includes cardiogenic embolism, large artery atherosclerosis, small vessel disease, and a host of less common mechanisms such as a vasculopathy other than dissection. Intracranial vertebral artery occlusive disease due to atherosclerosis is a more common cause of lateral medullary ischemia than is vertebral dissection. (See "Differential diagnosis of transient ischemic attack and acute stroke" and "Stroke: Etiology, classification, and epidemiology" and "Ischemic stroke in children and young adults: Epidemiology, etiology, and risk factors" and "Posterior circulation cerebrovascular syndromes", section on 'Lateral medullary infarction'.) Subarachnoid hemorrhage The differential diagnosis of subarachnoid hemorrhage includes saccular aneurysm rupture, bleeding from a vascular malformation, perimesencephalic nonaneurysmal subarachnoid hemorrhage, and a number of less common causes. Angiography is the key to determining whether subarachnoid hemorrhage is caused by intracranial dissection or another vascular abnormality. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis" and "Nonaneurysmal subarachnoid hemorrhage" and "Perimesencephalic nonaneurysmal subarachnoid hemorrhage".) SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stroke in adults" and "Society guideline links: Stroke in children" and "Society guideline links: Fibromuscular dysplasia".) SUMMARY AND RECOMMENDATIONS Location Extracranial carotid dissections typically occur 2 cm or more beyond the carotid bifurcation, near or adjacent to the level of the skull base. Intracranial carotid dissections are most frequent in the supraclinoid segment. Vertebral artery dissection most often occurs in the cervical transverse processes of C6 to C2 (V2 segment) or the extracranial segment between the transverse process of C2 and the foramen magnum at the base of the skull (V3 segment) ( figure 3). (See 'Anatomy and pathology' above.) Pathophysiology Separation of the arterial wall layers results in dissection. A false lumen arises in the space where blood seeps into the vessel wall ( figure 1). Hemorrhage may https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 13/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate be due to an intimal tear or result from rupture or other pathology in the vasa vasorum. Subintimal dissections cause luminal stenosis or occlusion whereas subadventitial dissections largely result in dissecting aneurysm formation ( figure 2). (See 'Pathophysiology' above.) Etiology Dissection may result from a combination of intrinsic deficiencies of vessel wall integrity and extrinsic factors, including minor trauma. Numerous proposed risk factors and inciting activities have been associated with dissection. (See 'Etiology' above.) Epidemiology Dissection of the cervical and cerebral arteries occurs in about 3 cases per 100,000 individuals across all ages yet accounts for up to one quarter of all strokes in the young. (See 'Epidemiology' above.) Clinical manifestations Evidence from population and hospital-based reports suggests that dissection most often results in ischemic stroke or transient ischemic attack, usually preceded or accompanied by local symptoms such as neck pain, headache, Horner syndrome ( figure 4), and/or cranial neuropathies ( figure 5). However, these studies may underestimate the proportion of cases that are asymptomatic or associated with local symptoms only. Uncommonly, intracranial dissection results in subarachnoid hemorrhage. (See 'Clinical manifestations' above.) Evaluation and diagnosis We obtain urgent noninvasive multimodal imaging with magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the head and neck, or computed tomography (CT) and computed tomography angiography (CTA) of the head and neck to confirm an initial diagnosis of cervicocephalic dissection and to guide serial treatment decisions. While clinical features may raise suspicion for dissection, the diagnosis is confirmed by neuroimaging findings, particularly the demonstration of a long tapered arterial stenosis, a tapered occlusion, a dissecting aneurysm (pseudoaneurysm), an intimal flap, a double lumen, or an intramural hematoma. (See 'Evaluation and diagnosis' above.) Treatment and prognosis The treatment and prognosis of cervicocephalic dissection is reviewed in detail separately. (See "Cerebral and cervical artery dissection: Treatment and prognosis".) Use of UpToDate is subject to the Terms of Use. REFERENCES https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 14/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate 1. Pannone A, Lucchetti G, Stazi G, et al. Internal carotid artery dissection in a patient with Beh et's syndrome. Ann Vasc Surg 1998; 12:463. 