Cervical Artery Dissection: A Hidden Cause of Stroke in Young Adults

When most people think about stroke, they picture an older patient with long-standing vascular risk factors. But stroke doesn't only affect the elderly. One of the leading causes of ischemic stroke in younger adults is cervical artery dissection—a condition that can occur after seemingly minor trauma, vigorous exercise, chiropractic manipulation, or sometimes without any obvious trigger.

In this episode of Brain to Bedside, we explore how carotid and vertebral artery dissections present, why they're so often missed, and what every emergency clinician should recognize. We'll discuss the classic and not-so-classic symptoms, the best imaging strategies for diagnosis, current treatment recommendations—including antiplatelet versus anticoagulation therapy—and when endovascular intervention may be appropriate.

Transcript

Jamie Sessions 0:00

Hey everyone, welcome to Brain to Bedside, where we take neurotopics and talk about them in a way that you can apply at the bedside. Today we're back with Dr. Lee Chung, and I'm going to give him a second to introduce himself.

Dr Lee Chung 0:13

Thank you, Jamie. My name is Lee Chung. I am one of the vascular neurologists at the University of Utah, and I help direct the telestroke network with a great group of individuals.

Jamie Sessions 0:25

Awesome. Thank you. So today we're diving into cervical artery dissection. So it's a very important but often underrecognized cause of stroke, especially in younger adults. Is that right?

Dr Lee Chung 0:37

Absolutely. Um, it's probably one of the leading causes of stroke among younger folks under the age of about 45 or 50. And it probably is making up somewhere around 10 to 25% of strokes in that age group.

Jamie Sessions 0:56

So yeah, I feel like with people, when they think of stroke, they think of like older patients, lots of risk factors, high blood pressure, AFib. But I think this is a good topic to talk about to remind us that stroke isn't just a disease of the elderly. And when we do see strokes in younger patients, that cervical artery dissection can be one of our differentials. Let's get into it. Dr. Chung, can you just start us out by telling us what is a cervical artery dissection?

Dr Lee Chung 1:23

Yes, it's a tear in the innermost layer, the intimal layer of an artery that leads up to the brain. And it can happen in the neck, which we call cervical artery dissections. It can also happen inside the brain. And I think that's an increasingly recognized phenomenon now that we have better imaging to look at possible tears in those blood vessels. And what we think happens is they're one of two things. Either the tear can block the normal lumen of that blood vessel and reduce the blood flow, or the tear exposes other tissue layers that become very thromogenic and thromus can form and either totally occlude the vessel or embolize distally to the brain and cause stroke.

Jamie Sessions 2:16

When you have a patient with a cervical artery dissection, is that an easy spot, an easy diagnosis, or is it a little bit harder to diagnose?

Dr Lee Chung 2:23

It's a little tricky. First of all, if the vessel's totally occluded, we don't get a good look at the actual blood vessel wall on the CTA scan. And so it the complete occlusion could obscure a dissection. However, there's sometimes clues. Often we talk about a flame-shaped tapering before the occlusion, and that kind of suggests maybe there's a flap that's sticking into the lumen and eventually closing it off completely. And now we have more advanced techniques with high-resolution vessel wall MRI, as well as the use of catheter angiogram, that we can get higher resolution uh images of the vessel and see if there's a dissection and a flap. However, most of the time dissections can be seen just on the CT angiogram. So that's usually the first tests that we do if that's what we're suspecting.

Jamie Sessions 3:17

And what causes a cervical artery dissection?

Dr Lee Chung 3:20

Yeah, there can be a lot of causes. We typically divide them into spontaneous and traumatic. Traumatic is pretty obvious. Usually there's a you know, MBC or a serious fall, or some kind of sports-related or assault-related trauma to the neck. Those are pretty obvious. The spontaneous dissections can include a bunch of different things, and usually we basically don't know for sure. Sometimes there can be something obvious like uh if someone's been sick and they've been coughing a lot or throwing up a lot. Um we see this in folks who are lifting weights and uh sometimes straining with something, but we've seen this happen even with very minor activities. Uh, I recall this one patient had a dissection from looking backwards to back up her car, and that just looking backwards alone was the moment she heard a pop and then suddenly developed both pain and stroke symptoms. And so sometimes we don't know. Sometimes patients have no recollection of any trauma or event, and those can be, you know, truly difficult to know, but those are all kind of lumped into the spontaneous category.

