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:

  1. Blunt or penetrating trauma to the neck
  2. Chiropractic manipulation
  3. Severe coughing, sneezing, vomiting
  4. Hyperextension or sudden head movements
  5. Strangulation or direct pressure on the neck

- Underlying conditions:

  1. Connective tissue disorders (e.g., Ehlers-Danlos syndrome, Marfan syndrome)
  2. Fibromuscular dysplasia
  3. Recent infections
  4. Hypertension
  5. Smoking

#### Pathophysiology - A tear in the intima allows blood to enter the arterial wall, creating a false lumen. - This may lead to:

  1. Stenosis (narrowing of the vessel)
  2. Thrombosis (clot formation)
  3. Embolization (dislodgement of clot fragments causing stroke)
  4. Aneurysm formation (weakening of the vessel wall)

#### Clinical Presentation Symptoms can vary widely but often include: - Neurological deficits:

  1. Ischemic stroke or transient ischemic attack (TIA)
  2. Hemiparesis, hemianesthesia
  3. Aphasia (if left-sided involvement)
  4. Visual disturbances (amaurosis fugax)

- Cervical pain and headache:

  1. Often ipsilateral to the dissection
  2. Sudden onset, persistent, and severe

- Horner’s syndrome (partial):

  1. Ptosis
  2. Miosis
  3. Anhidrosis (sometimes absent)

- Cranial nerve palsies (rare):

  1. CN IX-XII involvement due to mass effect

- Tinnitus, pulsatile bruit:

  1. 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):

  1. Antiplatelets (Aspirin, Clopidogrel): For non-occlusive dissections with minor symptoms
  2. 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:

  1. Rarely needed, reserved for cases with severe complications

4. Supportive care:

  1. Blood pressure control
  2. Pain management
  3. 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.