2. V lker W, Dittrich R, Grewe S, et al. The outer arterial wall layers are primarily affected in spontaneous cervical artery dissection. Neurology 2011; 76:1463. 3. Downer J, Nadarajah M, Briggs E, et al. The location of origin of spontaneous extracranial internal carotid artery dissection is adjacent to the skull base. J Med Imaging Radiat Oncol 2014; 58:408. 4. Chaves C, Estol C, Esnaola MM, et al. Spontaneous intracranial internal carotid artery dissection: report of 10 patients. Arch Neurol 2002; 59:977. 5. Arnold M, Bousser MG, Fahrni G, et al. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke 2006; 37:2499. 6. Lee VH, Brown RD Jr, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology 2006; 67:1809. 7. Arnold M, Kappeler L, Georgiadis D, et al. Gender differences in spontaneous cervical artery dissection. Neurology 2006; 67:1050. 8. Touz E, Gauvrit JY, Moulin T, et al. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology 2003; 61:1347. 9. Hassan AE, Zacharatos H, Mohammad YM, et al. Comparison of single versus multiple spontaneous extra- and/or intracranial arterial dissection. J Stroke Cerebrovasc Dis 2013; 22:42. 10. Arnold M, De Marchis GM, Stapf C, et al. Triple and quadruple spontaneous cervical artery dissection: presenting characteristics and long-term outcome. J Neurol Neurosurg Psychiatry 2009; 80:171. 11. Besselmann M, Vennemann B, Lowens S, et al. Internal carotid artery dissection. Neurology 2000; 54:442. 12. Ulbricht D, Diederich NJ, Hermanns-L T, et al. Cervical artery dissection: An atypical presentation with Ehlers-Danlos-like collagen pathology? Neurology 2004; 63:1708. 13. Brandt T, Morcher M, Hausser I. Association of cervical artery dissection with connective tissue abnormalities in skin and arteries. Front Neurol Neurosci 2005; 20:16. 14. Brandt T, Orberk E, Weber R, et al. Pathogenesis of cervical artery dissections: association with connective tissue abnormalities. Neurology 2001; 57:24. 15. Lucas C, Moulin T, Deplanque D, et al. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke 1998; 29:2646. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 15/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate 16. Morel A, Naggara O, Touz E, et al. Mechanism of ischemic infarct in spontaneous cervical artery dissection. Stroke 2012; 43:1354. 17. Arnold M, Cumurciuc R, Stapf C, et al. Pain as the only symptom of cervical artery dissection. J Neurol Neurosurg Psychiatry 2006; 77:1021. 18. Mehdi E, Aralasmak A, Toprak H, et al. Craniocervical Dissections: Radiologic Findings, Pitfalls, Mimicking Diseases: A Pictorial Review. Curr Med Imaging Rev 2018; 14:207. 19. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ 2000; 163:38. 20. Engelter ST, Grond-Ginsbach C, Metso TM, et al. Cervical artery dissection: trauma and other potential mechanical trigger events. Neurology 2013; 80:1950. 21. De Giorgio F, Vetrugno G, De Mercurio D, et al. 1. Dissection of the vertebral artery during a basketball game: a case report. Med Sci Law 2004; 44:80. 22. Stamboulis E, Raptis G, Andrikopoulou A, et al. Spontaneous internal carotid artery dissection: an uncommon cause of recurrent postpartum headache. J Neuroimaging 2011; 21:76. 23. Paciaroni M, Bogousslavsky J. Cerebrovascular complications of neck manipulation. Eur Neurol 2009; 61:112. 24. Reuter U, H mling M, Kavuk I, et al. Vertebral artery dissections after chiropractic neck manipulation in Germany over three years. J Neurol 2006; 253:724. 25. Leon-Sanchez A, Cuetter A, Ferrer G. Cervical spine manipulation: an alternative medical procedure with potentially fatal complications. South Med J 2007; 100:201. 26. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003; 60:1424. 27. Ernst E. Adverse effects of spinal manipulation: a systematic review. J R Soc Med 2007; 100:330. 28. Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke 2014; 45:3155. 29. Caso V, Paciaroni M, Bogousslavsky J. Environmental factors and cervical artery dissection. Front Neurol Neurosci 2005; 20:44. 30. Faivre A, Abdelfettah Z, Rodriguez S, Nicoli F. Neurological picture. Bilateral internal carotid artery dissection due to elongated styloid processes and shaking dancing. J Neurol Neurosurg Psychiatry 2009; 80:1154. