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Dissections (spontaneous)

Last modified by Hussein Abdallah on 2025/05/26 15:41

 

FACTS

Epidemiology

  • M > F, median age 45 

Pathophysiology of stroke

  1. Most commonly: embolization 2/2 platelet aggregation: nick in arterial wall --> creates prothrombogenic area that produces embolus
  2. tear is big enough that flap narrows artery, so not just embolic, but produces hemodynamic, flow-limiting stenosis 
  3. pseudoaneurysm
    1. if extracranial (petrous, cervical): low-risk, just treat with aspirin, rarely intervene unless mass effect
    2. if intracranial (rare, can be spontaneous or due to trauma): generally, do NOT put on AC, you worry if they get a pseudoaneurysm that they rupture
      • tx is coil off artery if have good contralateral, or reconstruct with pipeline (treats dissection and covers the whole)

CONSULT

HPI 

  • Any neck manipulations (chiropractor, yoga, pilates)
  • Any connective tissue disease 
    • fibromuscular dysplasia 
    • Marfan syndrome
    • EDS 
    • atherosclerosis
    • Takayasu's disease
    • syphillitic arteritis 
    • Moya moya disease
  • Strenuous physical activity (body builder, elite athlete)
  • Any contrast allergies? hives vs. anaphylaxis? 
  • Spontaneous VA dissections: FMD, migraine, OCPs
  • Any trauma, including trivial
    • simple neck turning, violent coughing, nose blowing (esp. if young women) 

FOCUSED EXAM

Complete stroke exam, include speech

ICA: 
- ipsilateral HA (orbital/periorbital vs. auricular/mastoid)
- carotidynia 
- incomplete Horner's (oculosympathetic palsy): ptosis and miosis w/o anhyidrosis (plexus around ECA = facial sweat glands is spared) 
- neck swelling
- scalp tenderness
- syncope
- amaurosis fugax

Vertebral
- neck pain (over occiput/posterior cervical region)
- TIAs/stroke

IMG 

CTH: evaluate for SAH, more common in posterior circulation > anterior circulation dissections 

A/P

[ ] CTA H&N to eval lesion 
[ ] MRI Brain w/o to eval for strokes
[ ] MRA also option to eval lesion - this is a noncontrast study, just a time of flight technique so may as well get while pt in scanner
[ ] Stroke c/s - usually manage spontaneous dissections 
[ ] #1 medical therapy: Likely ASA81 vs. Heparinization --> warfarin/DOAC (if pending procedures)  
[ ] DSA not necessarily indicated - injection can even worsen flap; endovascular treatment w/ balloons/stents can be done  

Tx paradigm:

1. embolus: typically, antiplatelet is adequate, if active thrombus in lumen: high risk emboli = anticoagulation

2. hemodynamic and symptomatic: need stent

Notes

Associated Syndromes

  • PCKD, Marfan Syndrome

Sites of intracranial dissections

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Figure 1A: MRA demonstrating distal petrous and proximal cavernous R ICA dissection. Figure 1B MRA demonstrating dissection flap in R cavernous ICA