Vessel monitoring and duration of antithrombotic therapy Repeat neurovascular imaging is suggested after three to six months from symptom onset or diagnosis of dissection to assess the status of the artery or arteries affected by dissection. For patients treated with anticoagulation in the acute phase, it is reasonable to stop warfarin and start long-term antiplatelet therapy after six months of anticoagulation, as long as symptoms are not recurrent and the arterial lesion is thrombosed or healed. (See 'Vessel monitoring and repeat imaging' above and 'Duration of antithrombotic therapy' above.) Recurrent ischemia requires evaluation for all causes Recurrence of TIA or ischemic stroke may be due to dissection or another stroke mechanism (eg, large artery atherosclerosis, cardiac embolism, small vessel disease, or other determined etiology) and should be thoroughly evaluated for all causes. (See 'Recurrent ischemia' above.) Subarachnoid hemorrhage due to intracranial dissection Subarachnoid hemorrhage is an uncommon complication of intracranial dissection and has a high risk of early rebleeding. Early repair is typically recommended. (See 'Subarachnoid hemorrhage due to intracranial dissection' above.) ACKNOWLEDGMENT The UpToDate editorial staff acknowledges Jeffrey Saver, MD, who contributed to earlier versions of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Kasner SE. CADISS: a feasibility trial that answered its question. Lancet Neurol 2015; 14:342. 2. Engelter ST, Rutgers MP, Hatz F, et al. Intravenous thrombolysis in stroke attributable to cervical artery dissection. Stroke 2009; 40:3772. 3. Georgiadis D, Baumgartner RW. Thrombolysis in cervical artery dissection. 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Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e601S. 21. Serkin Z, Le S, Sila C. Treatment of Extracranial Arterial Dissection: the Roles of Antiplatelet Agents, Anticoagulants, and Stenting. Curr Treat Options Neurol 2019; 21:48. 22. 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. 23. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364. 24. Debette S, Mazighi M, Bijlenga P, et al. 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Vasc Med 2011; 16:35. 26. CADISS trial investigators, Markus HS, Hayter E, et al. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol 2015; 14:361. 27. Markus HS, Levi C, King A, et al. Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection: The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA Neurol 2019; 76:657. 28. Engelter ST, Traenka C, Gensicke H, et al. Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial. Lancet Neurol 2021; 20:341. 29. Kasner SE. Antithrombotic therapy for cervical arterial dissection. Lancet Neurol 2021; 20:328. 30. Kennedy F, Lanfranconi S, Hicks C, et al. Antiplatelets vs anticoagulation for dissection: CADISS nonrandomized arm and meta-analysis. Neurology 2012; 79:686. 31. Chowdhury MM, Sabbagh CN, Jackson D, et al. Antithrombotic treatment for acute extracranial carotid artery dissections: a meta-analysis. Eur J Vasc Endovasc Surg 2015; 50:148. 32. Metso TM, Metso AJ, Helenius J, et al. Prognosis and safety of anticoagulation in intracranial artery dissections in adults. Stroke 2007; 38:1837. 33. Arauz A, M rquez JM, Artigas C, et al. Recanalization of vertebral artery dissection. Stroke 2010; 41:717. 34. Baracchini C, Tonello S, Meneghetti G, Ballotta E. Neurosonographic monitoring of 105 spontaneous cervical artery dissections: a prospective study. Neurology 2010; 75:1864. 35. Larsson SC, King A, Madigan J, et al. Prognosis of carotid dissecting aneurysms: Results from CADISS and a systematic review. Neurology 2017; 88:646. 36. 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. 37. Nedeltchev K, Bickel S, Arnold M, et al. R2-recanalization of spontaneous carotid artery dissection. Stroke 2009; 40:499. 38. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009; 8:668. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 15/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate 39. Arauz A, Hoyos L, Espinoza C, et al. Dissection of cervical arteries: Long-term follow-up study of 130 consecutive cases. Cerebrovasc Dis 2006; 22:150. 40. 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. 41. Donas KP, Mayer D, Guber I, et al. Endovascular repair of extracranial carotid artery dissection: current status and level of evidence. J Vasc Interv Radiol 2008; 19:1693. 42. Ansari SA, Thompson BG, Gemmete JJ, Gandhi D. Endovascular treatment of distal cervical and intracranial dissections with the neuroform stent. Neurosurgery 2008; 62:636. 43. Ecker RD, Levy EI, Hopkins LN. Acute neuroform stenting of a symptomatic petrous dissection. J Invasive Cardiol 2007; 19:E137. 44. Cohen JE, Leker RR, Gotkine M, et al. Emergent stenting to treat patients with carotid artery dissection: clinically and radiologically directed therapeutic decision making. Stroke 2003; 34:e254. 45. Biondi A, Katz JM, Vallabh J, et al. Progressive symptomatic carotid dissection treated with multiple stents. Stroke 2005; 36:e80. 