Jamie Sessions 4:43

Oh, interesting. That patient and looking backwards is interesting. Does it usually do the symptoms usually happen really suddenly like that? Like they'll hear something and obvious symptoms, or is it a more gradual onset sometimes for those stroke symptoms?

Dr Lee Chung 4:56

It's hard to know. Sometimes folks have sudden pain, and then it's pretty obvious. Sometimes the pain is insidious, and then they may do something like go to massage or get chiropractic manipulation, and then later on that pain turns into stroke symptoms. And so it's always hard for us to know chicken or egg, right? What whether it's some muscular pain that resulted in um uh some other intervention causing the dissection, or if all along there was the blood vessel tear and that's why the pain was there in the first place. Sometimes it's hard to sort out.

Jamie Sessions 5:28

And what kind of symptoms are typical for cervical artery dissection? Are they similar to stroke or are they different?

Dr Lee Chung 5:36

I think they can be divided into two categories. Sometimes there are symptoms from the dissection itself, which is usually pain. And depending on where the blood vessel is damaged, it can be pain in the front of the neck that sometimes can radiate to the eyeball. If it's in one of the vertebral arteries, sometimes the pain is in the back of the neck. And then sometimes intracranially, if there's a dissection, that pain can be referred through the trigenimal system to the kind of orbit, often right above the brow. And so sometimes the location of referred pain can give you a clue in terms of which blood vessel is torn. But the other kind of symptoms one can get from a dissection is if it causes a thrombus and either an occlusion or embolization, and then it causes stroke symptoms. And then those stroke symptoms can be anywhere that's fed by that blood vessel. And so those syndromes can look just like other ischemic strokes.

Jamie Sessions 6:41

All right, so let's take it to the bedside. We have a 38-year-old woman. She comes into the ER with neck pain and a throbbing headache behind her eye. She says that she went to the gym a few days earlier, as she typically does, did some heavy weightlifting. And at that time, she remembers feeling a little bit of a pull in her neck, thought maybe she strained in muscle, but it's not getting better. So she came to the ER where they treated her for the muscle pain and a headache, and then sent her home. Um she comes back the next day with slurred speech and right hand weakness. Does that happen a lot, do you think, where patients come in and they're initially treated just for the localized pain and then later come back with stroke symptoms?

Dr Lee Chung 7:22

Absolutely. And I think it's really difficult for uh emergency medicine providers because they see a lot of pain, a lot of neck pain, right? And the vast majority of the time, it's not a dissection, it's something else, musculoskeletal, etc. And so it's so difficult when there's no other clues in the history to suggest that um this may be a vessel dissection. Um, for this patient, though, you know, I do worry about pain that radiates up to the eye being concerning for uh carotid artery dissection. Um, and I think in general, um, emergency med providers are pretty good at picking up those red flags of, okay, this is not your typical neck strain. There's some extra symptoms that sound a little like a vessel injury. And uh, they tend to be pretty good. And nowadays, I think getting CTA is um is pretty easy. And so I think it's much more commonly used to quickly find a dissection.

Jamie Sessions 8:28

Okay, so now that our patient has come back, though, with the slurred speech and some right-hand weakness, this time they're calling you, they're calling the neurologist. So, what what are your next steps?

Dr Lee Chung 8:39

I think my first one would be to think about acute stroke and probably to think about the time windows as well, right? Because it based on uh when they develop these symptoms, they they may be a candidate for thrombolysis. So I think this would be a great person if they're in the time window to to uh do a stroke alert on. Um essentially, my thoughts would be um how severe are the symptoms, um, what other risks of bleeding, which we can chat about in the setting of dissection, and then are you know, are they a candidate for thrombolysis or other interventions to try to reverse the ischemia?

