Arterial Dissection. Pitfalls (1) “I have a pain in my neck and (or) head unlike anything I have...
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Transcript of Arterial Dissection. Pitfalls (1) “I have a pain in my neck and (or) head unlike anything I have...
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Arterial Dissection
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Pitfalls (1)
“I have a pain in my neck and
(or) head unlike anything I have
ever had before.”
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Pain referral common to Vertebral Pain referral common to Internal Carotid
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Pitfalls (2)
The pain was described as
throbbing, steady or sharp as
the “thunderclap” headache.
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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
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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.
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1. Recurrent stroke after dissection:10.7%(1st yr); 14.0%(3rd yr)
2. Recurrent stroke within 6m with anti-coagulation 2% comparedto anti-platelet 16.7%. (P=0.02)
3. Long term benefit remained uncertain.
(JNNP.2010; 81: 869-873.)
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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.)
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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…)
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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)
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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.
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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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Blessing Taiwan
( 部分內容圖片摘自網路僅供參考 )