46. Kadkhodayan Y, Jeck DT, Moran CJ, et al. Angioplasty and stenting in carotid dissection with or without associated pseudoaneurysm. AJNR Am J Neuroradiol 2005; 26:2328. 47. Edgell RC, Abou-Chebl A, Yadav JS. Endovascular management of spontaneous carotid artery dissection. J Vasc Surg 2005; 42:854. 48. Kim BM, Shin YS, Kim SH, et al. Incidence and risk factors of recurrence after endovascular treatment of intracranial vertebrobasilar dissecting aneurysms. Stroke 2011; 42:2425. 49. M ller BT, Luther B, Hort W, et al. Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg 2000; 31:980. 50. Chiche L, Praquin B, Koskas F, Kieffer E. Spontaneous dissection of the extracranial vertebral artery: indications and long-term outcome of surgical treatment. Ann Vasc Surg 2005; 19:5. 51. Ono H, Nakatomi H, Tsutsumi K, et al. Symptomatic recurrence of intracranial arterial dissections: follow-up study of 143 consecutive cases and pathological investigation. Stroke 2013; 44:126. 52. Debette S, Compter A, Labeyrie MA, et al. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol 2015; 14:640. 53. Mizutani T, Aruga T, Kirino T, et al. Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 1995; 36:905. 54. Bond KM, Krings T, Lanzino G, Brinjikji W. Intracranial dissections: A pictorial review of pathophysiology, imaging features, and natural history. J Neuroradiol 2021; 48:176. https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 16/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate 55. Paciaroni M, Bogousslavsky J. Cerebrovascular complications of neck manipulation. Eur Neurol 2009; 61:112. 56. 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. 57. Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology 2011; 77:1174. 58. Arnold M, Bousser MG, Fahrni G, et al. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke 2006; 37:2499. 59. Milhaud D, de Freitas GR, van Melle G, Bogousslavsky J. Occlusion due to carotid artery dissection: a more severe disease than previously suggested. Arch Neurol 2002; 59:557. 60. Dziewas R, Konrad C, Dr ger B, et al. Cervical artery dissection clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250:1179. 61. Traenka C, Grond-Ginsbach C, Goeggel Simonetti B, et al. Artery occlusion independently predicts unfavorable outcome in cervical artery dissection. Neurology 2020; 94:e170. 62. Fischer U, Ledermann I, Nedeltchev K, et al. Quality of life in survivors after cervical artery dissection. J Neurol 2009; 256:443. 63. Kloss M, Grond-Ginsbach C, Ringleb P, et al. Recurrence of cervical artery dissection: An underestimated risk. Neurology 2018; 90:e1372. 64. Dittrich R, Nassenstein I, Bachmann R, et al. Polyarterial clustered recurrence of cervical artery dissection seems to be the rule. Neurology 2007; 69:180. 65. Martin JJ, Hausser I, Lyrer P, et al. Familial cervical artery dissections: clinical, morphologic, and genetic studies. Stroke 2006; 37:2924. Topic 16649 Version 30.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 17/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate GRAPHICS Eligibility criteria for the treatment of acute ischemic stroke with intravenous thrombolysis (recombinant tissue plasminogen activator or tPA) Inclusion criteria Clinical diagnosis of ischemic stroke causing measurable neurologic deficit Onset of symptoms <4.5 hours before beginning treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal or at neurologic baseline Age 18 years Exclusion criteria Patient history Ischemic stroke or severe head trauma in the previous three months Previous intracranial hemorrhage Intra-axial intracranial neoplasm Gastrointestinal malignancy Gastrointestinal hemorrhage in the previous 21 days Intracranial or intraspinal surgery within the prior three months Clinical Symptoms suggestive of subarachnoid hemorrhage Persistent blood pressure elevation (systolic 185 mmHg or diastolic 110 mmHg) Active internal bleeding Presentation consistent with infective endocarditis Stroke known or suspected to be associated with aortic arch dissection Acute bleeding diathesis, including but not limited to conditions defined under 'Hematologic' Hematologic 3 Platelet count <100,000/mm * Current anticoagulant use with an INR >1.7 or PT >15 seconds or aPTT >40 seconds* Therapeutic doses of low molecular weight heparin received within 24 hours (eg, to treat VTE and ACS); this exclusion does not apply to prophylactic doses (eg, to prevent VTE) Current use (ie, last dose within 48 hours in a patient with normal renal function) of a direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect by laboratory tests such as aPTT, INR, ECT, TT, or appropriate factor Xa activity assays Head CT https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 18/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate Evidence of hemorrhage Extensive regions of obvious hypodensity consistent with irreversible injury Warnings Only minor and isolated neurologic signs or rapidly improving symptoms Serum glucose <50 mg/dL (<2.8 mmol/L) Serious trauma in the previous 14 days Major surgery in the previous 14 days History