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 16/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate 31. Prabhakar S, Bhatia R, Khandelwal N, et al. Vertebral artery dissection due to indirect neck trauma : an underrecognised entity. Neurol India 2001; 49:384. 32. Faivre A, Chapon F, Combaz X, Nicoli F. Internal carotid artery dissection occurring during intensive practice with Wii video sports games. Neurology 2009; 73:1242. 33. Dharmasaroja P, Dharmasaroja P. Sports-related internal carotid artery dissection: pathogenesis and therapeutic point of view. Neurologist 2008; 14:307. 34. Burneo JG, Shatz R, Papamitsakis NI, Mitsias PD. Neuroimages: amusement park stroke. Neurology 2000; 55:564. 35. Sheikh SI, Singhal AB. Extension of "roller coaster dissection" after tissue plasminogen activator. AJNR Am J Neuroradiol 2010; 31:E4. 36. Schneck M, Simionescu M, Bijari A. Bilateral vertebral artery dissection possibly precipitated in delayed fashion as a result of roller coaster rides. J Stroke Cerebrovasc Dis 2008; 17:39. 37. Blacker DJ, Wijdicks EF. A ripping roller coaster ride. Neurology 2003; 61:1255. 38. Lascelles K, Hewes D, Ganesan V. An unexpected consequence of a roller coaster ride. J Neurol Neurosurg Psychiatry 2001; 71:704. 39. Biousse V, Chabriat H, Amarenco P, Bousser MG. Roller-coaster-induced vertebral artery dissection. Lancet 1995; 346:767. 40. Bartsch T, Palaschewski M, Thilo B, et al. Internal carotid artery dissection and stroke after SCUBA diving: a case report and review of the literature. J Neurol 2009; 256:1916. 41. Walters GK. Cervicocranial artery dissection and scuba diving: Is there a link or is it serendipity? Undersea Hyperb Med 2018; 45:65. 42. Delasobera BE, Osborn SR, Davis JE. Thunderclap headache with orgasm: a case of basilar artery dissection associated with sexual intercourse. J Emerg Med 2012; 43:e43. 43. Karnik R, Rothmund T, Bonner G, et al. Inline skating as a possible cause of consecutive bilateral vertebral artery dissection. Acta Neurol Scand 2000; 101:70. 44. Furtner M, Werner P, Felber S, Schmidauer C. Bilateral carotid artery dissection caused by springboard diving. Clin J Sport Med 2006; 16:76. 45. Abe A, Nishiyama Y, Kamiyama H, et al. Symptomatic middle cerebral artery dissection in a young tennis player. J Nippon Med Sch 2009; 76:209. 46. DeBehnke DJ, Brady W. Vertebral artery dissection due to minor neck trauma. J Emerg Med 1994; 12:27. 47. Wechsler B, Kim H, Hunter J. Trampolines, children, and strokes. Am J Phys Med Rehabil 2001; 80:608. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 17/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate 48. Slankamenac P, Jesic A, Avramov P, et al. Multiple cervical artery dissection in a volleyball player. Arch Neurol 2010; 67:1024. 49. Low A, Dovey J, Ash-Miles J. Vertebral artery dissection in weightlifter with performance enhancing drug use. BMJ Case Rep 2011; 2011. 50. Cassidy JD, Boyle E, C t P, et al. Risk of Carotid Stroke after Chiropractic Care: A Population- Based Case-Crossover Study. J Stroke Cerebrovasc Dis 2017; 26:842. 51. Paulus JK, Thaler DE. Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? Yes. Chiropr Man Therap 2016; 24:42. 52. Chung CL, C t P, Stern P, L'Esp rance G. The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. J Manipulative Physiol Ther 2015; 38:672. 53. Debette S, Markus HS. The genetics of cervical artery dissection: a systematic review. Stroke 2009; 40:e459. 54. Grond-Ginsbach C, Debette S. The association of connective tissue disorders with cervical artery dissections. Curr Mol Med 2009; 9:210. 55. Debette S, Goeggel Simonetti B, Schilling S, et al. Familial occurrence and heritable connective tissue disorders in cervical artery dissection. Neurology 2014; 83:2023. 56. Giossi A, Ritelli M, Costa P, et al. Connective tissue anomalies in patients with spontaneous cervical artery dissection. Neurology 2014; 83:2032. 57. Gdynia HJ, K hnlein P, Ludolph AC, Huber R. Connective tissue disorders in dissections of the carotid or vertebral arteries. J Clin Neurosci 2008; 15:489. 58. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009; 8:668. 59. de Bray JM, Marc G, Pautot V, et al. Fibromuscular dysplasia may herald symptomatic recurrence of cervical artery dissection. Cerebrovasc Dis 2007; 23:448. 