The Clinical Features of Dissection of the Cervical Brain-Supplying Arteries

Abstract

Background: Dissections of the cervical brain-supplying arteries are a leading cause of ischemic stroke in young adults, with an annual incidence of 2.5-3 / 100 000 for carotid artery dissection and 1-1.5 / 100 000 for vertebral artery dissection. It can be assumed that many cases go unreported. We present the clinical features here to help physicians diagnose this disease entity as rapidly as possible.

Methods: This review is based on pertinent publications retrieved by a selective search in PubMed.

Results: Spontaneous dissection of the internal carotid or vertebral artery is characterized by a hematoma in the vessel wall. It often arises in connection with minor injuries; underlying weakness of the arterial wall (possibly only temporary) may be a predisposing factor. Acute unilateral pain is the main presenting symptom. In internal carotid dissection, the site of the pain is temporal in 46% of cases, and frontal in 19%; in vertebral artery dissection, it is nuchal and occipital in 80%. Pain and local findings, such as Horner syndrome, are generally present from the beginning, while stroke may arise only after a latency of hours to days. If the diagnosis is made early with MRI, CT, or ultrasound, and anticoagulation or antiplatelet drugs can help prevent a stroke, yet none of these methods can detect all cases. Recurrent dissection is rare, except in patients with connective tissue diseases such as Ehlers-Danlos syndrome or fibromuscular dysplasia. Spontaneous dissection of the great vessels of the neck must be differentiated from aortic dissection spreading to the supra-aortic vessels and from traumatic dissection due to blunt or penetrating vascular trauma.

Conclusion: Dissection of the cervical brain-supplying vessels is not always revealed by the imaging methods that are used to detect it. Stroke prevention thus depends on the physician's being aware of the symptoms and signs of this disease entity, so that early diagnosis can be followed by appropriate treatment.

Figure 1

Pathoanatomy of arterial dissection a) Dissection of the internal carotid artery or vertebral artery with a hematoma in the vessel wall due to rupture of the vasa vasorum. The intramural hematoma can progress toward the lumen with secondary rupture of the intima. b) Dissection of the aorta with rupture of the intima and formation of two lumina. Modified from (20).

Figure 2

Typical dissection sites at transitions from a mobile vascular segment to a segment fixed in bone. a) Internal carotid artery (ICA): Dissection at the point of entry into the petrous bone. b) Vertebral artery: The V3 segment above and below the first cervical vertebra are especially vulnerable (modified from [20]). CCA, common carotid artery; ICA, internal carotid artery.

Figure 3

Imaging studies for the demonstration of dissection. Duplex ultrasonography (a, b) of two different dissection findings of the vertebral artery; MRI/MRA (c, d) of a dissection of the vertebral artery between the first and second cervical vertebrae. (a) Eccentric wall thickening due to wall hematoma (arrows) from C3 to C5. (b) Stenosis with aliasing effect in color Doppler image (arrowhead), a short double lumen and eccentric wall thickening (arrow), at the C4 to C6 levels. (c) In this transverse, native, fat-saturated T1 sequence with suppression of blood flow, the bright signal indicates a fresh hematoma (arrow) in the vessel wall, which is well demarcated from the blood flow in the lumen, which is seen in black. d) Contrast-enhanced MRA reveals a high-grade stenosis of the vertebral artery between C1 and C2.