<< Cervical Artery Dissection: Early Recognition and Stroke Prevention (Stroke CME, Trauma CME and Pharmacology CME)


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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.

  1. * Lee VH, Brown RD, Jr., Mandrekar JN, et al. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006;67(10):1809-1812. (Cross-sectional study; 48 patients)
  2. Schwartz NE, Vertinsky AT, Hirsch KG, et al. Clinical and radiographic natural history of cervical artery dissections. J Stroke Cerebrovasc Dis. 2009;18(6):416-423. (Retrospective cohort study; 177 patients)
  3. Putaala J, Metso AJ, Metso TM, et al. Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: the Helsinki young stroke registry. Stroke. 2009;40(4):1195- 1203. (Retrospective cohort study; 1008 patients)
  4. Bogousslavsky J, Regli F. Ischemic stroke in adults younger than 30 years of age. Cause and prognosis. Arch Neurol. 1987;44(5):479-482. (Single-center prospective cohort study; 41 patients)
  5. Rafay MF, Armstrong D, Deveber G, et al. Craniocervical arterial dissection in children: clinical and radiographic presentation and outcome. J Child Neurol. 2006;21(1):8-16. (Retrospective cohort study; 16 patients)
  6. Leys D, Bandu L, Henon H, et al. Clinical outcome in 287 consecutive young adults (15 to 45 years) with ischemic stroke. Neurology. 2002;59(1):26-33. (Prospective cohort study; 287 patients)
  7. von Sarnowski B, Schminke U, Grittner U, et al. Cervical artery dissection in young adults in the stroke in young Fabry patients (SIFAP1) study. Cerebrovasc Dis. 2015;39(2):110-121. (Multicenter prospective nested control study; 4208 total patients, 439 patients with CAD)
  8. * Markus HS, Hayter E, Levi C, et al. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015;14(4):361-367. (Randomized controlled trial; 250 patients)
  9. Lyrer PA, Brandt T, Metso TM, et al. Clinical import of Horner syndrome in internal carotid and vertebral artery dissection. Neurology. 2014;82(18):1653-1659. (Multicener prospective nested control study; 496 patients)
  10. Daffner R, Weissman B, Wippold FI, et al. ACR Appropriateness Criteria®. Suspected spine trauma. Reston, VA: American College of Radiology; 2012. (Guidelines)
  11. Harrigan MR, Hadley MN, Dhall SS, et al. Management of vertebral artery injuries following non-penetrating cervical trauma. Neurosurgery. 2013;72 Suppl 2:234-243. (Guideline)
  12. Ricotta JJ, Aburahma A, Ascher E, et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54(3):e1-e31. (Guideline)
  13. * Biffl WL, Cothren CC, Moore EE, et al. Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma. 2009;67(6):1150-1153. (Review)
  14. * Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 2010;68(2):471- 477. (Practice guidelines)
  15. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/ AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/ SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke 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. Circulation. 2011;124(4):489-532. (Practice guidelines)
  16. Jauch EC, Saver JL, Adams HP, Jr., et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. (Practice guidelines)
  17. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020-3035. (Practice guidelines)
  18. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236. (Practice guidelines)
  19. Thomas LC, Rivett DA, Attia JR, et al. Risk factors and clinical presentation of cervical arterial dissection: preliminary results of a prospective case-control study. J Orthop Sports Phys Ther. 2015;45(7):503-511. (Prospective case control study; 45 patients)
  20. Engelter ST, Grond-Ginsbach C, Metso TM, et al. Cervical artery dissection: trauma and other potential mechanical trigger events. Neurology. 2013;80(21):1950-1957. (Multicenter prospective nested control study; 1897 patients)
  21. Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(10):3155-3174. (Scientific statement)
  22. Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003;250(10):1179-1184. (Retrospective cohort study; 126 patients)
  23. Grau AJ, Brandt T, Buggle F, et al. Association of cervical artery dissection with recent infection. Arch Neurol. 1999;56(7):851-856. (Prospective cohort study; 43 patients)
  24. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001;344(12):898-906. (Review)
  25. Arnold M, Cumurciuc R, Stapf C, et al. Pain as the only symptom of cervical artery dissection. J Neurol Neurosurg Psychiatry. 2006;77(9):1021-1024. (Retrospective cohort study; 20 patients)
  26. Hasan I, Wapnick S, Tenner MS, et al. Vertebral artery dissection in children: a comprehensive review. Pediatr Neurosurg. 2002;37(4):168-177. (Review)
