Cervical artery dissection is a rare but significant cause of stroke and headache/neckache, which is easy to overlook. Leading to a typically delay in diagnosis of 7 days. Unfortunately imaging the cervical arteries is not simple, with MRA being the method of choice. Hence these patients must be referred to the “Stroke Consultant”.

Presentation

• Onset – Often associated with twist/bend of neck, ranging from turning their head to forcible neck movement such as fall from a horse
• Head/Neckache – This is variable
  • Onset: progressive > thunderclap
  • Type: throbbing > constrictive
  • Laterality: unilateral or bilateral
  • However, almost all describe it as different to any previous head/neckache.
• Neurology – Depends on the artery affected (1:7 have multiple arteries affected), can be temporary (TIA) or permanent(Stroke)
  • Carotid – Anterior Circulation
    • Amaurosis Fugax – Sudden visual loss in one eye
    • Unilateral weakness/sensory loss
    • Horner’s Syndrome (partial ptosis, mitosis(small pupil), sunken eye, reduced sweating) – sympathetic chain
  • Vertebral – Posterior Circulation
    • Loss Pain/Temp sensation
      • Facial – Ipsilateral
      • Body – Contralateral
    • Dysphagia/Dysarthria – CN IX & X
    • Ataxia/Poor co-ordanation – Cerebellum
    • Vertigo – vestibular nucleus
    • Hemianopia – occipital lobe involvement
    • Horner’s Syndrome (partial ptosis, mitosis(small pupil), sunken eye) – sympathetic nerve compression
• Carotid bruit – Carotid dissection
• Pulsatile Tinitus – Carotid dissection

What to Do

• Senior Review
• Discuss with Radiology
  • Non-Contrast CT Head – this is to look for stroke and other emergent conditions but is unlikely to demonstrate dissection
  • CT angiogram – can demonstrate the dissection, however this may be performed after the non-con CT head to aid accuracy of scan.
• Refer to Stroke Consultant – They will need to discuss the presentation and review the patients CT head. They will then work out what is the most appropriate way to follow this patient up e.g Admission to stroke ward, TIA clinic, or ward review (if for example the patient is being admitted for trauma)
• Anticoagulation – this important in dissection to help prevent further neurological deficit, and will be directed by the Stroke Consultant.