What is a cervical artery dissection?
There are four main arteries that deliver blood to the brain — two carotid arteries and two vertebral arteries. The carotid arteries can be felt on each side of the lower neck, right below the angle of the jaw. The vertebral arteries are located in the back of the neck near the spine and cannot be felt on the outside of the body.
The artery walls are made up of three layers of different types of tissue, each with a specific function. A dissection happens when there is a tear in the artery wall and blood leaks between the layers, causing them to separate. You can think of it as what happens to plywood that gets wet and the layers of wood come apart. Cervical artery dissection can involve a carotid or vertebral artery, and sometimes the dissection involves more than one artery.
What causes a cervical artery dissection?
Certain medical conditions such as Marfan and Ehlers-Danlos syndromes — types of genetic connective tissue diseases — fibromuscular dysplasia and atherosclerosis (“hardening of the arteries”) increase your risk of cervical artery dissection. High blood pressure and smoking also increase your risk of cervical artery dissection. When a dissection happens without injury to the head or neck, it is called spontaneous dissection.
A traumatic injury to the neck, such as a car accident or fall, or from hyperextending the neck during sports or exercise can cause a cervical artery dissection. Heavy weight lifting and some invasive medical procedures have also been linked to cervical artery dissection.
How does a cervical artery dissection develop?
A cervical artery dissection starts as a tear in one layer of the artery wall. Blood leaks through the tear and spreads between the layers of the wall. As the blood collects in the area of the dissection, it forms a clot that limits blood flow through the artery. If the clot is large enough to completely block blood flow, it can cause a stroke. A stroke can also happen if pieces of the clot break off, travel up through the bloodstream and limit blood flow to the brain.
What is a pseduoaneurysm?
Depending on where the dissection is in the artery, the collection of blocked blood can cause that section of the artery to bulge (a pseudoaneurysm). Sometimes a pseudoaneurysm isn’t formed until after the artery dissects. A pseudoaneurysm in the brain can be fragile and break, causing bleeding around the brain (a subarachnoid hemorrhage). Pseudoaneurysms in the neck rarely break, but they can cause symptoms if they press on surrounding areas.
Symptoms of a cervical artery dissection
Sometimes a stroke is the first sign of a cervical artery dissection, and emergency treatment is needed. It is more common for symptoms to develop over a period of hours or days, even if the dissection is caused by trauma. Symptoms include headache, neck and face pain (especially pain around the eyes), vision problems such as double vision or a droopy eyelid, a “whooshing” sound in one of the ears (pulsatile tinnitus), or a sudden decrease in sense of taste and/or weakness on one side of the body.
A stroke is the most serious risk of a cervical artery dissection, and can happen hours, days or even a week after these symptoms begin.
How is a cervical artery dissection diagnosed?
If you have symptoms of cervical artery dissection, your doctor may order one or more tests to check your blood flow through the carotid and vertebral arteries and to see if there is a tear in the artery wall.
Helical computed tomography angiography (CTA) is becoming the gold standard to check for a cervical artery dissection. This is a noninvasive type of imaging that uses computed tomography (CT) technology and contrast dye to create a 3-D picture of the arteries.
Magnetic resonance angiography (MRA) is a very accurate, noninvasive imaging technique that uses a magnetic field and radio waves to create pictures of the carotid and vertebral arteries. This test can be done with or without contrast dye.
Both a CTA and MRA can show changes in the size and shape of the carotid and vertebral arteries, blood in the wall of the artery, whether or not there is a pseudoaneurysm, and changes to structures around the artery. CTA is especially useful because it can create cross-sectional images of the artery that show separation of the layers of the vessel wall. These studies can also check for brain tissue damage caused by the dissection.
Doppler ultrasonography (DUS) is being used more to identify cervical artery dissection. This noninvasive test can, in most cases, detect abnormal blood flow in a dissected artery. It is possible, though, that the dissection may be too high up in the neck or won’t show up well on an ultrasound.
Conventional angiography is an invasive test that uses contrast dye and X-ray to get pictures of the arteries. This test is not used as much since the newer, noninvasive tests have become more available. Angiography has a 1% risk of complications, including a procedure-related stroke.
What treatments are available for patients with cervical artery dissection?
In some cases, cervical artery dissection is not diagnosed until after you have a stroke. In this case, treatment involves preventing long-term damage from the stroke.
If you have symptoms of a cervical artery dissection but have not had a stroke, the goal of treatment is to prevent a stroke.
Treatment options are based on the patient’s individual needs. For example, a patient with fibromuscular dysplasia (FMD) will have different needs than a patient who has had a traumatic injury.
Medications
The first step in treatment for all patients with a cervical artery dissection is usually antiplatelet medication (such as aspirin) or anticoagulation medication to prevent blood clots, and ultimately, a stroke. Antiplatelets may used alone or with other medications. Sometimes, medication is given through an IV or injection. You will likely need to take medication for 3-6 months, and possibly longer.
Procedures
You may need to have a procedure if you:
- Aren’t able to take anticoagulant or antiplatelet medication.
- Have symptoms even after taking medications.
- Have very low blood flow to your brain because of a dissection.
Most procedures for cervical artery dissection treatment are minimally invasive, which means they are done through the blood vessels and there are no large incisions.
Angioplasty is used to repair the dissected section of artery with a tiny balloon that is inserted into the blood vessel with a catheter (long, thin tube) and removed. You may also need a stent, which is a small mesh tube that is put inside the artery and remains inside to hold it open. The stent is also put in place with a catheter. These procedures are often used together to provide the longest-lasting treatment.
Life after a cervical artery dissection
The risk of dying from a spontaneous cervical artery dissection is less than 5 percent. However, there is a much higher risk of long-term neurological problems. More than half of patients who have a spontaneous cervical artery dissection also have a stroke at the time of the dissection or in the hours or days following. Even so, about 75% of patients with spontaneous cervical artery dissection make a good recovery.
After a cervical artery dissection, there is a 1% risk of another dissection in the next 10 years. This risk is highest during the first few weeks after the first dissection. The risk is also higher among younger patients, but younger patients also respond better to treatments and have a better recovery than older patients do.
Some patients have persistent headaches after cervical artery dissection that last years after the event.
If you have had a cervical artery dissection, you should see a vascular or neurology specialist for a CTA, MRA or other imaging to learn about the severity and effects of the dissection. You will likely need to have follow-up imaging several months later. You may also need to be checked for vascular disease in other parts of your body.
You may need to make changes to your routine, such as exercise and activities that may increase the risk of another dissection.
How can I prevent cervical artery dissection?
If you have a disease that increases your risk of cervical artery dissection, such as fibromuscular dysplasia or vascular Ehlers-Danlos syndrome, it is important for you to see a vascular specialist and follow your plan of care.
Everyone can reduce the risk of cervical artery dissection by following the same steps that reduce the risk of heart disease — healthy eating, controlling your blood pressure control, weight management, exercise and not smoking.