  27. * Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology. 2011;77(12):1174-1181. (Prospective nested case control study; 982 patients)
  28. Bejot Y, Aboa-Eboule C, Debette S, et al. Characteristics and outcomes of patients with multiple cervical artery dissection. Stroke. 2014;45(1):37-41. (Prospective nested case control study; 149 patients)
  29. * Biffl WL, Ray CE, Jr., Moore EE, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg. 2002;235(5):699- 706. (Single-center prospective cohort study; 171 patients)
  30. Burlew CC, Biffl WL, Moore EE, et al. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012;72(2):330-335. (Prospective cohort study; 418 patients)
  31. Berne JD, Cook A, Rowe SA, et al. A multivariate logistic regression analysis of risk factors for blunt cerebrovascular injury. J Vasc Surg. 2010;51(1):57-64. (Prospective cohort study; 102 patients)
  32. Franz RW, Willette PA, Wood MJ, et al. A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries. J Am Coll Surg. 2012;214(3):313-327. (Systemic review/meta-analysis; 418 patients)
  33. von Babo M, De Marchis GM, Sarikaya H, et al. Differences and similarities between spontaneous dissections of the internal carotid artery and the vertebral artery. Stroke. 2013;44(6):1537-1542. (Multicenter prospective cohort study; 970 patients)
  34. Baumgartner RW, Bogousslavsky J. Clinical manifestations of carotid dissection. Front Neurol Neurosci. 2005;20:70-76. (Review)
  35. Baumgartner RW, Arnold M, Baumgartner I, et al. Carotid dissection with and without ischemic events: local symptoms and cerebral artery findings. Neurology. 2001;57(5):827- 832. (Prospective cohort study; 181 patients)
  36. Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology. 1995;45(8):1517-1522. (Retrospective cohort study; 161 patients)
  37. Hardmeier M, Haller S, Steck A, et al. Vertebral artery dissection presenting with fifth cervical root (C5) radiculopathy. J Neurol. 2007;254(5):672-673. (Case report)
  38. Tabatabai G, Schöber W, Ernemann U, et al. Vertebral artery dissection presenting with ispilateral acute C5 and C6 sensorimotor radiculopathy: A case report. Cases J. 2008;1:139-139. (Case report)
  39. Sturzenegger M. Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients. J Neurol. 1995;242(4):231-238. (Prospective cohort study; 41 patients)
  40. Biousse V, D’Anglejan-Chatillon J, Touboul PJ, et al. Time course of symptoms in extracranial carotid artery dissections. A series of 80 patients. Stroke. 1995;26(2):235-239. (Single-center case control mixed retrospective and prospective cohort study; 80 patients)
  41. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009;8(7):668- 678. (Review)
  42. Fabian TC, Patton JH, Croce MA, et al. Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996;223(5):513-525. (Prospective cohort study; 67 patients)
  43. Ramadan F, Rutledge R, Oller D, et al. Carotid artery trauma: a review of contemporary trauma center experiences. J Vasc Surg. 1995;21(1):46-55. (Review)
  44. Crawford JD, Allan KM, Patel KU, et al. The natural history of indeterminate blunt cerebrovascular injury. JAMA Surg. 2015;150(9):841-847. (Retrospective cohort study; 100 patients)
  45. Stein DM, Boswell S, Sliker CW, et al. Blunt cerebrovascular injuries: does treatment always matter? J Trauma. 2009;66(1):132-143. (Retrospective cohort study; 147 patients)
  46. Callcut RA, Hanseman DJ, Solan PD, et al. Early treatment of blunt cerebrovascular injury with concomitant hemorrhagic neurologic injury is safe and effective. J Trauma Acute Care Surg. 2012;72(2):338-345. (Retrospective cohort study; 77 patients)
  47. * Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517- 522. (Single-center prospective cohort study; 249 patients)
  48. Vilela MD, Kim LJ, Bellabarba C, et al. Blunt cerebrovascular injuries in association with craniocervical distraction injuries: a retrospective review of consecutive cases. Spine J. 2015;15(3):499-505. (Retrospective cohort study; 15 patients)
  49. Vranis NM, Mundinger GS, Bellamy JL, et al. Extracapsular mandibular condyle fractures are associated with severe blunt internal carotid artery injury: analysis of 605 patients. Plast Reconstr Surg. 2015;136(4):811-821. (Retrospective cohort study; 605 patients)
  50. Kerwin AJ, Bynoe RP, Murray J, et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma. 2001;51(2):308-314. (Prospective cohort study; 48 patients)
  51. Malhotra AK, Camacho M, Ivatury RR, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Ann Surg. 2007;246(4):632-642. (Prospective cohort study; 92 patients)