60. Olin JW, Froehlich J, Gu X, et al. The United States Registry for Fibromuscular Dysplasia: results in the first 447 patients. Circulation 2012; 125:3182. 61. Olin JW, Gornik HL, Bacharach JM, et al. Fibromuscular dysplasia: state of the science and critical unanswered questions: a scientific statement from the American Heart Association. Circulation 2014; 129:1048. 62. Kadian-Dodov D, Gornik HL, Gu X, et al. Dissection and Aneurysm in Patients With Fibromuscular Dysplasia: Findings From the U.S. Registry for FMD. J Am Coll Cardiol 2016; 68:176. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 18/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate 63. Talarowska P, Dobrowolski P, Klisiewicz A, et al. High incidence and clinical characteristics of fibromuscular dysplasia in patients with spontaneous cervical artery dissection: The ARCADIA-POL study. Vasc Med 2019; 24:112. 64. Rouvi re S, Michelini R, Sarda P, Pag s M. Spontaneous carotid artery dissection in two siblings with osteogenesis imperfecta. Cerebrovasc Dis 2004; 17:270. 65. Thal DR, Schober R, Schlote W. Carotid artery dissection in a young adult: cystic medial necrosis associated with an increased elastase content. Clin Neuropathol 1997; 16:180. 66. Heged s K. Reticular fiber deficiency in the intracranial arteries of patients with dissecting aneurysm and review of the possible pathogenesis of previously reported cases. Eur Arch Psychiatry Neurol Sci 1985; 235:102. 67. Weiss N, Demeret S, Sonneville R, et al. Bilateral internal carotid artery dissection in cystathionine beta-synthase deficiency. Eur Neurol 2006; 55:177. 68. Larranaga J, Rutecki GW, Whittier FC. Spontaneous vertebral artery dissection as a complication of autosomal dominant polycystic kidney disease. Am J Kidney Dis 1995; 25:70. 69. Vila N, Mill n M, Ferrer X, et al. Levels of alpha1-antitrypsin in plasma and risk of spontaneous cervical artery dissections: a case-control study. Stroke 2003; 34:E168. 70. Fantaneanu T, Veinot JP, Torres C, et al. Cervical arterial dissections due to segmental mediolytic arteriopathy. Neurology 2011; 77:295. 71. Mawet J, Boukobza M, Franc J, et al. Reversible cerebral vasoconstriction syndrome and cervical artery dissection in 20 patients. Neurology 2013; 81:821. 72. Rubinstein SM, Peerdeman SM, van Tulder MW, et al. A systematic review of the risk factors for cervical artery dissection. Stroke 2005; 36:1575. 73. Barbour PJ, Castaldo JE, Rae-Grant AD, et al. Internal carotid artery redundancy is significantly associated with dissection. Stroke 1994; 25:1201. 74. Kim BJ, Yang E, Kim NY, et al. Vascular Tortuosity May Be Associated With Cervical Artery Dissection. Stroke 2016; 47:2548. 75. Schievink WI, Mokri B, Piepgras DG. Angiographic frequency of saccular intracranial aneurysms in patients with spontaneous cervical artery dissection. J Neurosurg 1992; 76:62. 76. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001; 344:898. 77. Pepin M, Schwarze U, Superti-Furga A, Byers PH. Clinical and genetic features of Ehlers- Danlos syndrome type IV, the vascular type. N Engl J Med 2000; 342:673. 78. Schievink WI, Bj rnsson J, Piepgras DG. Coexistence of fibromuscular dysplasia and cystic medial necrosis in a patient with Marfan's syndrome and bilateral carotid artery dissections. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 19/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Stroke 1994; 25:2492. 79. Harrer JU, Sasse A, Kl tzsch C. Intimal flap in a common carotid artery in a patient with Marfan's syndrome. Ultraschall Med 2006; 27:487. 80. Wityk RJ, Zanferrari C, Oppenheimer S. Neurovascular complications of marfan syndrome: a retrospective, hospital-based study. Stroke 2002; 33:680. 81. Faivre L, Collod-Beroud G, Loeys BL, et al. Effect of mutation type and location on clinical outcome in 1,013 probands with Marfan syndrome or related phenotypes and FBN1 mutations: an international study. Am J Hum Genet 2007; 81:454. 82. Guillon B, Berthet K, Benslamia L, et al. Infection and the risk of spontaneous cervical artery dissection: a case-control study. Stroke 2003; 34:e79. 83. Hunter MD, Moon YP, Miller EC, et al. Influenza-Like Illness is Associated with Increased Short-Term Risk of Cervical Artery Dissection. J Stroke Cerebrovasc Dis 2021; 30:105490. 84. Witsch J, Rutrick SB, Lansdale KN, et al. Influenza-Like Illness as a Short-Term Risk Factor for Arterial Dissection. Stroke 2023; 54:e66. 