Dissection, Carotid and Vertebral Artery
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- 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.
CAD is responsible for 13–22% of all ischemic strokes in younger aged patients.
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.
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.
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
- 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
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
- Cystic medial necrosis
- Moyamoya disease
- Giant cell arteritis
- Temporal arteritis
- Those genetic disorders mentioned in “Genetics”