  52. Bonatti M, Vezzali N, Ferro F, et al. Blunt cerebrovascular injury: diagnosis at whole-body MDCT for multi-trauma. Insights Imaging. 2013;4(3):347-355. (Retrospective cohort study; 32 patients)
  53. * Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236(3):386-393. (Prospective cohort study; 216 patients)
  54. Munera F, Soto JA, Palacio D, et al. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology. 2000;216(2):356-362. (Prospective pretest-posttest study; 60 patients)
  55. Eastman AL, Muraliraj V, Sperry JL, et al. CTA-based screening reduces time to diagnosis and stroke rate in blunt cervical vascular injury. J Trauma. 2009;67(3):551-556. (Prospective pretest-posttest study; 105 patients)
  56. Inaba K, Munera F, McKenney M, et al. Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. J Trauma. 2006;61(1):144-149. (Prospective cohort study; 106 patients)
  57. Mutze S, Rademacher G, Matthes G, et al. Blunt cerebrovascular injury in patients with blunt multiple trauma: diagnostic accuracy of duplex Doppler US and early CT angiography. Radiology. 2005;237(3):884-892. (Retrospective cohort study; 24 patients)
  58. Chen CJ, Tseng YC, Lee TH, et al. Multisection CT angi-ography compared with catheter angiography in diagnosing vertebral artery dissection. AJNR Am J Neuroradiol. 2004;25(5):769-774. (Retrospective cohort study; 30 patients)
  59. * Eastman AL, Chason DP, Perez CL, et al. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma. 2006;60(5):925-929. (Prospective pretest-posttest study; 146 patients)
  60. Baracchini C, Tonello S, Meneghetti G, et al. Neurosonographic monitoring of 105 spontaneous cervical artery dissections: a prospective study. Neurology. 2010;75(21):1864-1870. (Retrospective cohort study; 105 patients)
  61. Rundek T, Katsnelson M. Is frequent ultrasound monitoring of spontaneous cervical artery dissection clinically useful? Neurology. 2010;75(21):1858-1859. (Editorial)
  62. Flis CM, Jager HR, Sidhu PS. Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol. 2007;17(3):820-834. (Review)
  63. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333(24):1581-1587. (Double-blind randomized control trial; 624 patients)
  64. Arnold M, Nedeltchev K, Sturzenegger M, et al. Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature. Arch Neurol. 2002;59(4):549-553. (Retrospective cohort study; 7 patients)
  65. Georgiadis D, Baumgartner RW. Thrombolysis in cervical artery dissection. Front Neurol Neurosci. 2005;20:140-146. (Retrospective cohort study; 50 patients)
  66. Qureshi AI, Chaudhry SA, Hassan AE, et al. Thrombolytic treatment of patients with acute ischemic stroke related to underlying arterial dissection in the United States. Arch Neurol. 2011;68(12):1536-1542. (Retrospective cohort study; 488 patients)
  67. Tsivgoulis G, Zand R, Katsanos AH, et al. Safety and outcomes of intravenous thrombolysis in dissection-related ischemic stroke: an international multicenter study and comprehensive meta-analysis of reported case series. J Neurol. 2015;262(9):2135-2143. (Prospective international multicenter cohort study; 39 patients)
  68. Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42(9):2515-2520. (Review)
  69. * Engelter ST, Dallongeville J, Kloss M, et al. Thrombolysis in cervical artery dissection--data from the Cervical Artery Dissection and Ischaemic Stroke Patients (CADISP) database. Eur J Neurol. 2012;19(9):1199-1206. (Multicenter prospective nested cohort study; 68 patients)
  70. Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139(5):540-545. (Single-center prospective nonequivalent control pretest-posttest study; 114 patients)
  71. Georgiadis D, Arnold M, von Buedingen HC, et al. Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients. Neurology. 2009;72(21):1810-1815. (Prospective cohort study; 298 patients)
  72. Kennedy F, Lanfranconi S, Hicks C, et al. Antiplatelets vs anticoagulation for dissection: CADISS nonrandomized arm and meta-analysis. Neurology. 2012;79(7):686-689. (Multicenter, rospective, nonrandomized study; 88 patients)
  73. Menon R, Kerry S, Norris JW, et al. Treatment of cervical artery dissection: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2008;79(10):1122-1127. (Review)
  74. Harrigan MR, Weinberg JA, Peaks YS, et al. Management of blunt extracranial traumatic cerebrovascular injury: a multidisciplinary survey of current practice. World J Emerg Surg. 2011;6:11. (Cross-sectional study; survey of 785 subjects)
  75. Lichy C, Metso A, Pezzini A, et al. Predictors of delayed stroke in patients with cervical artery dissection. Int J Stroke. 2015;10(3):360-363. (Multicenter prospective nested case control study; 965 patients)
