery dissection

Carotid artery dissection

Carotid artery dissection occurs when a tear in the arterial intima allows blood to enter and split the vessel wall, creating a false lumen

tear in the arterial intima allows blood to enter and split the vessel wall, creating a false lumen

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. It is an important, potentially reversible cause of stroke in younger adults and should be considered in patients presenting with head or neck pain, neurological deficits or signs of sympathetic disruption following minor trauma.

Causes and risk factors

• Blunt trauma or rapid neck movement (e.g. whiplash)
• Connective tissue disorders (e.g. Ehlers–Danlos, Marfan syndrome)
• Recent upper respiratory infection or coughing bouts
• Fibromuscular dysplasia
• Hypertension
• Spontaneous cases with no clear precipitant

Pathophysiology

• Intimal tear allows blood to enter the vessel wall
  Intimal tear allows blood to enter the vessel wall
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  , forming a haematoma
• Narrowing of the true lumen reduces cerebral perfusion
• Thrombus formation at the dissection site may embolise distally
• Compression of adjacent sympathetic fibres can produce Horner’s syndrome

Features

• Unilateral neck pain or headache, often sudden in onset
  A new, painful Horner’s syndrome (ptosis, miosis, anhidrosis sparing the forehead) should be considered carotid artery dissection until proven otherwise
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  Importance: 87
• Ipsilateral Horner’s syndrome (ptosis, miosis, anhidrosis sparing the forehead)
• Transient ischaemic attack or stroke symptoms, especially in young or otherwise low-risk patients
  Carotid artery dissection is a leading cause of stroke in younger adults and should be considered even after minor neck trauma
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  Importance: 54
• Pulsatile tinnitus
• Possible preceding neck trauma or manipulation, including minor trauma

Investigations

• CT angiography of head and neck (first-line in most UK emergency settings)
  CT angiography of the head and neck is the first-line investigation for suspected carotid artery dissection
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  Importance: 68
• MRI/MRA with fat-suppressed sequences to visualise mural haematoma
• Duplex ultrasound (limited sensitivity, supportive if positive)
• Stroke/TIA workup including ECG, blood tests and risk factor assessment

Management

• Antithrombotic therapy: antiplatelet therapy is first-line for most; anticoagulation used selectively based on specialist advice
  Initial management of carotid artery dissection is antithrombotic therapy, with antiplatelets preferred first-line unless there is a specific indication for anticoagulation
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  Importance: 47
• BP control and vascular risk optimisation
• Neurology or stroke specialist input for all suspected cases
• Endovascular or surgical intervention only in rare cases (e.g. worsening neurological deficit despite treatment, expanding pseudoaneurysm)
• Avoid high-impact neck manipulation during recovery

+PassMedicine Notes

Carotid artery dissection occurs when a tear in the arterial intima allows blood to enter and split the vessel wall, creating a false lumen. It is an important, potentially reversible cause of stroke in younger adults and should be considered in patients presenting with head or neck pain, neurological deficits or signs of sympathetic disruption following minor trauma.

Causes and risk factors

• Blunt trauma or rapid neck movement (e.g. whiplash)
• Connective tissue disorders (e.g. Ehlers–Danlos, Marfan syndrome)
• Recent upper respiratory infection or coughing bouts
• Fibromuscular dysplasia
• Hypertension
• Spontaneous cases with no clear precipitant

Pathophysiology

• Intimal tear allows blood to enter the vessel wall, forming a haematoma
• Narrowing of the true lumen reduces cerebral perfusion
• Thrombus formation at the dissection site may embolise distally
• Compression of adjacent sympathetic fibres can produce Horner’s syndrome

Features

• Unilateral neck pain or headache, often sudden in onset
• Ipsilateral Horner’s syndrome (ptosis, miosis, anhidrosis sparing the forehead)
• Transient ischaemic attack or stroke symptoms, especially in young or otherwise low-risk patients
• Pulsatile tinnitus
• Possible preceding neck trauma or manipulation, including minor trauma

Investigations

• CT angiography of head and neck (first-line in most UK emergency settings)
• MRI/MRA with fat-suppressed sequences to visualise mural haematoma
• Duplex ultrasound (limited sensitivity, supportive if positive)
• Stroke/TIA workup including ECG, blood tests and risk factor assessment

Management

• Antithrombotic therapy: antiplatelet therapy is first-line for most; anticoagulation used selectively based on specialist advice
• BP control and vascular risk optimisation
• Neurology or stroke specialist input for all suspected cases
• Endovascular or surgical intervention only in rare cases (e.g. worsening neurological deficit despite treatment, expanding pseudoaneurysm)
• Avoid high-impact neck manipulation during recovery