1. Cervical Artery Dysfunction

2. Vascular Anatomy Posterior system (20%)– Vertebrobasilar arterial
Tethering at C2, C1 and atlanto-occipital membrane
Right angled bends

3. Vascular Anatomy
Anterior system (80%) – Internal and External carotid arteries

4. Pathology
Cervical Artery Dysfunction is an umbrella term to describe injury to the arteries within the neck
Includes a range of pathologies and not just “Dissection”
Injury to the arteries can alter blood flow to the brain, head, neck and face
Signs generally categorised into
Ischemic and Retinal
Non Ischemic

5. Pathophysiology Often a dissection, but not always A small tear
Blood penetrates vessel wall
Causing aneurysms and/or false lumen
Causing stenosis, inflammation of tissue (vascular and local)
Nociceptors in blood vessels
Stenosis restricts blood flow
Atherosclerosis increases risk of dissection

6. Mechanism of Injury Traumatic Insidious Coughing Sneezing Head turning
RTC
Insidious
Atherosclerosis
Inflammation
Connective tissue disease
Upper cervical instability

7. Associated Pathologies
Cervical instability
Whiplash Associated Disorders
Diabetes
Hypertension
Cardiac Disease
Hypercholesterolemia
Blood Clotting Disorders

8. Classification

9. Internal Carotid Artery Dysfunction Non Ischemic Signs
Horner’s Syndrome- 82% of cases
Dropping eyelid (ptosis)
Sunken eye (enophthalmia)
Small constricted pupil (miosis)
Facial Dryness (anhidrosis)
The superior cervical sympathetic ganglion supplying the eye are found in the carotid sheath and follow the course of the carotid artery

10. Internal Carotid Artery Dysfunction Non Ischemic Signs
Lower Cranial Nerve Dysfunction (IX – XII)
Glossopharyngeal (Palate Elevation and Gag Reflex)
Vagus (Palate Elevation and Gag Reflex)
Accessory (Resisted Cervical Rotation and Shoulder Shrug)
Hypoglossal (Stick Tongue out and into sides of mouth)
Acute onset head or neck pain like no other
Ipsilateral neck and facial pain

11. Internal Carotid Artery Dysfunction Ischemic Signs
Signs of Cerebral Stroke or Retinal Ischemia
Transient Ischemic Attack
Ischemic Stroke
Retinal Ischemia
Painless episodic loss of vision
Localized/patchy blurring of vision
Weakness of eye muscles
Protrusion of eye
Swelling of the eye
Unlikely to present in a physiotherapy clinic, however be aware of Retinal Ischemic changes

12. Vertebral Artery Dysfunction Non Ischemic Signs
Ipsilateral posterior neck pain and occipital headaches
C5/6 Nerve root impairment (rare)
Weakness Wrist Extension
Weakness Elbow Flexion
Sensation change thumb side hand, wrist and forearm

13. Vertebral Artery Dysfunction Ischemic Signs
5D’s and 3N’s
Ataxia
Vomiting
Vascular Dizziness is very common with Vertebral artery dysfunctions
Does not improve with repeated rotations

14. Subjective Mechanism of Injury History of Migraine type headache
Traumatic usually
History of Migraine type headache
Cranial Nerve Dysfunction
PMH
Cardiac and/or Vascular Disease
Hypertension
Hypercholesterolemia
Diabetes
Blood clotting disorders
Anticoagulant therapy
Long term steroid use
Family History
Vascular and Cardiac disease in family

15. Objective
Potential Red Flags massively affect the order of your objective examination
Diagnostic Medical Work UP
Blood Pressure
Cranial Nerve Testing
Active ROM
Passive ROM
Never continue the examination if you suspect serious pathology is present or you do not possess the skills to perform relevant examinations (e.g cranial nerves, BP)
Always REFER ON when necessary

16. Special Tests Blood Pressure Testing Cranial Nerve Testing
Special Tests not useful and more likely to cause injury

17. Further Investigation
Ultrasound Doppler
Arteriography
Magnetic Resonance Angiography

18. General Management

19. Conservative - Management
Medic Led
Monitor BP
Statins, Anti coagulants
No physical therapy