of gastrointestinal bleeding (remote) or genitourinary bleeding Seizure at the onset of stroke with postictal neurologic impairments Pregnancy** Arterial puncture at a noncompressible site in the previous seven days Large ( 10 mm), untreated, unruptured intracranial aneurysm Untreated intracranial vascular malformation Additional warnings for treatment from 3 to 4.5 hours from symptom onset Age >80 years Oral anticoagulant use regardless of INR Severe stroke (NIHSS score >25) Combination of both previous ischemic stroke and diabetes mellitus ACS: acute coronary syndrome; aPTT: activated partial thromboplastin time; ECT: ecarin clotting time; INR: international normalized ratio; PT: prothrombin time; NIHSS: National Institutes of Health Stroke Scale; tPA: intravenous alteplase; TT: thrombin time; VTE: venous thromboembolism. Although it is desirable to know the results of these tests, thrombolytic therapy should not be delayed while results are pending unless (1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia, (2) the patient is currently on or has recently received anticoagulants (eg, heparin, warfarin, a direct thrombin inhibitor, or a direct factor Xa inhibitor), or (3) use of anticoagulants is not known. Otherwise, treatment with intravenous tPA can be started before availability of coagulation test results but should be discontinued if the INR, PT, or aPTT exceed the limits stated in the table, or 3 if platelet count is <100,000 mm . With careful consideration and weighting of risk-to-benefit, patients may receive intravenous alteplase despite one or more warnings. Patients who have a persistent neurologic deficit that is potentially disabling, despite improvement of any degree, should be treated with tPA in the absence of other contraindications. Any of the following should be considered disabling deficits: Complete hemianopia: 2 on NIHSS question 3, or Severe aphasia: 2 on NIHSS question 9, or Visual or sensory extinction: 1 on NIHSS question 11, or https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 19/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate Any weakness limiting sustained effort against gravity: 2 on NIHSS question 5 or 6, or Any deficits that lead to a total NIHSS >5, or Any remaining deficit considered potentially disabling in the view of the patient and the treating practitioner using clinical judgment Patients may be treated with intravenous alteplase if glucose level is subsequently normalized. The potential risks of bleeding with alteplase from injuries related to the trauma should be weighed against the anticipated benefits of reduced stroke-related neurologic deficits. The increased risk of surgical site bleeding with alteplase should be weighed against the anticipated benefits of reduced stroke-related neurologic deficits. There is a low increased risk of new bleeding with alteplase in the setting of past gastrointestinal or genitourinary bleeding. However, alteplase administration within 21 days of gastrointestinal bleeding is not recommended. Alteplase is reasonable in patients with a seizure at stroke onset if evidence suggests that residual impairments are secondary to acute ischemic stroke and not to a postictal phenomenon. * Alteplase can be given in pregnancy when the anticipated benefits of treating moderate or severe stroke outweigh the anticipated increased risks of uterine bleeding. The safety and efficacy of administering alteplase is uncertain for these relative exclusions. Although these were exclusions in the trial showing benefit in the 3 to 4.5 hour window, intravenous alteplase appears to be safe and may be beneficial for patients with these criteria, including patients taking oral anticoagulants with an INR <1.7. Adapted from: 1. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359:1317. 2. Del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator. A science advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40:2945. 3. Re-examining Acute Eligibility for Thrombolysis (TREAT) Task Force:, Levine SR, Khatri P, et al. Review, historical context, and clari cations of the NINDS rt-PA stroke trials exclusion criteria: Part 1: rapidly improving stroke symptoms. Stroke 2013; 44:2500. 4. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scienti c rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016; 47:581. 5. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344. Graphic 71462 Version 26.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 20/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate 2 ABCD score 2 The ABCD score can be used to estimate the risk of ischemic stroke in the first two days after TIA. The score is tallied as follows: Age: 60 years 1 point <60 years 0 points Blood pressure elevation when first assessed after TIA: Systolic 140 mmHg or diastolic 90 mmHg 1 point Systolic <140 mmHg and diastolic <90 mmHg 0 points Clinical features: Unilateral weakness 2 points Isolated speech disturbance 1 point Other 0 points Duration of TIA symptoms: 60 minutes 2 points 10 to 59 minutes 1 point <10 minutes 0 points Diabetes: Present 1 point Absent 0 points Data from: Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and re nement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369:283. Graphic 62381 Version 3.