NeurologyTier 2Disease (DEADMAN)

Cervicocerebral artery dissection

Description

Tear in the wall of the internal carotid or vertebral artery, creating a false lumen (intramural haematoma) that can occlude the vessel or embolise distally -> ischaemic stroke
An important cause of stroke in younger patients (<50 years)

~2% of all ischaemic strokes, but up to 20% of strokes in patients <45 years
Carotid dissection is more common than vertebral; can be spontaneous or traumatic

Triggers: trauma (including minor - chiropractic neck manipulation, sudden neck hyperextension), connective tissue disorders (vascular Ehlers-Danlos, Marfan, fibromuscular dysplasia), or spontaneous with an underlying arteriopathy not always identified
Intramural haematoma -> luminal narrowing and/or thrombus formation with distal embolisation - the predominant stroke mechanism, not simple flow-limitation

Classic triad (all three present in only a minority): unilateral neck/head pain, partial Horner's syndrome (miosis + ptosis, no anhidrosis - post-ganglionic), and delayed cerebral/retinal ischaemia (can be hours-days after the pain)
CTA or MRA neck - "string sign" (long tapered stenosis), intimal flap, or intramural haematoma (crescent sign on fat-saturated MRI)
Lower cranial nerve palsies (IX-XII) can occur with carotid dissection from local mass effect

Antithrombotic therapy (antiplatelet or anticoagulation) - the CADISS trial showed no significant difference between antiplatelet and anticoagulant therapy for preventing recurrent stroke; choice individualised (anticoagulation avoided if a large or haemorrhagic infarct)
Thrombolysis/thrombectomy are not contraindicated by dissection alone if within window and otherwise eligible
Endovascular stenting reserved for progressive/refractory ischaemia despite medical therapy

Connective tissue disorders (vascular Ehlers-Danlos, Marfan, fibromuscular dysplasia), recent trauma/neck manipulation, migraine (weak association)

Most dissected arteries recanalise within 3-6 months with medical therapy alone
Recurrent dissection risk is low overall but higher with an underlying connective tissue disorder or fibromuscular dysplasia - screen other vascular territories in that setting

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