ABDULLAH ALI BAKSH

CASE PRESENTATION
 CHIEF COMPLAINT

37-year-old female presents with headache, neck

pain, and visual changes
 VITAL SIGNS

BP: 114/62

HR: 84

RR: 18

T: 36.5°C

Sat: 99% on RA
 WHAT DOES THE PATIENT LOOK LIKE?

Patient is uncomfortable-appearing secondary to

pain, holding head, in mild distress, lying still
supine on stretcher.
 PRIMARY SURVEY

Airway: speaking in full sentences

Breathing: no apparent respiratory distress, no

cyanosis

Circulation: dry and cool skin, normal capillary

refill
 ACTION

Oxygen via NC or nonrebreather mask (if

needed)

Two large-bore peripheral IV lines

CBC, BMP, LFT, coagulation studies, blood type

and cross-match, urine hcg

ECG

Repeat Vitals
 REPEAT VITALS

BP: 114/62

HR: 84

RR: 18

Sat: 99% on RA
 HISTORY
HPI: a 37-year-old female status postmotor vehicle
accident 2 days ago presents with persistent right-sided
headache and neck pain since the accident.

Today she had an episode of darkening of the vision in

her right eye, lasting 10 minutes. Her vision is now back
to baseline.

Two days ago the patient was a restrained passenger

in a vehicle that rear-ended another.

She was seen at an outside hospital at that time and had a

normal head CT.

Patient denies slurred speech, weakness, numbness, nausea,

vomiting, bowel or bladder changes, photophobia, or fever.
 HISTORY
PMHx: none

PSHx: none

Allergies: NKDA

Meds: none

Social: occasional alcohol use, denies tobacco

or drugs

FHx: noncontributory
 DIFFERENTIALS “NECK TRAUMA”
Penetrating neck trauma
Blunt neck trauma
Strangulation
Vertebral and carotid artery dissection

Whiplash injury

Cervical neck trauma

Cervical spine fractures and dislocations
Spinal cord trauma
Isolated transverse process fractures
 BEDSIDE INVESTIGATIONS

RBS - normal

ECG
ECG
 PHYSICAL EXAMINATION
General: alert, oriented × 3, holding head, in mild distress

Head: normocephalic, atraumatic

Eyes: mild right ptosis, right pupil 3 mm, left pupil 5 mm,
extraocular movements intact,visual acuity normal, normal
sweating on both sides of face.

Ears: normal tympanic membranes

Nose: no discharge

Neck: right paraspinal neck tenderness, right carotid bruit (must

ask), no mid-line C-spine tenderness

Pharynx: normal dentition, no lesions, no swelling

Chest: nontender
 PHYSICAL EXAMINATION
Lungs: clear bilaterally

Heart: rate and rhythm regular, no murmurs, rubs, or gallops

Abdomen: normal bowel sounds, soft, nontender

Urogenital: deferred

Extremities: full range of motion, no deformity, normal pulses

Back: nontender

Neuro: alert and oriented × 3, mild right ptosis, right pupil 3 mm, left
pupil 5 mm, extraocular movements intact, no facial droop, sensation
intact, 5/5 motor in all extremities, no cerebellar findings, normal DTRs,
downgoing toes and gait

Skin: warm and dry

Lymph: no lymphadenopathy
 MANAGEMENT
Analgesia:

Narcotic analgesia (Fentanyl, Morphine, Dilaudid, or oxycodone)

Consult neurology

Review blood results

Imaging

i. CT noncontrast of brain

ii. CT C-spine

iii. CT neck with angiography OR MRA neck

iv. X-ray C-spine

 FURTHER ON...

Patient: pain improves with pain medications

B- Hcg: negative
C-SPINE XRAY
CT BRAIN
CT C-SPINE
 “TypeMRA
a quote
NECKhere.”

+ DISSECTION OF
–JOHNNY
CAROTID
APPLESEED
ARTERY ON RIGHT SIDE
DIAGNOSIS

CAROTID ARTERY DISSECTION

INTRODUCTION
Incidence : 2.5-3 per 100,000 (rare)

Most frequent cause of stroke in young and middle

aged patients

Dissection can be extracranial (common, age 40) or

intracranial (rare, more serious, age 20-30)

They maybe of spontaneous or traumatic etiology

****Consider in trauma patients who have

neurological deficits despite normal head CT ****

****Consider in patient with CVA + neck pain****

ETIOLOGY
Traumatic carotid dissection:

Can be minor or major trauma, blunt or penetrating

May even follow minor indirect trauma, such as neck

manipulation by chiropractor,talking on the phone for
long time, coughing

Spontaneous carotid dissection:

