Digital subtraction angiography remains the gold standard for diagnosis of cervical artery dissections. In addition to clear images, angiography provides an assessment of blood flow that is not possible on computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) imaging. However, the test is invasive, labor-intensive, and is associated with risks such as stroke/TIA and bleeding or development of pseudoaneurysm at the puncture site. In addition, it may not be readily available or feasible in some patients in the acute setting. If it is performed, the angiogram may show an intimal flap, irregular tapering, luminal stenosis or occlusion, a string sign due to flow through a severely stenotic vessel, a double lumen, or a pseudoaneurysm. (See Figure 3.) Angiography still has a role in the evaluation and management of patients with suspected cervical arterial dissection, but it should be reserved for patients in whom other imaging is nondiagnostic and dissection is strongly suspected or in patients for whom there is concern for dissecting intracranial pseudoaneurysm.
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