Guideline sources The following summarized guidelines for the evaluation and management of cervical artery dissection are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ASA 2021; 2019), the European Stroke Organisation (ESO 2021), the Society for Cardiovascular Angiography and Interventions (SCAI/SNIS/SVM/AANS/ASNR/CNS/AANN/SVS/AHA/ACR/SAIP/ACC/ASA/SIR 2011), and the Society for Vascular Surgery (SVS 2011). 1 2 3 4 5 6 6 6 7 8 Definition Cervical artery dissection is a term that encompasses carotid and vertebral artery dissection. 6 Epidemiology The majority of cervical artery dissections are spontaneous, while a smaller percentage of cases involve cervical trauma and cervical spine manipulations. A tear in the intima or rupture of the vasa vasorum with bleeding within the media may represent the initial precipitating factor. 6 7 Disease course Clinical manifestations of carotid artery dissections include neck pain, headache, and Horner's syndrome, which may be followed by retinal or cerebral ischemia in carotid artery dissections. Vertebral artery dissection presents with occipito-cervical pain, followed by posterior circulation https://web.pathway.md/diseases/recDLNkzXJZMkdUpe 1/5 6/29/23, 3:49 AM Cervical artery dissection Pathway ischemic symptoms including vertigo, dysarthria, visual field deficit, ataxia, and diplopia. Disease progression may lead to spinal cord infarction and stroke. 6 Prognosis and risk of recurrence Cervical artery dissection is associated with a mortality rate of 15-20% and is increased in patients with severe disability at presentation. 8 Guidelines 1. Diagnostic investigations Diagnostic imaging: obtain contrast-enhanced CT angiography, MRA, or catheter-based contrast angiography for the diagnosis of cervical artery dissection. B 2. Medical management Intravenous thrombolysis: consider performing IV thrombolysis with alteplase, if the standard inclusion/exclusion criteria are met, in patients with symptomatic extracranial artery dissection with acute ischemic stroke within 4.5 hours of onset. C Antithrombotic therapy: As per AHA 2021 guidelines: Initiate antithrombotic therapy for at least 3 months to prevent recurrent stroke or TIA in patients with extracranial carotid or vertebral artery dissection associated with ischemic stroke or TIA. B Consider initiating aspirin or warfarin to prevent recurrent stroke or TIA in patients with ischemic stroke or TIA within < 3 months after an extracranial carotid or vertebral artery dissection. C As per ESO 2021 guidelines, consider initiating anticoagulant or antiplatelet therapy in patients with symptomatic extracranial artery dissection in the acute phase. B Show 2 more As per AHA 2019 guidelines, consider initiating antiplatelet or anticoagulant therapy for 3-6 months in patients with acute ischemic stroke and extracranial carotid or vertebral arterial dissection. C Landmark trials: CADISS https://web.pathway.md/diseases/recDLNkzXJZMkdUpe 2/5 6/29/23, 3:49 AM Cervical artery dissection Pathway In patients with extracranial carotid and vertebral dissection with onset of symptoms within As per ASA 2011 guidelines, consider initiating anticoagulation (heparin, LMWH, or warfarin) or the past 7 days, antiplatelet treatment was not superior to anticoagulant treatment with antiplatelet therapy (aspirin, clopidogrel, or the combination of ER dipyridamole and aspirin) for respect to ipsilateral stroke or death at 3 months, in the intention-to-treat population. at least 3-6 months in patients with extracranial carotid or vertebral artery dissection associated CADISS trial investigators et al. Lancet Neurol. 2015 Apr. with ischemic stroke or TIA. C As per SVS 2011 guidelines, initiate antithrombotic therapy (antiplatelet agents or anticoagulation) in patients with carotid artery dissection. B Antihypertensive therapy: insufficient evidence to assess the safety and effectiveness of - antagonists, angiotensin inhibitors, and nondihydropyridine CCBs to lower BP to the normal range and reduce arterial wall stress. I 3. Therapeutic procedures Mechanical thrombectomy: consider performing mechanical thrombectomy in patients with acute ischemic stroke due to extracranial artery dissection and large vessel occlusion of the anterior circulation. C Endovascular therapy: As per AHA 