85. Pezzini A, Caso V, Zanferrari C, et al. Arterial hypertension as risk factor for spontaneous cervical artery dissection. A case-control study. J Neurol Neurosurg Psychiatry 2006; 77:95. 86. Debette S, Metso T, Pezzini A, et al. Association of vascular risk factors with cervical artery dissection and ischemic stroke in young adults. Circulation 2011; 123:1537. 87. Metso TM, Metso AJ, Salonen O, et al. Adult cervicocerebral artery dissection: a single-center study of 301 Finnish patients. Eur J Neurol 2009; 16:656. 88. Metso TM, Tatlisumak T, Debette S, et al. Migraine in cervical artery dissection and ischemic stroke patients. Neurology 2012; 78:1221. 89. Rist PM, Diener HC, Kurth T, Sch rks M. Migraine, migraine aura, and cervical artery dissection: a systematic review and meta-analysis. Cephalalgia 2011; 31:886. 90. De Giuli V, Grassi M, Lodigiani C, et al. Association Between Migraine and Cervical Artery Dissection: The Italian Project on Stroke in Young Adults. JAMA Neurol 2017; 74:512. 91. Magalh es JE, Sampaio Rocha-Filho PA. Migraine and cerebrovascular diseases: Epidemiology, pathophysiological, and clinical considerations. Headache 2018; 58:1277. 92. Benninger DH, Herrmann FR, Georgiadis D, et al. Increased prevalence of hyperhomocysteinemia in cervical artery dissection causing stroke: a case-control study. Cerebrovasc Dis 2009; 27:241. 93. Ortiz J, Ruland S. Cervicocerebral artery dissection. Curr Opin Cardiol 2015; 30:603. 94. Arnold M, Pannier B, Chabriat H, et al. Vascular risk factors and morphometric data in cervical artery dissection: a case-control study. J Neurol Neurosurg Psychiatry 2009; 80:232. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 20/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate 95. Raser JM, Mullen MT, Kasner SE, et al. Cervical carotid artery dissection is associated with styloid process length. Neurology 2011; 77:2061. 96. Baldino G, Di Girolamo C, De Blasis G, Gori A. Eagle Syndrome and Internal Carotid Artery Dissection: Description of Five Cases Treated in Two Italian Institutions and Review of the Literature. Ann Vasc Surg 2020; 67:565.e17. 97. Salehi Omran S, Parikh NS, Poisson S, et al. Association between Pregnancy and Cervical Artery Dissection. Ann Neurol 2020; 88:596. 98. Traenka C, Kloss M, Strom T, et al. Rare genetic variants in patients with cervical artery dissection. Eur Stroke J 2019; 4:355. 99. Wang K, Zhao S, Zhang Q, et al. Whole-exome sequencing reveals known and novel variants in a cohort of intracranial vertebral-basilar artery dissection (IVAD). J Hum Genet 2018; 63:1119. 100. Debette S, Kamatani Y, Metso TM, et al. Common variation in PHACTR1 is associated with susceptibility to cervical artery dissection. Nat Genet 2015; 47:78. 101. Martin JJ, Hausser I, Lyrer P, et al. Familial cervical artery dissections: clinical, morphologic, and genetic studies. Stroke 2006; 37:2924. 102. Schievink WI, Mokri B, Piepgras DG, Kuiper JD. Recurrent spontaneous arterial dissections: risk in familial versus nonfamilial disease. Stroke 1996; 27:622. 103. Grond-Ginsbach C, Klima B, Weber R, et al. Exclusion mapping of the genetic predisposition for cervical artery dissections by linkage analysis. Ann Neurol 2002; 52:359. 104. Wiest T, Hyrenbach S, Bambul P, et al. Genetic analysis of familial connective tissue alterations associated with cervical artery dissections suggests locus heterogeneity. Stroke 2006; 37:1697. 105. Atalay YB, Piran P, Chatterjee A, et al. Prevalence of Cervical Artery Dissection Among Hospitalized Patients With Stroke by Age in a Nationally Representative Sample From the United States. Neurology 2021; 96:e1005. 106. Beletsky V, Nadareishvili Z, Lynch J, et al. Cervical arterial dissection: time for a therapeutic trial? Stroke 2003; 34:2856. 107. Schievink WI, Mokri B, O'Fallon WM. Recurrent spontaneous cervical-artery dissection. N Engl J Med 1994; 330:393. 108. Paciaroni M, Georgiadis D, Arnold M, et al. Seasonal variability in spontaneous cervical artery dissection. J Neurol Neurosurg Psychiatry 2006; 77:677. 109. Kim BM, Kim SH, Kim DI, et al. Outcomes and prognostic factors of intracranial unruptured vertebrobasilar artery dissection. Neurology 2011; 76:1735. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 21/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate 110. Debette S, Compter A, Labeyrie MA, et al. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol 2015; 14:640. 111. Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology 2011; 77:1174. 