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 21/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate National Institutes of Health Stroke Scale (NIHSS) Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (ie, repeated requests to patient to make a special effort). Instructions Scale definition Score 1a. Level of consciousness: The investigator must choose a response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement 0 = Alert; keenly responsive. 1 = Not alert; but arousable by minor stimulation to obey, answer, or respond. 2 = Not alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped). _____ (other than reflexive posturing) in response to noxious stimulation. 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic. 1b. Level of consciousness questions: The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend 0 = Answers both questions correctly. 1 = Answers one question correctly. 2 = Answers neither question correctly. the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial _____ answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues. 1c. Level of consciousness commands: The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is 0 = Performs both tasks correctly. _____ 1 = Performs one task correctly. 2 = Performs neither task correctly. made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (ie, https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 22/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. 2. Best gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If the patient has a conjugate deviation of the 0 = Normal. 1 = Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present. 2 = Forced deviation, or total gaze paresis not overcome by the oculocephalic eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (cranial nerves III, IV or VI), score a 1. maneuver. _____ Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre- existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy. 3. Visual: Visual fields (upper and lower 0 = No visual loss. quadrants) are tested by confrontation, using finger counting or visual threat, as 1 = Partial hemianopia. 2 = Complete hemianopia. appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as 3 = Bilateral hemianopia (blind including cortical blindness). normal. If there is unilateral blindness or enucleation, visual fields in the remaining _____ eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. 4. Facial palsy: Ask - or use pantomime to 0 = Normal symmetrical movements. _____ encourage - the patient to show teeth or raise eyebrows and close eyes. Score 1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling). symmetry of grimace in response to noxious 2 = Partial paralysis (total or near-total stimuli in the poorly responsive or non- comprehending patient. If facial paralysis of lower face). trauma/bandages, orotracheal tube, tape or https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 23/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate other physical barriers obscure the face, 3 = Complete paralysis of one or both sides these should be removed to the extent (absence of facial movement in the upper possible. and lower face). 5. Motor arm: The limb is placed in the appropriate position: extend the arms 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice 2 = Some effort against gravity; limb and pantomime, but not noxious cannot get to or maintain (if cued) 90 (or 45) stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in degrees, drifts down to bed, but has some effort against gravity. _____ the case of amputation or joint fusion at the shoulder, the examiner should record the 3 = No effort against gravity; limb falls. score as untestable (UN), and clearly write 4 = No movement. the explanation for this choice. UN = Amputation or joint fusion, explain:________________ 5a. Left arm 5b. Right arm 6. Motor leg: The limb is placed in the appropriate position: hold the leg at 30 0 = No drift; leg holds 30-degree position for full 5 seconds. degrees (always tested supine). Drift is 1 = Drift; leg falls by the end of the 5-second scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency period but does not hit bed. 2 = Some effort against gravity; leg falls to in the voice and pantomime, but not noxious stimulation. Each limb is tested in bed by 5 seconds, but has some effort against gravity. turn, beginning with the non-paretic leg. Only in the case of amputation or joint _____ 3 = No effort against gravity; leg falls to fusion at the hip, the examiner should bed immediately. record the score as untestable (UN), and clearly write the explanation for this choice. 4 = No movement. UN = Amputation or joint fusion, explain:________________ 6a. Left leg 6b. Right leg 7. Limb ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. 0 = Absent. _____ 1 = Present in one limb. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. 