By Dr. Abdolghader
(Carotid and Vertebral) — The Ultimate Step-by-Step, Can’t-Miss Bedside Guide
Clinical Scenario to Anchor the Learning
Case :
35-year-old woman presents with right-sided neck pain and a droopy right eyelid. She thought she pulled something during yoga 2 days ago. Now she’s got a weird headache behind her eye and feels “foggy.”
Neuro exam is otherwise non-focal. CT head is normal.
What should trigger you?
➡️ Unilateral neck pain + partial Horner syndrome + anterior headache = CTA neck/head NOW
STEP 1: Know When to Suspect Dissection — Don’t Miss These Red Flags
Key Clinical Triggers:
- Unilateral neck pain or facial/orbital headache
- Horner syndrome (ptosis, miosis)
- Cranial nerve palsy (especially CN XII)
- Amaurosis fugax (transient monocular vision loss)
- Stroke symptoms in a young patient
- Posterior circulation signs (ataxia, vertigo, dysarthria, diplopia)
💥 Most dissections are spontaneous or triggered by trivial trauma (e.g., yoga, cough, sneezing, chiropractic manipulation). Never rule out based on “minor trauma.”
STEP 2: Understand the Pathophysiology (Simple)
A tear in the arterial wall allows blood to track between layers → forming an intramural hematoma or pseudoaneurysm → this causes:
- Thromboembolism → Stroke
- Mass effect → CN palsies or radiculopathy
- Compromised perfusion → TIA or ischemia
- Disruption of sympathetic fibers → Horner syndrome
STEP 3: History + Exam – What to Ask and Look For
| Ask | Look |
| Sudden or progressive neck/head pain | Horner syndrome (ptosis + miosis ± anhidrosis) |
| Minor trauma, stretching, neck strain | CN deficits (esp. CN XII: tongue deviation) |
| Visual symptoms (monocular loss = CAD; diplopia = VAD) | Ataxia, nystagmus, dysarthria = think VAD |
| Timing of symptoms (pain first → neuro later) | Pulsatile tinnitus or bruit over carotids |
STEP 4: Localize the Dissection – CAD vs VAD
| Feature | Carotid Artery Dissection (CAD) | Vertebral Artery Dissection (VAD) |
| Pain location | Anterior neck, orbital, facial | Posterior neck, occipital |
| Stroke territory | Anterior (MCA/ACA) | Posterior (brainstem/cerebellum) |
| Classic sign | Horner syndrome | Ataxia, vertigo, Wallenberg |
| Visual | Amaurosis fugax (monocular) | Diplopia |
| CN palsy | CN XII, dysgeusia | Lower CNs (IX–XII), Wallenberg |
| Rare sign | Pulsatile tinnitus | Radiculopathy (C5–C6 if aneurysmal) |
STEP 5: Imaging – What to Order and Why
Always start with:
- Non-contrast CT head – to rule out hemorrhage or large infarct
- CTA Head + Neck – test of choice to visualize dissection:
- Tapering stenosis (“string sign”)
- Intimal flap
- Pseudoaneurysm
If CTA inconclusive but symptoms persist:
- MRI Brain + MRA Neck – for posterior strokes or subtle ischemia
🧠 Tip: Dissections can be bilateral in up to 10–20%. Image both sides.
STEP 6: Treatment – Practical ED Management
First-line (per UpToDate 2025 & CADISS trial):
- Antiplatelet (Aspirin 325 mg PO) OR
- Anticoagulation (Heparin drip → DOAC or warfarin)
→ Equally effective for stroke prevention
❌ Do NOT use both. No added benefit, higher risk.
Thrombolysis (tPA):
- OK if indicated (e.g., stroke within window)
- Dissection is NOT a contraindication
BP Goals:
- No universal target → use stroke protocol guidelines
- Avoid hypertensive surges or excessive lowering if ischemia present
STEP 7: Disposition
| Scenario | Action |
| Dissection without infarct | Admit to stroke/tele service |
| Evolving symptoms or posterior circulation stroke | ICU + neurology |
| Recurrent TIAs or large pseudoaneurysm | May need neurosurgery or vascular referral |
| Stable, improving, no infarct | Possible early discharge with rapid neuro follow-up (rare) |
STEP 8: Pitfalls to Avoid
| Pitfall | Fix |
| “Too young for stroke” bias | Image all young strokes thoroughly |
| Relying on “classic triad” | Only 8% have it. Act on any 1 symptom |
| Missing subtle Horner | Always check pupils in dim light |
| CT head normal → done | Always follow with CTA if suspicion remains |
| Ignoring minor trauma | Most CAD/VADs follow low-energy mechanisms |
BONUS Mnemonic:
DISSECT
| Letter | Reminder |
| D | Don’t dismiss minor trauma or weird symptoms |
| I | Image early with CTA head & neck |
| S | Subtle Horner syndrome = clue |
| S | Stroke in the young = dissection until proven otherwise |
| E | Examine for CN palsy, tinnitus, visual changes |
| C | Choose one antithrombotic (aspirin or anticoag) |
| T | Think VAD in posterior signs (ataxia, vertigo) |
ED Checklist Summary
- 🔲 Young patient + neuro signs + neck/head pain = image
- 🔲 CTA head/neck is the key test
- 🔲 Aspirin or Heparin, not both
- 🔲 Involve Neurology early
- 🔲 Dissection is not a tPA exclusion
- 🔲 Admit all confirmed dissections
- 🔲 Posterior signs = don’t forget VAD
📚 References
- UpToDate 2025: Cervical and Cerebral Artery Dissection – Clinical Features & Diagnosis
- UpToDate 2025: Treatment and Prognosis
- CADISS Trial, Lancet Neurology 2015
- AHA/ASA Guidelines for Acute Ischemic Stroke