2021 guidelines, consider performing endovascular therapy to prevent recurrent stroke or TIA in patients with stroke or TIA and extracranial carotid or vertebral artery dissection experiencing recurrent events despite antithrombotic therapy. C As per ESO 2021 guidelines: Insufficient evidence to recommend endovascular or surgical treatment in patients after acute extracranial artery dissection with residual stenosis or dissecting aneurysms. I Consider performing endovascular or surgical treatment of post-acute extracranial artery dissection in exceptional situations, such as recurrent ischemic events despite optimal antithrombotic therapy or expanding dissecting aneurysms causing compression, after assessment by a multidisciplinary team (neurologist, neuroradiologist, neurosurgeon, and neurointerventionalist). E As per AHA 2019 guidelines, insufficient evidence to recommend extracranial endovascular stenting in patients with acute ischemic stroke and extracranial carotid or extracranial vertebral artery dissection experiencing definite recurrent cerebral ischemic events despite medical therapy. I As per ASA 2011 guidelines, consider performing carotid angioplasty and stenting in patients with ischemic neurological symptoms not responding to antithrombotic therapy after acute carotid artery dissection. C As per SVS 2011 guidelines, consider performing an intervention (balloon angioplasty and stenting preferred over open surgery) in patients remaining symptomatic on medical therapy. C Clinical findings https://web.pathway.md/diseases/recDLNkzXJZMkdUpe 3/5 6/29/23, 3:49 AM Cervical artery dissection Pathway Symptoms Past medical history Change in taste Acute ischemic stroke Facial pain Ehlers-danlos syndrome Fainting FMD Headache Hyperhomocysteinemia Neck pain Marfan syndrome Neck swelling Migraine Tinnitus Osteogenesis imperfecta Vision loss Polycystic kidney disease Visual disturbances TIA Traumatic injury Vascular exam Neurological exam Cervical bruit Cranial nerve palsy Ocular exam Ptosis Miosis Head and neck exam Cervical tenderness Studies 2015 CADISS In patients with extracranial carotid and vertebral dissection with onset of symptoms within the past 7 days, antiplatelet treatment was not superior to anticoagulant treatment with respect to ipsilateral stroke or death at 3 months, in the intention-to-treat population. CADISS trial investigators et al. Lancet Neurol. 2015 Apr. References 1. Dawn O Kleindorfer, Amytis Towfighi, Seemant Chaturvedi 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 Jul;52 7):e364-e467. Open 2. Brott TG, Halperin JL, Abbara S et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of https://web.pathway.md/diseases/recDLNkzXJZMkdUpe 4/5 6/29/23, 3:49 AM Cervical artery dissection Pathway NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011 Jul 26;124 4 489 532. Open 3. William J Powers, Alejandro A Rabinstein, Teri Ackerson 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 Dec;50 12):e344-e418. Open 4. Stephanie Debette, Mikael Mazighi, Philippe Bijlenga et al. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J. 2021 Sep;6 3 XXXIX LXXXVIII. Open 5. John J Ricotta, Ali Aburahma, Enrico Ascher et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011 Sep;54 3):e1 31. Open 6. Blum CA, Yaghi S. Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. Arch Neurosci. 2015 Oct;2 4 . pii: e26670. Open 7. Michael T Haneline, Gary N Lewkovich. An analysis of the etiology of cervical artery dissections: 1994 to 2003. J Manipulative Physiol Ther. 2005 Oct;28 8 617 22.2005 Oct;28 8 617 22. Open 8. Yuksel Kaplan, Ozden Kamisli, Sibel Altinayar et al. What are the Predictors of Death in Patients With Cranio-Cervical Artery Dissection?. Noro Psikiyatr Ars. 2015 Jun;52 2 117 123.2015 Jun;52 2 117 123. Open 9. Christina A. Blum and Shadi Yaghi. Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. Arch Neurosci. 2015 Oct; 2 4 e26670. Open 10. Michael T. Haneline, and Anthony L. Rosner. The etiology of cervical artery dissection. J Chiropr Med. 2007 Summer; 6 3 110 120. Open 11. Y ksel KAPLAN, zden KAMI LI, Sibel ALTINAYAR et al. What are the Predictors of Death in Patients With Cranio-Cervical Artery Dissection?. Noro Psikiyatr Ars. 2015 Jun; 52 2 117 123. Open https://web.pathway.md/diseases/recDLNkzXJZMkdUpe 5/5