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Dissection, Carotid and Vertebral Artery

Dissection, Carotid and Vertebral Artery is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Cervical artery dissection (CAD) is subcategorized into internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD).
  • CAD accounts for 2–2.5% of all ischemic strokes.

Epidemiology

CAD is responsible for 13–22% of all ischemic strokes in younger aged patients.

Incidence
The incidence of CAD has been reported to be 2.6 to 3.0 per 100,000 inhabitants per year. The ratio of ICAD:VAD may vary in different populations.

Prevalence
The average age of patients presenting with CAD is approximately 45 years.

Etiology and Pathophysiology

Intramural hematoma is the pathophysiologic hallmark of CAD.

  • Caused by a subintimal tear into the arterial wall of the carotid and vertebral artery
  • Intramural blood accumulation subjacent to the adventitia can cause Horner syndrome, narrowing of the arterial lumen, and subsequent cerebral ischemia.
  • Arterial rupture can result in subarachnoid hemorrhage (SAH) or pseudoaneurysm.
  • Resulting cerebral ischemic events are more often due to embolism rather than hemodynamic compromise from luminal narrowing.
  • Iatrogenic dissections can also occur due to catheter manipulation or balloon angioplasty.
Genetics

There is an increased incidence of CAD in patients with MTHFR C677T genotype. The following genetic disorders have been associated with a higher risk of CAD:

  • Fibromuscular dysplasia
  • Ehlers-Danlos syndrome type IV
  • Marfan syndrome
  • α1-Antitrypsin deficiency
  • Osteogenesis imperfecta
  • Autosomal dominant polycystic kidney disease
  • Homocysteinuria

Risk Factors

  • History of radiotherapy to the neck
  • Neck manipulation
  • Neck trauma, even if minor
  • Recent infection
  • Carotid or vertebral artery aneurysm
  • Genetic disorders mentioned above and associated conditions listed below
  • Oral contraceptives

General Prevention

No specific prevention measures are known.

Commonly Associated Conditions

  • Retinal ischemia and ischemic optic neuropathy (CAD)
  • Spinal cord ischemia and cervical radiculopathies (VAD)
  • Oculosympathetic palsy (CAD more often than VAD)
  • Low-lying carotid bifurcation
  • Migraine
  • Cystic medial necrosis
  • Moyamoya disease
  • Giant cell arteritis
  • Temporal arteritis
  • Those genetic disorders mentioned in “Genetics”

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Citation

Stephens, Mark B., et al., editors. "Dissection, Carotid and Vertebral Artery." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117501/all/Dissection__Carotid_and_Vertebral_Artery.
Dissection, Carotid and Vertebral Artery. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117501/all/Dissection__Carotid_and_Vertebral_Artery. Accessed April 18, 2019.
Dissection, Carotid and Vertebral Artery. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117501/all/Dissection__Carotid_and_Vertebral_Artery
Dissection, Carotid and Vertebral Artery [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 18]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117501/all/Dissection__Carotid_and_Vertebral_Artery.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Dissection, Carotid and Vertebral Artery ID - 117501 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117501/all/Dissection__Carotid_and_Vertebral_Artery PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -