Emergency department management
The management of patients diagnosed with cervical artery dissection begins with evaluation of candidacy for fibrinolytic therapy with tissue plasminogen activator (tPA). This should be done in consultation with a neurologist. Dissection patients were included in the National Institute of Neurological Disorders and Stroke IV tPA trial (NINDS).11 No adverse bleeding events were seen. There was slightly less neurologic improvement seen in the dissection group compared with the non-dissection group (but still greater than the control group). Most patients with dissection present much later than the 3-hour symptom window for tPA, and the dissection must be limited to extra-cranial vessels in order for tPA to be considered. Emerging research suggests that endovascular stenting may also improve neurologic outcomes in dissection patients in the acute phase of stroke.12 Admit all patients with cervical artery dissection to a telemetry-monitored hospital bed, as even patients who are relatively asymptomatic from their dissection may progress to ischemic stroke with devastating neurologic deficits.
The long-term treatment of cervical artery dissections is anti-platelet therapy with aspirin 325 mg daily or anticoagulation with warfarin with a goal INR 2-3 for 3-6 months. Both have been shown to reduce the progression to ischemic stroke. No study has ever shown a significant advantage of anticoagulation over anti-platelet therapy.13 In one study, treatment of traumatic dissection with anti-platelet or anticoagulant therapy reduced the incidence of stroke from 64% to 6.8% for carotid dissection and from 54% to 2.6% for vertebral dissection.14 If the patient is not a candidate for tPA, then a heparin drip should be started in the ED. Once the patient is admitted, the neurologist can then determine whether the patient will ultimately be on aspirin or warfarin. Blood pressure goals in the acute setting have not been clearly established, but pilot studies recommend permissive hypertension of the systolic blood pressure up to 200 mm Hg.4
Headache and neck pain are common chief complaints in the emergency department. While they are usually of benign etiology, they might represent early symptoms of a cervical arterial dissection. Dissection needs to be considered in any young patient who presents with neurologic symptoms or signs. Important clinical clues that suggest dissection include any focal neurologic deficit in the setting of headache, facial pain, or neck pain. A partial Horner syndrome should heighten your suspicion. In every case, emergency physicians should question patients about any preceding trauma, and be sure to tell them it doesn’t matter how trivial that trauma might seem. Typical screening tests like non-contrast CT and lumbar puncture may miss an uncomplicated dissection. When dissection is suspected, CTA neck is the next appropriate test. Making the diagnosis is critical, as progression to stroke can be reduced by appropriate therapy. Long term anti-platelet or anticoagulation therapy is recommended.
- Courtney P. Top twenty primary discharge diagnoses in the emergency room in Harris County, Texas in 2009: Breakdown by age and payer source. July 2011. https://sph.uth.edu/Top-2009-ER-diagnoses-by-age-and-payer-source.
- Hoy DG, Protani M, De R, et al. The epidemiology of neck pain. Best practice and research clinical rheumatology. 2010 Dec;24(6):783-791.
- Stahmer S, Raps EC, and Mines DI. Carotid and vertebral artery dissections. Emergency Med Clinics of N America. 1997;15(3):677-698.
- Shea K, Stahmer S. Carotid and vertebral arterial dissections in the emergency department. Emerg Med Pract. 2012 Apr;14(4):1-23.
- Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection–clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003;250(10):1179-1184.
- Biousse V, D’Anglejan-Chatillon J, Touboul PJ, et al. Time course of symptoms in extracranial carotid artery dissections. A series of 80 patients. Stroke. 1995;26(2):235-239.
- Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology. 1995;45(8):1517-1522.
- Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. Am J Roentgenol. 2009;193(4):1167-1174.
- Levy C, Laissy JP, Raveau V, et al. Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography. Radiology 1994;190:97-103.
- Munera F, Soto JA, Palacio D, et al. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology. 2000;216(2):356-362.
- Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333(24):1581-1587.
- Menon R, Kerry S, Norris JW, et al. Treatment of cervical artery dissection: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. Oct 2008;79(10):1122-1127.
- Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236(3):386-393.
- Georgiadis D, Arnold M, von Buedingen HC, et al. Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients. Neurology. 2009;72(21):1810-1815.
- Touze E, Gauvrit JY, Moulin T, et al. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology. 2003;61(10):1347-1351.
- Savitz SI, and Caplan LR. Vertebrobasilar Disease. N Engl J Med. 2005;352(25):2618-2626.