2 = Present in two limbs. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is UN = Amputation or joint fusion, explain:________________ scored only if present out of proportion to weakness. Ataxia is absent in the patient https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 24/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick 0 = Normal; no sensory loss. when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial Only sensory loss attributed to stroke is scored as abnormal and the examiner pain with pinprick, but patient is aware of should test as many body areas (arms [not being touched. hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, score of 2, "severe or total sensory loss," should only be given when a severe or total and leg. _____ loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best language: A great deal of information about comprehension will be 0 = No aphasia; normal. _____ 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of obtained during the preceding sections of the examination. For this scale item, the comprehension, without significant limitation on ideas expressed or form of patient is asked to describe what is happening in the attached picture, to name expression. Reduction of speech and/or comprehension, however, makes the items on the attached naming sheet and to read from the attached list of sentences. Comprehension is judged from responses conversation about provided materials difficult or impossible. For example, in conversation about provided materials, here, as well as to all of the commands in the preceding general neurological exam. If examiner can identify picture or naming card content from patient's response. visual loss interferes with the tests, ask the patient to identify objects placed in the 2 = Severe aphasia; all communication is hand, repeat, and produce speech. The through fragmentary expression; great need intubated patient should be asked to write. The patient in a coma (item 1a=3) will for inference, questioning, and guessing by the listener. Range of information that can automatically score 3 on this item. The examiner must choose a score for the be exchanged is limited; listener carries burden of communication. Examiner cannot patient with stupor or limited cooperation, but a score of 3 should be used only if the https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 25/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate patient is mute and follows no one-step identify materials provided from patient commands. response. 3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be 0 = Normal. normal, an adequate sample of speech must be obtained by asking patient to read or 1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty. repeat words from the attached list. If the patient has severe aphasia, the clarity of 2 = Severe dysarthria; patient's speech is so articulation of spontaneous speech can be _____ slurred as to be unintelligible in the absence rated. Only if the patient is intubated or has other physical barriers to producing speech, of or out of proportion to any dysphasia, or is mute/anarthric. the examiner should record the score as untestable (UN), and clearly write an UN = Intubated or other physical barrier, explanation for this choice. Do not tell the explain:________________ patient why he or she is being tested. 11. Extinction and inattention (formerly 0 = No abnormality. neglect): Sufficient information to identify 1 = Visual, tactile, auditory, spatial, or neglect may be obtained during the prior testing. If the patient has a severe visual loss personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities. preventing visual double simultaneous stimulation, and the cutaneous stimuli are 2 = Profound hemi-inattention or normal, the score is normal. If the patient _____ extinction to more than one modality; does not recognize own hand or orients to has aphasia but does appear to attend to both sides, the score is normal. The only one side of space. presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. _____ Adapted from: Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non- neurologists in the context of a clinical trial. Stroke 1997; 28:307. Graphic 61698 Version 8.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 26/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate Modified Rankin Scale Score Description 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 Dead Reproduced with permission from: Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604. Copyright 1988 Lippincott Williams & Wilkins. Graphic 75411 Version 13.0 https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 27/28 7/5/23, 12:34 PM Cerebral and cervical artery dissection: Treatment and prognosis - UpToDate Contributor Disclosures David S Liebeskind, MD Consultant/Advisory Boards: Cerenovus [Stroke]; Genentech [Stroke]; Medtronic [Stroke]; Stryker [Stroke]. Speaker's Bureau: Astra-Zeneca [Stroke]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/cerebral-and-cervical-artery-dissection-treatment-and-prognosis/print 28/28