Carotid and Vertebral Artery Dissection

Carotid and vertebral artery dissections are associated with trauma, though the trauma is often trivial e.g. chiropractic manipulation. For example, following an episode of trauma, one of two pathological events may occur:

• A haemorrhage into the vessel wall leading to occlusion of the vessel. This may then cause cerebral ischaemia (Fig 1 below, left)
• An intimal tear. This may cause ischaemia or result in embolic phenomena minutes to months after the initial event. TIAs are common, and if the vertebral arteries are implicated, evidence of brainstem dysfunction will occur (Fig 2 below, right)

Presentation

Classically, there is an abrupt onset of unilateral headache, neck or face pain. With vertebral artery dissections, brainstem and cerebellar signs are typically seen. Hypertension and Marfan’s syndrome are known associations.

Horner’s syndrome

A Horner’s syndrome (see image – affected left pupil) may be seen with both vertebral and carotid artery dissections. Because this pathology is associated with patients in middle age, this diagnosis should be considered in any ‘young’ patient (<50 years) who presents with symptoms of a stroke. Horner’s syndrome presents with a small pupil and drooping eyelid.

Learning Bite: 

Carotid/vertebral artery dissection should be considered in any patient with unilateral headache associated with face or neck pain, and any patient with a Horner’s syndrome.

More information on this subject can be found in the session about cervical artery dissection.