  76. Wagenaar AE, Burlew CC, Biffl WL, et al. Early repeat imaging is not warranted for high-grade blunt cerebrovascular injuries. J Trauma Acute Care Surg. 2014;77(4):540-545. (Prospective cohort study; 582 patients)
  77. Nedeltchev K, Bickel S, Arnold M, et al. R2-recanalization of spontaneous carotid artery dissection. Stroke. 2009;40(2):499- 504. (Prospective cohort study; 249 patients)
  78. Fields JD, Lutsep HL, Rymer MR, et al. Endovascular mechanical thrombectomy for the treatment of acute ischemic stroke due to arterial dissection. Interv Neuroradiol. 2012;18(1):74-79. (Multicenter prospective cohort study; 10 patients)
  79. Donas KP, Mayer D, Guber I, et al. Endovascular repair of extracranial carotid artery dissection: current status and level of evidence. J Vasc Interv Radiol. 2008;19(12):1693-1698. (Review)
  80. Engelter ST, Rutgers MP, Hatz F, et al. Intravenous thrombolysis in stroke attributable to cervical artery dissection. Stroke. 2009;40(12):3772-3776. (Case-control cohort study; 55 patients)
  81. Chandra A, Suliman A, Angle N. Spontaneous dissection of the carotid and vertebral arteries: the 10-year UCSD experience. Ann Vasc Surg. 2007;21(2):178-185. (Retrospective cohort study; 20 patients)
  82. Metso TM, Metso AJ, Helenius J, et al. Prognosis and safety of anticoagulation in intracranial artery dissections in adults. Stroke. 2007;38(6):1837-1842. (Prospective case-control cohort study; 103 patients)
  83. Yamada M, Kitahara T, Kurata A, et al. Intracranial vertebral artery dissection with subarachnoid hemorrhage: clinical characteristics and outcomes in conservatively treated patients. J Neurosurg. 2004;101(1):25-30. (Prospective cohort study; 24 patients)
  84. Rabinov JD, Hellinger FR, Morris PP, et al. Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol. 2003;24(7):1421-1428. (Retrospective cohort study; 35 patients)
  85. Strozyk D, Mehta BP, Meyers PM, et al. Coil embolization of intracranial dissecting vertebral artery aneurysms with subclavian steal. J Neuroimaging. 2011;21(1):62-64. (Case report)
  86. Arnold M, Camus-Jacqmin M, Stapf C, et al. Postpartum cervicocephalic artery dissection. Stroke. 2008;39(8):2377-2379. (Comparative study; 102 patients)
  87. Roach ES, Golomb MR, Adams R, et al. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39(9):2644-2691. (Guideline)
  88. Goldenberg NA, Bernard TJ, Fullerton HJ, et al. Antithrombotic treatments, outcomes, and prognostic factors in acute childhood-onset arterial ischaemic stroke: a multicentre, observational, cohort study. Lancet Neurol. 2009;8(12):1120-1127. (Multicenter prospective cohort study; 661 patients)
  89. Beslow LA, Jordan LC. Pediatric stroke: the importance of cerebral arteriopathy and vascular malformations. Childs Nerv Syst. 2010;26(10):1263-1273. (Review)
  90. Arnold M, Steinlin M, Baumann A, et al. Thrombolysis in childhood stroke: report of 2 cases and review of the literature. Stroke. 2009;40(3):801-807. (Review)
  91. Manco-Johnson MJ, Grabowski EF, Hellgreen M, et al. Recommendations for tPA thrombolysis in children. On behalf of the Scientific Subcommittee on Perinatal and Pediatric Thrombosis of the Scientific and Standardization Committee of the International Society of Thrombosis and Haemostasis. Thromb Haemost. 2002;88(1):157-158. (Guideline)
  92. deVeber G, Roach ES, Riela AR, et al. Stroke in children: recognition, treatment, and future directions. Semin Pediatr Neurol. 2000;7(4):309-317. (Review)
  93. Azarakhsh N, Grimes S, Notrica DM, et al. Blunt cerebrovascular injury in children: underreported or underrecognized?: A multicenter ATOMAC study. J Trauma Acute Care Surg. 2013;75(6):1006-1011. (Multi-institutional retrospective cohort study; 538 patients)
  94. Kopelman TR, Berardoni NE, O’Neill PJ, et al. Risk factors for blunt cerebrovascular injury in children: do they mimic those seen in adults? J Trauma. 2011;71(3):559-564. (Retrospective cohort study; 127 patients)
  95. Touze E, Gauvrit JY, Moulin T, et al. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology. 2003;61(10):1347-1351. (Retrospective multicenter cohort study; 459 patients)
  96. Schievink WI, Roiter V. Epidemiology of cervical artery dissection. Front Neurol Neurosci. 2005;20:12-15. (Review)
Publication Information

Rhonda Cadena, MD

Publication Date

July 1, 2016

CME Expiration Date

August 1, 2019

CME Credits

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

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CME Information

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