Incidence
- Spontaneous dissection: incidence ≈ 2 per 100,000, mostly seen in 5th decade
Aetiology
- Severe hypertension
- Neck trauma
- May develop spontaneously in young adults
- Genetic / hereditary disorders likely – e.g. Ehlers-Danlos
Clinical
- Sx due to cerebral ischaemia
- Horner’s syndrome
- Acute neck pain associated with localized cervical tenderness (at angle of mandible)
Pathology
- Primary lesion is an intimal tear at the distal end of carotid bulb
- Tear of tunica intima or between tunica media & adventitia (? originating from vasa vasorum)
Investigations
- Arteriography: characteristic pattern of tapered narrowing at / just beyond the distal portion of the carotid bulb ± intimal flap
Management
- Anticoagulation = Mainstay of Rx
- Heparin → Warfarin
- Antiplatelet agents: Aspirin
- Intervention reserved for pts with recurrent TIAs → Stenting
- If stenting unsuccessful & sx persist, ligation can be performed if the carotid back pressure is > 65mmHg
- Extracranial to intracranial bypass will be needed if the pressure is low
Prognosis / Natural Hx
- In most pts, intramural clot will be resorbed, restoring a normal lumen
- Healing usually takes 3 – 6 months
- Incidence of contralateral disease higher than the general population
- Mortality rate < 5%
Follow-up