Carotid Artery Dissection

Carotid artery dissection is an important cause of stroke to consider in patients younger than 50 years. It is the commonest cause of stroke in males aged under 45 and has an associated mortality of up to 5% [43].

The incidence of carotid artery dissection (CAD) is quoted as 2.6-3.0 per 100,000 population, although the true incidence may be higher as many remain undiagnosed [44].

Head or neck trauma – including manipulation by a chiropractor – is a known precipitating factor, but is not always present. Aneurysm, hypertension and atherosclerosis are also associated with CAD. However, dissection should be especially considered in patients with an ischaemic stroke, but without the usual cardiovascular risk factors.

Presentation can vary from incidental findings of asymptomatic disease to cerebrovascular events, ipsilateral headache, face or neck pain, and Horner’s syndrome.

Approximately 25% of patients can experience neck pain alone. It is usually sudden, severe and persistent.

Diagnosis

If suspected, immediate investigation is needed with either CT angiography or MRA.

Treatment

Full resolution occurs in excess of 90% of cases. There is a marked lack of evidence supporting treatment approaches. Since the most recent inconclusive Cochrane review [45], one randomised control trial has been published, which found no difference in efficacy of antiplatelet and anticoagulant drugs at preventing stroke and death in patients with symptomatic carotid and vertebral artery dissection [46].

More information on this subject can be found in in the Learning Zone session on Cervical Artery Dissection.