Jamie Sessions 9:22

All right, so your patient on exam, she had that uh sudden facial drope, she had the right hand weakness, and she has some slurred speech, but she's otherwise healthy. Does this fit the typical presentation for a cervical artery dissection and subsequent stroke?

Dr Lee Chung 9:38

I think it could. The different symptoms that one might get from a vessel dissection kind of depend on what the vessel is and what territories it feeds. And so when someone gets a carotid artery dissection, they may have anterior stroke symptoms. And so those are the most common stroke symptoms, right? And they can look just like other anterior circulation strokes. And so those would be a unilateral weakness or numbness, and those could include a horner syndrome. Uh if the dissection is affecting the sympathetic fibers in um around the carotid artery, they could have tosis, a small pupil, and um it could affect speech, it could cause a field cut. And so I think anterior circulation, carotid dissective could cause any of those symptoms. The posterior circulation dissections, such as in the vertebral artery, uh, can be a little trickier to find because sometimes they're a little more subtle. Often that pain is, you know, in the rear of the head and radiates up to the occiput, but they may also get vertigo or ataxia or imbalance, and you know, those can be kind of hard to sort out from non-stroke causes. They may get double vision or slurred speech from affecting the brain stem. They may get isolated nausea and vomiting. We've seen that before. Um, they may have field cuts from going up to the occipital lobe. So the posterior circulation symptoms can be a little trickier to sort out and identify, but I think in the setting of any kind of sudden onset, especially with neck pain and even potentially a mechanism such as this patient, um, would all fit pretty well. Um, in her case, though, I think uh her eye pain and the symptoms she had fit best with probably a carotid artery dissection.

Jamie Sessions 11:38

So, in general, do you think it's fair to say that if you see a young patient that had some kind of sudden neurological symptom, whether it seems anterior or posterior, and they have that headache or neck pain, that we should be thinking dissection?

Dr Lee Chung 11:50

Definitely. Yeah. I think among young folks, it's a very common story that leads them to a diagnosis of stroke. Um, and so um I think our uh emergency medicine colleagues are pretty tuned into this and are pretty good about um kind of digging in a little bit deeper and looking at those vessels.

Jamie Sessions 12:11

And then what about the patients that are lucky enough to have a dissection diagnosed before they have a stroke? What is the acute and long-term treatment for those patients?

Dr Lee Chung 12:22

There's some debate. I think it also diverges in terms of whether it's a traumatic or spontaneous dissection. I think there's a lot of literature coming out of trauma that supports dual antiplatelet therapy. Um, however, I think it's still a gray area. There's some uh secondary analyses of some big data sets we have of cervical artery dissections that suggest that there are some patients that may benefit from anticoagulation. So I think it's still a kind of moving target and individualized selection for those patients is really important. So I think um uh having neurology or neurosurgery involved would be pretty important to help select the safest treatment to prevent an initial stroke from that dissection.

Jamie Sessions 13:11

And then is that true also? So obviously, if a patient came in with stroke symptoms, we'd go down the stroke pathway and take care of that, treat that. But then would they also have a similar long-term management after that?

Dr Lee Chung 13:23

I think it matters how they heal, and we almost always will continue to watch that blood vessel to make sure that it's healing up well. Sometimes patients can develop secondary complications from those dissections, such as aneurysms or pseudoaneurisms, depending on where the tear is. And those may need a different treatment. Um, sometimes patients will develop pseudoaneurysms that are at risk of rupturing and will need to do um endovascular therapy to try to protect that vessel from rupture and reduce the stroke risk.

Jamie Sessions 14:03

Is the typical dissection patient getting endovascular therapy or only in those extreme cases like the pseudoaneurism?

