1. Arterial Dissection

3. Pitfalls (1) “I have a pain in my neck and (or) head unlike anything I have ever had before.”

4. Pain referral common to VertebralPain referral common to Internal Carotid

5. Pitfalls (2) The pain was described as throbbing, steady or sharp as the “thunderclap” headache.

6. Diagnosing VAD/CAD  CT or MRI are not sensitive enough to detect arterial dissections. –MRA, carotid ultrasound, or DSA are more sensitive. Rarely administered unless physician suspects CAD/VAD  Accurate diagnosis of CAD/VAD in younger stroke patients is rare. –Physicians and patients are relatively unaware of the link between precipitating events and presenting signs/ symptoms

8. Treatment  Aimed at preventing CVA. –Anticoagulation and antiplatelet therapy. –Surgery required in very few cases. Bypass Stenting  Patient prognosis is dependent on the timeline of diagnosis and subsequent treatment. If the dissection is discovered early, patients have a excellent prognosis for recovery from symptoms. Can J Neurol Sci. 2000; 27(4): 292-6.

9. 1.Recurrent stroke after dissection: 10.7%(1 st yr); 14.0%(3 rd yr) 2.Recurrent stroke within 6m with anti-coagulation 2% compared to anti-platelet 16.7%. (P=0.02) 3.Long term benefit remained uncertain. (JNNP.2010; 81: 869-873.)

10.  Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients. 1. No significant difference. 2. Aspirin may be better. (NEUROLOGY, 2009; 72: 1810-5.)

11. Preventive measures  Avoid trauma to the head and neck.  Wear seatbelts when driving or riding in vehicles. (*)  Take appropriate safety precautions for sporting events –Helmet. –Padding.  Be aware that extended or extreme neck extension or cervical manipulation may increase risk for arterial dissection. *( cases report of dissection with seatbelt use…)

12. The following might suggest: headache is due to dissection of a carotid artery  Sudden severe, unilateral pain (70% of cases)  New onset bilateral headache (20%, not necessarily explosive at onset)  New onset unilateral upper neck pain (under the jaw or mandible) - 6% of cases.  New onset facial pain - 17% of cases.  New onset pulsatile tinnitus- 7% of cases.  Thunderclap headache- occurred in one of 65 cases (1.5%) of dissection. (www.severe-headache-expert.com)

13. Conclusion  Dissections accounts for 10-25% of all ischemic strokes in young/middle aged persons.  Median time from onset of headache to neurological symptoms is 4 days with carotid artery dissection, and 14.5 hours of vertebral artery dissection.  Highly suspicion of dissection in patients of TIA’s or stroke with a history of trauma or chiropractic manipulation.

14. Conclusion  Most common associated with a headache of subacute onset.  15-20% of patients presented with a thunderclap headache.  Headache reported by 60-95% of patients with carotid artery dissection and 70% of patients with vertebral artery dissection.  Headache generally occurred ipsilateral to the dissection area, involved the face, jaw, ears, periorbital, frontal and temporal regions, with neck pain in 30-40 % of patients. (Postgrad Med J. 2005;81: 383-388.)

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