Often idiopathic, increased incidence with strong

family history

Maybe related to underlying vascular pathologies :

HTN, connective tissue diseases (Marfan syndrome)
PATHOPHYSIOLOGY

Intimal tear or direct bleeding in arterial wall ->

intramural hematoma -> stenosis of arterial
lumen or aneurysm formation -> formation of
associated thrombi which may embolize distally
to cause ischemia (STROKE/TIA)

If tear extends intracranially -> SAH

Most commonly involves ICA, 2 cm cephalad

from bifurcation of common carotid to skull
base
SIGN AND SYMPTOMS
Pain: Unilateral headache, neck pain, facial pain

Pain can precede other symptoms by hours - days (median 4

days)

Headache most commonly is frontotemporal, severity may mimic

SAH or migraine

Partial Horner Syndrome: (Ptosis + Miosis - Anhydrosis) .

Sympathetic fibers for facial sweating are closely associated with
ECA and NOT ICA

Cranial nerve palsies : CN XII most commonly, abnormal taste,

pulsatile tinnitus

Ischemia: TIA/ stroke with associated anterior circulation deficits

(Hemiparesis, hemisensory loss, aphasia, neglect, amaurosis
fugax)
INVESTIGATIONS
Bedside
RBS ( r/o hypoglycemia in patients with Neurological deficits)
ECG (AF suggests an alternative cardiac source of emboli)

Laboratory
CBC
ESR, CRP
BMP
Coagulation profile

Imaging

First line : CTA neck or MRA

Doppler ultrasound:: Highly operator dependent, relatively poor

sensitivity of low grade stenosis. Should NOT be used as first line test.
EVALUATION

DENVER SCREENING CRITERIA is one way to

evaluate for blunt cerebrovascular injury (BCVI)

If positive findings on screening —> Obtain

CTA/MRA
DENVER SCREENING CRITERIA
MANAGEMENT

Options :

Anti platelet therapy

Anticoagulation with Heparin

Thrombolysis

Endovascular interventions

Continue antiplatelet or anticoagulation for 3 to

6 months and then re-imaging prior to
discontinuing medical therapy
ANTICOAGULATION WITH HEPARIN AND
WARFARIN

Traumatic Extracranial dissections

Do CT brain to r/o ICH before administering

Goal is to prevent further progression of

neurological deficits
ANTIPLATELET THERAPY WITH ASPIRIN

Intracranial dissection

Large infarcts; NIHSS>15

Extracranial dissection ONLY when NO

neurological deficit

If tPA given , wait 24hrs before starting

antiplatelet therapy
THROMBOLYSIS

Spontaneous extracranial dissection

Avoid in cases of intracranial dissection and

aortic rupture
ENDOVASCULAR INTERVENTION WITH
STENTING

Used when medical therapy fails

Usually used for extracranial carotid

dissection when medical management
fails or contraindicated

Improves outcomes are associated with

reconstitution of flow within 6 hours
PROGNOSIS
Risk of stroke :

Greatest in first 24 hours of dissection and

decreases over the next 7 days

Relatively low after 2 weeks

Extracranial dissection have more favorable

prognosis than intracranial dissection

Intracranial ICA dissection has high mortality

(75%)
FURTHER MANAGEMENT

Neurology consultation

Heparin

Admitted under trauma unit / surgical unit with

vascular unit input
JUST REMEMBER !!!
Carotid artery dissection is rare, but is a common cause of
stroke under 50 yrs of age

Always consider carotid dissection as cause of ischemic

symptoms in young patients w/o thrombotic/embolism stroke
risk factors or with neck pain

Trauma patients with significant head/neck trauma and

neurological deficits, think of carotid dissection

Consider carotid dissection in patients with headache or neck

pain that started in context of activities that cause torsion or
blunt trauma to neck

Can occur spontaneously or secondary to minor trauma, such

as chiropractic manipulation, talkin gn on the phone for long
periods of time, coughing, MVC
JUST REMEMBER !!!
Patient can present with headache, neck pain, facial pain,
hypoageusia (decreased taste) or focal neurological deficits.
Some may have partial Horner’s syndrome (Ptosis+ Miosis only

If dissection is traumatic extracranial, treatment involves

anticoagulation with heparin

If dissection is spontaneous extracranial, treatment involves

thrombolytics

If dissection is intracranial , give antiplatelet therapy with Aspirin

Endovascular stenting is preferred when medical therapy fails or

contraindicated

Anticoagulant or antiplatelet should be continued for 3 -6 months,

and re-imagined prior to discontinuing medical therapy
RESOURCES

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“Type a quote here.”

–JOHNNY APPLESEED