Cervicocephalic Arterial Dissections 2005 06 14 Arterial Dissection

Cervicocephalic Arterial Dissections 洪國華 2005 -06 -14

Arterial Dissection • A tear in the intima or media of the artery

Consequences of Arterial Dissections a. Formation of elongated intramural hematoma b. Complete occlusion of arterial lumen c. Creating a false lumen d. Creating a dissecting aneurysm

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Dissecting aneurysm

False Aneurysm or Pseudoaneurysm • Pseudoaneurysm happened in traumatic extracranial arterial dissection (Vs dissecting aneurysm secondary to spontaneous dissection)

How does it cause a stroke? • Extracranial arterial dissection – Occlusion by false lumen or superimposed thrombus – Embolism • Intracranial arterial dissection – Subarachnoid hemorrhage

Which arteries are prone to dissection? ⅔ Internal carotid artery (just above the bifurcation) ⅓ Vertebral artery (80% at C 2 level)

What causes arterial dissection? ① Traumatic dissection a. Definite b. Trivial (‘spontaneous’ in fact? ) ② Spontaneous dissection (incidence = 5/100 000)

Traumatic Dissection • • • Whiplash injury Neck manipulation Iatrogenic cerebral angiography Sports Reversing the car Painting the ceiling

Spontaneous Dissection • Fibromuscular dysplasia • Cystic media necrosis • Known heritable connective tissue disorders • Marfan’s syndrome • Ehler-Danlos syndrome type IV & VI • Osteogenesis imperfecta • Pseudoxanthoma elasticum • Polycystic kidney • Possibly atheromatous risk factors

Clinical features of carotid artery dissection • Pain around the eye or frontal region, sometimes in the neck • Focal monocular or carotid territory ischemic symptoms • Horner’s syndrome • Cranial nerve palsy • Neck bruit or pulsatile tinnitus may occur

Clinical features of vertebral artery dissection • Focal vertebrobasilar ischemic symptoms, most commonly features of a lateral medullary or cerebellar infarct, especially if preceded by a posterior neck pain or occipital headache

Diagnosis of stroke due to artery dissection • Consistent clinical features • CT (or MRI) brain scan shows an ischemic stroke in the territory of a major cerebral artery • Duplex sonography • MRA and MRI of brain and neck • Contrast intra-arterial

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Long segmental narrowing String sign Dissecting aneurysm Tapered occlusion False lumen

Treatment • • • No controlled study Antiplatelet therapy Anticoagulant Placement of stents Surgical treatment

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