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					Vertebral Artery Dissection
Evaluation and Management


     William Barsan, M.D.
    University of Michigan
                    History
• 29 y.o. female with hx of migraine. Had
    sudden onset of falling and vertigo for 1
    minute in the morning - resolved. Felt
    light headed and noticed left neck pain
    radiating to left temporal area (dull ache -
    not migrainous).
•   Past History: migraine
•   Meds: BCP, Imitrex prn

                                    William Barsan, M.D.
                 Evaluation

•   BP: 137/88     P: 80       Afebrile
•   Eyes: normal w/o nystagmus
•   Neuro: no focal deficits
•   MRI/MRA: left vertebral artery dissection




                                  William Barsan, M.D.
           Management
• Admission to Neurology service
• IV Heparin, d/c on Warfarin
• Evaluation for Ehler-Danlos IV




                             William Barsan, M.D.
                          References
Silbert et al: “Headache and Neck Pain in Spontaneous Carotid and Vertebral Artery
    Dissections,” Neurology 45:1517-1522, 1995.
Documents signs and symptoms in 161 patients with dissection.

Biousse et al: “Head Pain in Non-Traumatic Carotid Artery Dissection,” Cephalgia
   14:33-36, 1994.
Discusses presenting signs and symptoms of carotid artery dissection.

Schierink et al: “Heritable Connective Tissue Disorders in Cervical Artery
   Dissections,” Neurology 50:1166-1169, 1998.
Documents that connective tissue disorders are common in dissection patients
   although they don’t meet the classic criteria for diagnosis.

Wityk: “Stroke in a Healthy 46 year old man,” JAMA 285(21):2757-2762, 2001
Case presentation of spontaneous carotid dissection with a literature review.



                                                             William Barsan, M.D.
                  Outcome
• MRI/MRA 6 months later
    – Normalization of vertebral artery appearance
• Workup for connective tissue disorder
    negative
•   Coumadin d/c
•   Remains well one year later



                                    William Barsan, M.D.
            Summary
• Etiology
• History
• Physical exam
• Diagnostic workup
• Treatment


                      William Barsan, M.D.
                 Etiology
•   Peak incidence 40’s
•   2.5% of first strokes
•   Carotid - males = females
•   Vertebral - females > males
•   Association with arteriopathy/trauma




                                William Barsan, M.D.
         Arteriopathies
• Fibromuscular dysplasia
• Ehlers-Danlos type IV
• Marfan’s




                            William Barsan, M.D.
              Etiology
• Trauma - may be mild
• Spontaneous
• Cervical manipulation
• Association with migraine
• Respiratory infections (?)


                           William Barsan, M.D.
      Stroke Mechanism
• Occlusion of lumen
• Thrombosis/embolus




                       William Barsan, M.D.
                 History
•   Precedent trauma
•   Associated neurological symptoms
•   Migraine (25-50%)
•   Headache, neck pain
•   Amaurosis fugax
•   Pulsatile tinnitus
•   Cranial nerve paresis

                              William Barsan, M.D.
          Carotid vs. Vertebral
•   Neck pain - 26% vs. 46%
•   Headache - 68% vs. 69%
•   Symptom development - 4 days vs. 14 hours
•   Carotid - eye, facial, ear pain




                                William Barsan, M.D.
             Physical Exam
• Horner’s syndrome (carotid)
• Cranial nerve palsies
  – II, IV, V, VI, VII, IX, X, XII
• Stroke syndrome



                                     William Barsan, M.D.
      Diagnostic Workup
• Ultrasound
• MRA
• Angiography




                    William Barsan, M.D.
     Location of Dissection
• Carotid - C1 - C2 level
• Vertebral - C1 - C2 level




                              William Barsan, M.D.
            Treatment
• Acute stroke - thrombolysis
• IV heparin
• Admission
• Warfarin for 3-6 months
• Re-imaging


                          William Barsan, M.D.

				
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posted:1/25/2013
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