Carotid Dissection

Background

Accounts for 25% of strokes in younger patients (1% of all ischaemic strokes)
Headache ususually unilateral, gradual onset with delayed cranial nerve palsies (seen in 10%, particularly hypoglossal nerve palsy - speech and swallowing symptoms)
Most frequently 50-60yo
May have Hx of connective tissue disease (Ehlers-Danlos or Marfan’s)

Ischaemic infarction in the ipsilateral middle cerebral artery territory = faciobrachial sensorimotor deficits
Headache, facial or neck pain (3/4 cases)
Cranial nerve IX-XII palsies
Pulsatile tinnitus (1/4 cases)
Partial Horner’s syndrome (ptosis and miosis but no anyhdrosis) is characteristic of internal carotid artery dissectio (1/3 cases)
Horner’s syndrome = disruption of the oculosympathetic plexus surrounding the internal carotid artery
Acute Horner’s syndrome is a medical emergency

Tongue muscles (intrisnsic an extrinsic) = hypoglossal nerve
Hypoglossal nerve leaves skull via hypoglossal canal then lies with internnal jugular vein, hypoglosaal nerve, vagus and carotid
Leaves carotid with at lingual artery level to supply tongue
Supranuclear nerve injury (above medulla) = contralateral muscle weakness
Infranuclear palsy = unilateral weakness = deviation of tongu towards lesion side

ABC (airway, breathing, and circulation)
Beware (prevent) hypotension (or dehydration)
EM senior to discuss imaging ± intra-arterial thrombolysis/stenting with neuroradiologist
Involve stroke team early
Assess swallowing ± suctioning (secretions)
Bloods for coag status
Inflammatory markers / vasculitis / sickle cell
LMWH for VTE prophylaxis
Pressure area, bowel and bladder care
Later - echo etc. for cardioembolic source
Aim of treatment = prevention of stroke with antiplatelet or antithrombotic drugs
Seek and treat other vascular risk factors (BP, Cholesterol etc)
Endovascular stent considered in those with recurrent ischaemic symptoms despite maximal medical management, and for those with expanding pseudoaneurysms