112. Morris NA, Merkler AE, Gialdini G, Kamel H. Timing of Incident Stroke Risk After Cervical Artery Dissection Presenting Without Ischemia. Stroke 2017; 48:551. 113. Mokri B, Sundt TM Jr, Houser OW, Piepgras DG. Spontaneous dissection of the cervical internal carotid artery. Ann Neurol 1986; 19:126. 114. Manabe H, Yonezawa K, Kato T, et al. Incidence of intracranial arterial dissection in non- emergency outpatients complaining of headache: preliminary investigation with MRI/MRA examinations. Acta Neurochir Suppl 2010; 107:41. 115. Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology 1995; 45:1517. 116. Gallerini S, Marsili L, Bartalucci M, et al. Headache secondary to cervical artery dissections: practice pointers. Neurol Sci 2019; 40:613. 117. Diamanti S, Longoni M, Agostoni EC. Leading symptoms in cerebrovascular diseases: what about headache? Neurol Sci 2019; 40:147. 118. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018; 38:1. 119. Mitsias P, Ramadan NM. Headache in ischemic cerebrovascular disease. Part I: Clinical features. Cephalalgia 1992; 12:269. 120. Guillon B, Biousse V, Massiou H, Bousser MG. Orbital pain as an isolated sign of internal carotid artery dissection. A diagnostic pitfall. Cephalalgia 1998; 18:222. 121. Richoz O, Scott Schutz J, M gevand P. Pearls & Oy-sters: unusual manifestations of bilateral carotid artery dissection: deep monocular pains. Neurology 2012; 78:e16. 122. Shankar Kikkeri N, Nagarajan E, Sakuru RC, Bollu PC. Horner Syndrome Due to Spontaneous Internal Carotid Artery Dissection. Cureus 2018; 10:e3382. 123. Flaherty PM, Flynn JM. Horner syndrome due to carotid dissection. J Emerg Med 2011; 41:43. 124. Mokri B, Silbert PL, Schievink WI, Piepgras DG. Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery. Neurology 1996; 46:356. 125. Mattioni A, Paciaroni M, Sarchielli P, et al. Multiple cranial nerve palsies in a patient with internal carotid artery dissection. Eur Neurol 2007; 58:125. 126. English SW, Passe TJ, Lindell EP, Klaas JP. Multiple cranial neuropathies as a presentation of spontaneous internal carotid artery dissection: A case report and literature review. J Clin https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 22/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Neurosci 2018; 50:129. 127. Song JX, Lin XM, Hao ZQ, et al. Ocular manifestations of internal carotid artery dissection. Int J Ophthalmol 2019; 12:834. 128. Crum B, Mokri B, Fulgham J. Spinal manifestations of vertebral artery dissection. Neurology 2000; 55:304. 129. Wagner F, Mono ML, K ndgen H, et al. Cervical polyradiculopathy caused by vertebral artery dissection. Lancet 2013; 381:1510. 130. Quinn C, Salameh J. Vertebral artery dissection causing an acute C5 radiculopathy. Neurology 2013; 81:1101. 131. Eberhardt O, Topka H. Compressive Cervical Radiculopathy due to Vertebral Artery Dissection. J Stroke Cerebrovasc Dis 2015; 24:e115. 132. Pelkonen O, Tikkakoski T, Luotonen J, Sotaniemi K. Pulsatile tinnitus as a symptom of cervicocephalic arterial dissection. J Laryngol Otol 2004; 118:193. 133. Shimizu Y, Yagi M. Pulsatile tinnitus and carotid artery dissection. Auris Nasus Larynx 2018; 45:175. 134. Kellert L, Kloss M, Pezzini A, et al. Prognostic significance of pulsatile tinnitus in cervical artery dissection. Eur J Neurol 2016; 23:1183. 135. Biousse V, Touboul PJ, D'Anglejan-Chatillon J, et al. Ophthalmologic manifestations of internal carotid artery dissection. Am J Ophthalmol 1998; 126:565. 136. Biousse V, Schaison M, Touboul PJ, et al. Ischemic optic neuropathy associated with internal carotid artery dissection. Arch Neurol 1998; 55:715. 137. Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist 2012; 18:245. 138. Cadena R. Cervical artery dissection: early recognition and stroke prevention. Emerg Med Pract 2016; 18:1. 139. Traenka C, Dougoud D, Simonetti BG, et al. Cervical artery dissection in patients 60 years: Often painless, few mechanical triggers. Neurology 2017; 88:1313. 140. Hakimi R, Sivakumar S. Imaging of Carotid Dissection. Curr Pain Headache Rep 2019; 23:2. 141. Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol 2009; 193:1167. 142. Vertinsky AT, Schwartz NE, Fischbein NJ, et al. Comparison of multidetector CT angiography and MR imaging of cervical artery dissection. AJNR Am J Neuroradiol 2008; 29:1753. