Chapter 93 - Carotid artery dissection

Question 1

incidence of spontaneous carotid dissection

Answer 1

1.7-2.6%

Question 2

Risk factors for spontaneous carotid dissection

Answer 2

1) HTN
2) migraine
3) winter time
4) recent infection
5) connective tissue disorder

Question 3

Vascular abnormalities associated with spontaneous dissection

Answer 3

1) FMD
2) EDS4
3) cystic medial necrosis
4) marfan
5) autosomal dominant polycystic kidney disease
6) osteogenesis imperfecta type I

Question 4

Symptoms of carotid dissection

Answer 4

TRIAD 33% only

1) head + neck pai
2) Horner (oculosympathetic palsy)
3) hemishperic syndrome

4) amaurosis fugax
5) pulsatile tinnitus
6) CN palsy
7) anisocoria

Question 5

Oculosympathetic palsy different from Horner

Answer 5

doesn’t include facial anhidrosis

sympathetic fibers for those run along external carotid

Question 6

Traumatic carotid dissection after blunt injury

Answer 6

0. 86%

3. 2% if altered LOC and neck/head injury

Question 7

Mechanism of trauma-induced carotid dissection

Answer 7

Extreme cervical hyperextension or lateral hyperflexion

Question 8

Mandatory evaluation for neck trauma

Answer 8

1) active bleed
2) expanding hematoma
3) cervical bruit age > 50
4) brain infarction
5) neuro deficit
6) horner
7) head/neck pain
8) cervical spine fracture
9) GCS < 6
10) petrous bone fracture
11) diffuse axonal injury
12) basilar skull fracture
13) LeFort II or III #

Question 9

Gold standard for diagnosing carotid dissection

Answer 9

4 vessel selective cerebral angiography

Question 10

radiographic signs of carotid dissection

Answer 10

1) 2-4 cm distal to bulb
2) stenosis is irregular
3) long tapering stenosis ends before petrous portion
4) occlusion = tapered flamelike appearance
5) aneurysm fusiform in distal subcranial segment

Question 11

Cerebral infarction in spontaneous carotid dissection rate

Answer 11

42%

20-58% have persistent neurologic deficits

mortality 30%

Question 12

Medically tx spontaneous carotid dissection rate of recurrent dissection

Answer 12

0.3-1.4%

Question 13

Recurrent stroke after med mgnt of spontaneous carotid dissection

Answer 13

0.3-3.4% per year

Question 14

How often do spontaneous carotid dissections induced aneurysm resolve

Answer 14

2/3

Question 15

Cervical artery dissection in stroke study (CADISS)

Answer 15

1) 264 patients
2) antiplatelet vs anticoagulation
3) no difference in antiplt vs AC
4) no increase in stroke risk after dissection when there’s an aneurysm involved - can be treated medically

Question 16

Antiplatelet vs anticoagulation in carotid dissection

Answer 16

No clear evidence of difference

for both carotid and vertebral

Question 17

Indication for surgical treatment in carotid artery dissection

Answer 17

1) fluctuating or deteriorating clinical neurological symptoms
2) compromised cerebral flow
3) contraindication to antithrombotic therapy
4) expanding aneurysm or symptomatic

Question 18

Indications for delayed surgical treatment of carotid artery dissection > 6 months

Answer 18

1) persistent high grade stenosis

2) new/persistent aneurysm 2x normal ICA

Question 19

When is ligation of ICA safe

Answer 19

stump pressure > 70 mmHg

balloon occlusion test passed

Question 20

complication of carotid surgery after dissection

Answer 20

1) mortality 2%
2) ipsilateral stroke 8%
3) loss of primary patency 20%
4) cranial nerve dysfunction 58%

Question 21

Cervical artery dissection and ischaemic stroke patients CADISP

Answer 21

multicenter study

thrombolysis did not increase bleeding or stroke