Cervical Carotid Artery Dissection [Neurosurgery Wiki]

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====== Cervical Carotid Artery Dissection ======


===== #### **Definition** =====

Cervical carotid artery dissection (CCAD) is a condition in which a tear occurs in the inner layer (intima) of the carotid artery, leading to an intramural hematoma, stenosis, or pseudoaneurysm formation. It is a significant cause of ischemic stroke, especially in young adults.

#### **Etiology**
CCAD can occur spontaneously or be triggered by trauma. Risk factors include:
- **Mechanical/traumatic causes:** 
  - Blunt or penetrating trauma to the neck
  - Chiropractic manipulation
  - Severe coughing, sneezing, vomiting
  - Hyperextension or sudden head movements
  - Strangulation or direct pressure on the neck
- **Underlying conditions:** 
  - Connective tissue disorders (e.g., Ehlers-Danlos syndrome, Marfan syndrome)
  - Fibromuscular dysplasia
  - Recent infections
  - Hypertension
  - Smoking

#### **Pathophysiology**
- A tear in the intima allows blood to enter the arterial wall, creating a false lumen.
- This may lead to:
  - **Stenosis** (narrowing of the vessel)
  - **Thrombosis** (clot formation)
  - **Embolization** (dislodgement of clot fragments causing stroke)
  - **Aneurysm formation** (weakening of the vessel wall)

#### **Clinical Presentation**
Symptoms can vary widely but often include:
- **Neurological deficits:** 
  - Ischemic stroke or transient ischemic attack (TIA)
  - Hemiparesis, hemianesthesia
  - Aphasia (if left-sided involvement)
  - Visual disturbances (amaurosis fugax)
- **Cervical pain and headache:** 
  - Often ipsilateral to the dissection
  - Sudden onset, persistent, and severe
- **Horner’s syndrome (partial):** 
  - Ptosis
  - Miosis
  - Anhidrosis (sometimes absent)
- **Cranial nerve palsies (rare):** 
  - CN IX-XII involvement due to mass effect
- **Tinnitus, pulsatile bruit:** 
  - May be noted in cases with significant turbulence

#### **Diagnosis**
- **Imaging studies:**
  1. **CTA (CT angiography):** First-line for rapid assessment
  2. **MRI/MRA:** Identifies intramural hematoma and vessel narrowing
  3. **Doppler ultrasound:** Can be useful but is less sensitive
  4. **DSA (Digital Subtraction Angiography):** Gold standard but invasive

#### **Treatment**
Management depends on symptom severity and stroke risk:

1. **Antithrombotic therapy (First-line for most patients):** 
   - **Antiplatelets (Aspirin, Clopidogrel):** For non-occlusive dissections with minor symptoms
   - **Anticoagulation (Heparin, Warfarin, DOACs):** Preferred if embolic risk is high

2. **Endovascular treatment (for select cases):** 

[[Cervical Carotid Artery Dissection Endovascular treatment]] 


3. **Surgical intervention:** 
   - Rarely needed, reserved for cases with severe complications

4. **Supportive care:** 
   - Blood pressure control
   - Pain management
   - Stroke rehabilitation if neurological deficits occur

#### **Prognosis**
- Most patients recover well with early diagnosis and treatment.
- Risk of recurrent dissection is low (~1-2% per year).
- Long-term monitoring is recommended, particularly in patients with connective tissue disorders.