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 23/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate 143. Provenzale JM. MRI and MRA for evaluation of dissection of craniocerebral arteries: lessons from the medical literature. Emerg Radiol 2009; 16:185. 144. Benninger DH, Baumgartner RW. Ultrasound diagnosis of cervical artery dissection. Front Neurol Neurosci 2006; 21:70. 145. Imray CH, Pattinson KT. Potential role for TCD-directed antiplatelet agents in symptomatic carotid artery dissection. Stroke 2006; 37:767. 146. Sengelhoff C, Nebelsieck J, Nassenstein I, et al. Neurosonographical follow-up in patients with spontaneous cervical artery dissection. Neurol Res 2008; 30:687. 147. Wessels T, Mosso M, Krings T, et al. Extracranial and intracranial vertebral artery dissection: long-term clinical and duplex sonographic follow-up. J Clin Ultrasound 2008; 36:472. 148. Nebelsieck J, Sengelhoff C, Nassenstein I, et al. Sensitivity of neurovascular ultrasound for the detection of spontaneous cervical artery dissection. J Clin Neurosci 2009; 16:79. 149. Arnold M, Baumgartner RW, Stapf C, et al. Ultrasound diagnosis of spontaneous carotid dissection with isolated Horner syndrome. Stroke 2008; 39:82. 150. Dittrich R, Dziewas R, Ritter MA, et al. Negative ultrasound findings in patients with cervical artery dissection. Negative ultrasound in CAD. J Neurol 2006; 253:424. 151. Choi KD, Jo JW, Park KP, et al. Diffusion-weighted imaging of intramural hematoma in vertebral artery dissection. J Neurol Sci 2007; 253:81. 152. Lum C, Chakraborty S, Schlossmacher M, et al. Vertebral artery dissection with a normal- appearing lumen at multisection CT angiography: the importance of identifying wall hematoma. AJNR Am J Neuroradiol 2009; 30:787. 153. Bonati LH, Wetzel SG, Gandjour J, et al. Diffusion-weighted imaging in stroke attributable to internal carotid artery dissection: the significance of vessel patency. Stroke 2008; 39:483. 154. Bachmann R, Nassenstein I, Kooijman H, et al. High-resolution magnetic resonance imaging (MRI) at 3.0 Tesla in the short-term follow-up of patients with proven cervical artery dissection. Invest Radiol 2007; 42:460. 155. Naggara O, Touz E, Marsico R, et al. High-resolution MR imaging of periarterial edema associated with biological inflammation in spontaneous carotid dissection. Eur Radiol 2009; 19:2255. 156. Silverman IE, Wityk RJ. Transient migraine-like symptoms with internal carotid artery dissection. Clin Neurol Neurosurg 1998; 100:116. Topic 14082 Version 37.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 24/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate GRAPHICS The progression of a dissection, thrombus development, and total vessel occlusion Courtesy of Dr. Mounzer Kassab. Graphic 57866 Version 2.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 25/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Mechanism of dissecting aneurysm formation Lateral and cross-sectional schematic view of the carotid artery. (A) Aneurysmal dilatation of the vessel related to a hemorrhage between the media and the adventitia (subadventitial dissection). (B) Communication between the arterial lumen and the dissection cavity or disappearance of the hematoma may lead to the formation of an extraluminal pouch or a fusiform dilatation. Reproduced with permission from: Guillon B, Brunereau L, Biousse V, et al. Long-term follow-up of aneurysms developed during extracranial internal carotid artery dissection. Neurology 1999; 53:117. Copyright 1999 Lippincott Williams & Wilkins. Graphic 57174 Version 4.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 26/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Segments of the vertebral artery The vertebral artery is divided into four anatomic segments: V1 Origin of the vessel to the foramina of the sixth cervical (C6) transverse process. V2 Intraforaminal segment from the sixth to the second cervical vertebral body (C6 to C2). V3 From the second cervical (C2) foramina to the base of the skull. V4 Intracerebral segment of the vertebral artery. The vertebral arteries merge to form the basilar artery and are intradural. Graphic 56466 Version 6.