High Risk, Low Prevalence: Spontaneous Cervical Artery Dissection

Spontaneous cervical artery dissection is an uncommon but important cause of stroke in younger adults, especially ages 35 to 53. Headache, neck pain, or facial pain plus a focal deficit, partial Horner syndrome, or recent minor neck trauma should push CTA head and neck high on the workup.

Bedside Recognition of Cervical Artery Dissection

• Younger stroke phenotype: sCAD skews younger than typical ischemic stroke, with a mean age of 35 to 53, and accounts for up to one quarter of strokes in patients under 45.
• Pain plus neurologic warning signs: Headache is the most common symptom, but isolated pain is uncommon; think dissection when head, neck, or facial pain travels with focal deficits, cranial neuropathy, or Horner findings.
• Minor trauma association: A seemingly trivial inciting event matters here: over 40% of patients report sudden head or neck movement from coughing, sports, whiplash, or even neck cracking, and many barely remember it.
• Carotid versus vertebral clues: Carotid dissection classically causes anterior head or face pain with partial Horner syndrome, while vertebral dissection points more toward posterior headache, vertigo, ataxia, and brainstem symptoms.
• Multivessel disease possibility: Dissection may not stop at one vessel; up to 20% of patients have multiple sites involved, a useful reminder when the symptoms seem broader than a single vascular territory. We get into the bedside pattern recognition in the episode.

Imaging and Initial Management

• CTA as first test: CTA of the head and neck is the diagnostic study of choice, with sensitivity and specificity both above 90%, making it the practical frontline test in the ED.
• MRI and MRA role: MRI and MRA also perform well for diagnosis, but real-world access and timing often make them second-line rather than the first imaging move in emergency care.
• Ultrasound limitations: Ultrasound can show an intimal flap, intramural hematoma, or flow abnormality, but limited visualization near the skull base means it cannot safely rule out sCAD.
• Neurology first call: Early specialist input matters because antiplatelet therapy and anticoagulation have broadly similar outcomes, but the choice hinges on stroke burden, vessel severity, and bleeding risk.
• Stroke and hemorrhage pathways: Thrombolysis is not automatically excluded in ischemic stroke from sCAD, while intracranial dissection carries a meaningful subarachnoid hemorrhage risk that shifts management fast. We walk through those fork-in-the-road decisions in the chapter.
• Medical therapy effect: For non-thrombolysis candidates, antithrombotic treatment is the core therapy and cuts embolic stroke risk from roughly 60% to under 4% in most patients.

References:

1. Kleindorfer DO, 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. Epub 2021 May 24. Erratum in: Stroke. 2021 Jul;52(7):e483-e484. PMID: 34024117.
2. Long B, et al. High risk and low prevalence diseases: Spontaneous cervical artery dissection. Am J Emerg Med. 2023 Nov 11;76:55-62. Epub ahead of print. PMID: 37995524.
3. Engelter ST, et al. Intravenous thrombolysis in stroke attributable to cervical artery dissection. Stroke. 2009 Dec;40(12):3772-6.Epub 2009 Oct 15. PMID: 19834022.
4. Engelter ST, et al. Cervical Artery Dissection and Ischaemic Stroke Patients-Study Group. Thrombolysis in cervical artery dissection--data from the Cervical Artery Dissection and Ischaemic Stroke Patients (CADISP) database. Eur J Neurol. 2012 Sep;19(9):1199-206. Epub 2012 Mar 26. PMID: 22448957.