AKT · Cardiovascular/Vessels, aorta & venouslow yield

Carotid & cervical artery dissection

Tear in the carotid/vertebral arterial wall → intramural haematoma, thromboembolism

Overview

A tear in the wall of a carotid or vertebral artery, often after minor neck trauma or spontaneously (connective tissue disease), creating an intramural haematoma. It is an important cause of stroke in younger patients. The carotid triad is unilateral head/neck pain, a partial Horner's syndrome and cerebral/retinal ischaemia.

Recognise

Unilateral neck/head/facial pain, often after trivial trauma or neck movement; younger patient
Carotid: partial Horner's (ptosis + miosis, sparing sweating), with TIA/stroke or amaurosis fugax
Vertebral: posterior-circulation symptoms (vertigo, ataxia, occipital headache); pulsatile tinnitus

Red flags

Stroke/TIA from dissection → urgent stroke pathway; thrombolysis decisions need imaging confirmation
Connective tissue disease (Marfan, Ehlers-Danlos) raises risk — consider in spontaneous dissection

Differentials & how to tell them apart

Migrainerecurrent stereotyped headache without Horner's or vessel abnormality

Ischaemic stroke from other causecardioembolic/atherosclerotic; older, vascular risk factors

Cluster headacheautonomic features but no vessel dissection on imaging

Investigations

CT or MR angiography of the head and neck (the diagnostic test — vessel wall haematoma/tapering); MRI brain for infarction; consider connective tissue work-up in spontaneous cases.

Management

Antithrombotic therapy (antiplatelet or anticoagulation) to prevent stroke

1Suspect in a younger patient with unilateral neck pain + partial Horner's or posterior-circulation symptoms; confirm with CT/MR angiography of the neck.Gate: Acute ischaemic stroke from dissection → stroke pathway and thrombolysis decision guided by imaging — don't miss the dissection as the mechanism.
2Start antithrombotic therapy (antiplatelet or anticoagulation) to prevent further embolism; stent for recurrent ischaemia; investigate connective tissue disease in spontaneous cases.

Antithrombotic therapy — antiplatelet or anticoagulation — to prevent thromboembolic stroke; choice individualised; thrombolysis for acute stroke per imaging/protocol

Blood pressure control / avoid neck manipulation — supportive; treat connective tissue contributors

Endovascular stenting — reserved for recurrent ischaemia despite medical therapy or specific anatomy

Key points

Younger patient + unilateral neck/head pain + partial Horner's (ptosis/miosis with preserved sweating) + TIA/stroke = carotid dissection → CT/MR angiogram of the neck, then antithrombotic therapy. Think connective tissue disease in spontaneous cases.

Monitor & prognosis

Repeat vessel imaging for healing, neurological status, antithrombotic duration.

Most dissections heal with medical therapy; stroke risk is highest early.

Source: Stroke guidelines; cross-ref neurology