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 27/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Pathology of internal carotid artery dissection Elastica van Gieson stain of specimens from a 61-year-old man with internal carotid artery dissection and fibromuscular dysplasia. (A) Postmortem exposition of intramural hematoma of the right internal carotid artery above the bifurcation (arrow). (B) Cross-section of the dissected artery shows subintimal and intramedial hematoma (small arrows). (C) Longitudinal section with zipper-like separation within the arterial wall (large arrow) corresponding to the false lumen and myxoid degeneration of the media (small arrows). Asterisk: true lumen; Scale bar: 0.25 mm. Reproduced with permission from: Besselmann M, Vennemann B, Lowens S, et al. Internal carotid artery dissection. Neurology 2000; 54:442. Copyright 2000 Lippincott Williams & Wilkins. Graphic 73102 Version 4.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 28/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Horner syndrome due to internal carotid artery dissection (A) Horner syndrome (miosis and ptosis). (B) Multiple left frontoparietal acute ischemic lesions on diffusion- weighted MRI. (C) Carotid angiography with evidence of left extracranial internal carotid artery occlusion. (D) Internal carotid artery mural hematoma due to dissection evident on MRI scan. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 29/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate (E) Intimal flap (arrows) appearance on Duplex scan, a pathognomonic sign of dissection. Reproduced with permission from: Mazzucco S, Rizzuto N. Teaching NeuroImage: Horner syndrome due to internal carotid artery dissection. Neurology 2006; 66:E19. Copyright 2006 Lippincott Williams & Wilkins. Graphic 80623 Version 5.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 30/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Isolated hypoglossal nerve palsy due to internal carotid artery dissection (A) The patient's tongue deviated to the left. (B) T1-weighted MRI demonstrates narrowing of the lumen and intramural hematoma in the left internal carotid artery. (C) True fast MRI with steady-state precession reveals the anatomic juxtaposition of the hypoglossal nerve (arrowhead) and the dissected internal carotid artery (arrow). Reproduced with permission from: Okunomiya T, Kageyama T, Suenaga T. Teaching NeuroImages: Isolated hypoglossal nerve palsy due to internal carotid artery dissection. Neurology 2012; 79:e37. Copyright 2012 Lippincott Williams & Wilkins. Graphic 86467 Version 4.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 31/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate String sign on MR angiography Left internal carotid artery dissection in a 43-year-old man. A hemorrhagic crescent on axial T1 cervical MRI (A) and the string sign on follow-up neck MR angiography (B) are consistent with dissection. MRI: magnetic resonance imaging; MR: magnetic resonance. Reproduced with permission from: Pary LF, Rodnitzky RL. Traumatic internal carotid artery dissection associated with taekwondo. Neurology 2003; 60:1392. Copyright 2003 Lippincott Williams & Wilkins. Graphic 65212 Version 6.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 32/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Flame-shaped occlusion of internal carotid artery from dissection Digital subtraction angiogram (lateral projection) shows an internal carotid artery occlusion secondary to dissection, as indicated by the typical flame- shaped appearance and location of the occlusion distal to the carotid bifurcation. Reproduced with permission from: Koch S, Lorenzo D, Rabinstein AA, Lam B. Ischemic optic neuropathy and carotid dissection. Neurology 2005; 64:827. Copyright 2005 Lippincott Williams & Wilkins. Graphic 61851 Version 5.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 33/39 7/6/23, 12:24 PM Cerebral and cervical artery dissection: Clinical features and diagnosis - UpToDate Intracranial dissection with intimal flap (A, B) Diffusion-weighted sequence of MRI of the brain shows acute infarction in the right MCA territory. (C, D) Catheter angiography showed irregularities of the right supraclinoid internal carotid artery, extending into the M1 segment of the right MCA. An intimal flap (arrow) indicates dissection. MRI: magnetic resonance imaging; MCA: middle cerebral artery. Reproduced with permission from: Suter B, El-Hakam LM. Child neurology: stroke due to nontraumatic intracranial dissection in a child. Neurology 2009; 72:e100. Copyright 2009 Lippincott Williams & Wilkins. Graphic 55635 Version 6.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-clinical-features-and-diagnosis/print 34/39 7/6/23, 12:24 PM