You arrive for your shift in the ED on a busy Friday night. Your first patient is a 29-year-old man who was a restrained driver in a motor vehicle crash, where he ran off the road going 75 mph. He was intubated on the scene for airway protection. On examination, he has a GCS 6T score, a large scalp laceration, symmetric pupils, and he withdraws all extremities from painful stimulation. His cardiac, pulmonary, and abdominal examination is without significant findings, and his extremities have scattered abrasions. His initial trauma imaging included a portable chest x-ray, a noncontrast CT head and cervical spine, and a CT of the abdomen/pelvis with contrast. The CT head showed a diffuse axonal injury and a temporal bone fracture. The remainder of the imaging showed no significant traumatic injuries. You wonder: What else should be done at this point? What are his biggest risks right now? Should I be concerned about the temporal bone fracture?
As you are pondering these questions, your next patient arrives. He is a healthy 42-year-old man who came to the ED due to neck pain. He was involved in a low-speed rear-end motor vehicle crash 2 days ago and felt fine, but today he developed severe pain in his left neck that radiates to his left jaw. On examination, he has diffuse paraspinal tenderness that you presume to be muscle spasm, no apparent jaw abnormalities that would cause his pain, and his neurological examination is negative. You obtain a CT head and c-spine without contrast, which are both read as negative. You think this is all musculoskeletal, but you can’t shake the presence of jaw pain, and you wonder: What else could this be? You give him some pain medications and decide to check on him later.
After leaving that patient’s room, you are called to the bedside of another patient just brought in by EMS. She is a 54-year-old woman with an acute onset of vertigo and nausea/vomiting that started while she was at dinner with her family, 30 minutes prior to presentation. In the history, you note that she is otherwise healthy and takes no medications. She does experience chronic neck discomfort, for which she sees a chiropractor routinely, but she has never experienced symptoms like this. On examination, she has nystagmus to left lateral gaze and left-sided ataxia. You send her for a stat CT head without contrast and order stat labs. You think that she might be having a stroke, so you consult neurology for emergent evaluation. You have heard about the possibility of neck manipulation and dissection, but you wonder if she qualifies for any treatment.
Although a cervical artery dissection is rarely seen in the emergency department (ED), it can have devastating consequences if it is not recognized. The incidence of spontaneous dissection is only approximately 2 to 3 in 100,000 people per year, with carotid dissections more common (1.7 in 100,000) than vertebral artery dissections (0.97 in 100,000 people). Traumatic dissections occur in approximately 1 in every 1000 trauma patients;1 however, they cause approximately 2% of strokes in all ages and up to 20% of strokes in patients aged < 45 years.2-7 Given the subtlety of symptoms in many patients, the diagnosis is often delayed until irreversible neurological injury has occurred.
Cervical artery dissections can occur spontaneously or with a traumatic event, even with trivial or forgotten trauma. Symptoms may be delayed and they may be similar to what are seen in patients presenting on a daily basis to the ED, such as headache, neck pain, and dizziness. In the obtunded trauma patient, signs or symptoms of dissection may not be readily apparent and the diagnosis will rely solely on advanced screening criteria. Unfortunately, 67% of these patients go on to develop ischemia as a result of the dissection, many within the first 24 hours.
Early treatment with an antithrombotic agent has been shown to be beneficial in the prevention of stroke due to dissection; however, the specific agent to use is not standardized. One recent randomized controlled trial attempted to determine superiority of antiplatelet agents versus anticoagulants, but still left us without an answer.8 Therefore, treatment remains the physician’s choice and must be specialized for each patient based on comorbidities, risk of stroke, and contraindications to therapy.
This issue of Emergency Medicine Practice will review the mechanism of injury of cervical artery dissections, identify common presenting signs or symptoms and factors that place trauma patients at high risk, and discuss current diagnostic criteria and treatment options so that emergency clinicians can make a determination on the best treatment available for each patient.
A literature search was performed using PubMed, the Cochrane Library, and The National Guideline Clearinghouse (www.guideline.gov) with the search terms carotid artery dissection, vertebral artery dissection, cervical artery dissection, blunt cerebral vascular injury, dissecting intracranial aneurysm, intracranial dissection, and stroke dissection. The search was limited to human studies in the English language from 2001 to the present. The search yielded more than 1400 articles that were reviewed for appropriateness. Only clinically relevant, peer-reviewed journal articles were included.
The Cochrane Database search yielded only 1 relevant article involving antithrombotic drugs for carotid artery dissection.9 One randomized controlled trial was found regarding medical, surgical, or endovascular treatment.8 Due to the low incidence of cervical artery dissections, there is a paucity of trials, and most of the data are from cohort and case-control studies in which patients with dissection were compared to patients without dissection with regard to symptoms, risk factors, imaging, treatment, and outcomes. The National Guideline Clearinghouse has many guidelines related to the treatment of headache or stroke that mention cervical artery dissection, but there are no specific guidelines present regarding the workup and treatment. (See Table 1.)
Consensus guidelines that relate to cervical artery dissection include the American College of Radiology 2012 guideline for suspected spine trauma that addresses recommendations for screening imaging in adults and children;10 a 2013 guideline published in Neurosurgery that discusses the management of vertebral artery injuries in trauma;11 a 2011 Society for Vascular Surgery guideline that discusses the management of extracranial carotid disease;12 the Western Trauma Association 2009 guidelines that address screening for and treatment of blunt cere-brovascular injuries;13 and the Eastern Association for the Surgery of Trauma 2010 guidelines that address the treatment and the screening and diagnostic imaging that expanded the risk criteria and included children aged < 12 years in the setting of trauma.14 In addition, the 2011 practice guidelines from the combined societies ASA/ACCF/AHA/AANN/ AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/ SVM/SVS (American Stroke Association, American College of Cardiology Foundation/American Heart 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 Neurointerventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery) reviewed the management of patients with all types of extracranial carotid and vertebral artery disease that included dissection.15 The AHA/ASA 2013 guidelines for the treatment of acute stroke,16 the AHA/ASA 2015 focused update regarding endovascular treatment for stroke,17 and the AHA/ ASA 2014 guidelines for the prevention of stroke were also reviewed.18 There are currently no American College of Emergency Physicians guidelines on cervical artery dissections.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Rhonda Cadena, MD
July 1, 2016
August 1, 2019
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke CME, 4 Trauma CME, and 1 Pharmacology CME credits
Upon completion of this article, you should be able to:
Date of Original Release: July 1, 2016. Date of most recent review: June 10, 2016. Termination date: July 1, 2019.
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Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 1, 2016. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke CME, 4 Trauma CME, and 1 Pharmacology CME credits, subject to your state and institutional approval.
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Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
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