![]() The segmental anatomy was defined microsurgically by Lister et al. Occasionally arises from a common origin with the anterior inferior cerebellar artery ~20% arise extracranially, inferior to the foramen magnumġ0% arise from the basilar rather than vertebral artery Spinal manifestations of vertebral artery dissection.The PICA is a paired artery that originates from the vertebral artery V4 segment. Time course of symptoms in extracranial carotid artery dissections: a series of 80 patients. Biousse V, D’Anglejan-Chatillon J, Touboul PJ, Amarenco P, Bousser MG.Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery. Mokri B, Silbert PL, Schievink WI, Piepgras DG.Headache and neck pain in spon- taneous internal carotid and vertebral artery dissections. Head pain in non-traumatic carotid artery dissection: a series of 65 patients. Biousse V, D’Anglejan-Chatillon J, Massiou H, Bousser M-G.Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Vertebreal artery dissection presenting as acute cerebrovascular accident. Spontaneous dissection of the carotid and vertebral arteries. Look for other cranial nerve involvement, especially III,IV,VII and XII.Oculosympathetic Palsy(Horner’s Syndrome).Internal carotid Artery dissection can present with thunderclap headache. The initial discussion of carotid and vertebral artery dissection, resulted from a discussion of differentials of sudden headache. Most dissections will heal spontaneously and about 90% of stenoses resolve within 3 to 6 months, either by recanalisation or reduction of aneurysm size. The mortality rate from Carotid and Vertebral Artery dissection is less than 5%(4), with more than 75% of those having a stroke, progressing to a good functional recovery. Surgical or endovascular treatment is reserved for those with ongoing symptoms.Treatmentĩ0% of ischaemic symptoms are due to thromboembolic sources. The use of ultrasound may be useful in the first instance, as it identifies an abnormal flow patterns. CT angiography is probably the test to do, being almost as good as MRI/MRA. Making this diagnosis is all about the imaging. Note that although rare, unilateral arm pain or weakness(usually C5-C6) can result from cervical root involvement, or spinal epidural hematomas(8). This crossing of pain and temperature loss, helps in making the diagnosis Contralateral pain and temperature deficits of the torso.Ipsilateral pain and temperature Deficits of the face and cranial nerves.Lateral Medullary Syndrome known as Wallenberg’s syndrome will involve:.These will be of the brain stem (lateral medulla), thalamus, cerebral or cerebellar hemispheres.Transient ischaemic attacks do not occur as often as with carotid artery dissections.This is usually posterior neck pain in 50% of patients.The initial presentation is pain in the posterior neck or head followed by ischaemic symptoms. 25% of patients report pulsatile tinnitus(6). Note that other cranial nerves may be involved, especially hypoglossal(CN12) Cranial nerves III, IV and VII, including taste sensation may be affected. Up to 90% of patients will have transient ischemic attacks with transient monocular blindness.20% have an ischaemic stroke without warning(7).Cerebral or Retinal ischaemia signs, which manifest days to weeks later.Miosis and Ptosis occurs in Partial Horner’s Syndrome (oculosympathetic palsy).In most cases the headache is gradual, but it can be ‘thunderclap’ in nature.Headache can involve the whole head, the front-temporal area or the occipital area(5).Ipsilateral facial or orbital pain is present in about 50% of cases(5).Ipsilateral neck pain occurs in 25% of cases(4).Pain to one side of the head, face or neck.Two of the three can assist us in making the diagnosis: There is a classic triad of symptoms and signs, but these only occur in 30% of cases(1). Clinical Presentation Internal Carotid Artery Dissection. It can manifest as headache(the most common early symptom(3)) with or without neck pain. Dissection of the vertebral artery occurs in 1 per 100,000 of the population, however it makes up about 25% of all cerebral events in those less than 40 year of age(2). Spontaneous dissection of the carotid artery occurs in 3 per 100,000 of the population annually(1). These can include Cerebral Venous Thrombosis and carotid Artery Dissection. When we do rule this out, we still need to consider the other possible causes of a thunderclap headache. Although there are several potential causes of sudden headache(shown below), the main aetiology we try to exclude in the emergency department, is aneurysmal rupture. Patients can present to us with a sudden severe headache, also known as a thunderclap headache.
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