Dr Lee Chung 14:09

That's a good question. Usually patients don't need an intervention. Um, it's typically reserved for when patients have either really severe occlusion or they're continuing to have strokes despite medical management, or the way the vessel is healing is evolving into a high risk situation. But most of the time we manage these blood vessel tears with just medication. But we have to be vigilant about how they do. Um, and so that's why we get the surveillance imaging. Thankfully, most of the time, 70 to 90 percent patients do really well with just medications.

Jamie Sessions 14:52

Okay, I briefly mentioned, you know, if a patient did come in with a stroke after a dissection, that we would go down the typical stroke pathway, but what about thrombolytics? Are those appropriate in these cases?

Dr Lee Chung 15:02

That's an interesting question. I think intuitively, I would typically be pretty scared to give a patient with a torn blood vessel a clot dissolving medication, right? Like, are we going to rupture that vessel? Are they gonna bleed? Um, it turns out when we look at the registries of patients who've received thrombolytics that the risk of bleeding complications is pretty low, even among dissection as a cause of the stroke. And um, it seems like um it's um the risk is pretty similar to people who don't have a dissection. So it's not considered a contraindication per the American or European guidelines. And we do offer thrombolysis if the symptoms are disabling. Um caution about um the unknowns about the dissection, but we've had many patients with dissections who got thrombolysis and did really well. Um, so I would typically offer it um uh irrespective of whether they have that dissection. Um, in some cases, there is a large vessel occlusion either from the dissection itself or distal embolization, and those patients are still candidates for mechanical thrombectomy through um uh cathether. Um, I think they are challenging cases because um the team, interventional team, has to get past a dissection flap often. Um, sometimes it requires a stent, sometimes uh it makes it more difficult to get a vessel open if if the dissection flap keeps closing down. And we have had cases like that. And so I think it's those are challenging cases, but still ones that we want to carefully consider and offer um uh clot removal if it's feasible.

Jamie Sessions 16:59

What are outcomes typically for cervical artery dissection patients? What do they look like at about a year out?

Dr Lee Chung 17:05

About a year out, patients tend to look really good. Um, I think the mortality is really low, um, probably less than 5%. Most patients recover really well. I think the big question is whether they had a stroke with the dissection or not, right? Patients that didn't have a stroke with the dissection, they tend to do really well. Their brain tissue doesn't have any scarring. Um and the patients that had a stroke, uh, it's usually this the stroke itself that is kind of dictating how they're looking at a year as opposed to the dissection. Um, by a year, most of the time, that blood vessel is is healed. Um the tricky part is getting to that point because within the first couple weeks after dissection, it can hurt. You know, even if there's no stroke, it just hurts. The torn blood vessel is um uh is is can be pretty rough. And so I think supporting them with um uh medications um as that vessel's healing is really important. This is one of the rare situations in which I'll, as a vascular neurologist, prescribe opiate medications because sometimes non-opiate medications just aren't doing it because it hurts so bad. Um so um typically though, once the vessel starts healing, there's a lot of improvement almost universally in that discomfort. So that's good news.

Jamie Sessions 18:25

All right, and then to wrap it up, I think some of our take-home pearls we discussed, and add any if you think of anything else, Dr. Chung, uh cervical artery dissection, something to think about when you see neurosymptoms or strokes in younger patients, especially if they come with headache and neck pain. And then to remember that vertebral dissections will often look like those posterior circulation strokes that we uh see a little bit. And that early treatment uh is best to help prevent an actual stroke being caused by these dissections. Anything to add to that, Dr. Chunk?

Dr Lee Chung 19:01

No, I think that's very good. Um, and I'm just appreciative of our emergency medicine colleagues who tend to be good at seeing these red flags and kind of going the extra mile to look at these vessels when they're worried about a dissection. And then finally, just not to be hesitant about thrombolysis if a dissection patient is otherwise a good candidate due to stroke symptoms.

Jamie Sessions 19:26

All right. Well, thank you very much for joining us today, Dr. Chung.

Dr Lee Chung 19:31

Thank you so much for having me, Jamie.