Skip to main content

Advertisement

SpringerLink
Log in

Identification of Cervical Artery Dissections: Imaging Strategies and Literature Review

  • Neurologic Emergencies (J MILLER, SECTION EDITOR)
  • Published:
Current Emergency and Hospital Medicine Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Vertebral or carotid artery dissections, collectively called cervical artery dissections (CeADs), are uncommon, regularly missed vascular injuries. They are associated with major trauma, but also occur spontaneously or with relatively minor trauma. Diagnosis hinges on imaging identification. Previously, catheter angiogram was the gold standard, but currently, there is no consensus on the initial imaging study.

Recent Findings

Computer tomography angiography (CTA) is the most common initial study for CeAD, but can fail to identify some dissections. MRI/MRA provides better images and is preferred in the pediatric population, but misses some pathology. Newer MRI/MRA techniques are improving diagnostic accuracy for CeADs. Ultrasound is increasingly used for screening and monitoring. Treatment focuses on preventing thromboembolic events with antiplatelet or anticoagulation medications, though neither appears superior based on the CADISS trial.

Summary

No imaging study is the best initial CeAD study. MRI/MRA is preferred for pediatric patients. Ultrasound has good specificity for CeAD identification with caveats.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, Noorollah LD, Panagos PD, Schievink WI, Schwartz NE, Shuaib A, Thaler DE, Tirschwell DL. American Heart Association Stroke Council. 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):3155–74. https://doi.org/10.1161/STR.0000000000000016. Epub 2014 Aug 7. Erratum in: Stroke. 2016 Nov;47(11):e261. PMID: 25104849.

  2. Robertson JJ, Koyfman A. Cervical artery dissections: a review. J Emerg Med. 2016;51(5):508–18. https://doi.org/10.1016/j.jemermed.2015.10.044. Epub 2016 Sep 12 PMID: 27634674.

  3. Cadena R. Cervical artery dissection: early recognition and stroke prevention. Emerg Med Pract. 2016;18(7):1–24. Epub 2016 Jul 1 PMID: 27315017.

  4. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009;8(7):668–78. https://doi.org/10.1016/S1474-4422(09)70084-5. PMID: 19539238.

  5. Engelter ST, Traenka C, Von Hessling A, Lyrer PA. Diagnosis and treatment of cervical artery dissection. Neurol Clin. 2015;33(2):421–41. https://doi.org/10.1016/j.ncl.2014.12.002. PMID: 25907914.

  6. Martinelli O, Venosi S, BenHamida J, Malaj A, Belli C, Irace FG, Gattuso R, Frati G, Gossetti B, Irace L. Therapeutical options in the management of carotid dissection. Ann Vasc Surg. 2017;41:69–76. https://doi.org/10.1016/j.avsg.2016.07.087. Epub 2016 Dec 1 PMID: 27916638.

  7. Peng J, Liu Z, Luo C, Chen L, Hou X, Xiao L, Zhou Z. Treatment of cervical artery dissection: antithrombotics, thrombolysis, and endovascular therapy. Biomed Res Int. 2017;2017:3072098. https://doi.org/10.1155/2017/3072098. Epub 2017 May 21. PMID: 28607929; PMCID: PMC5457766.

  8. Traenka C, Dougoud D, Simonetti BG, Metso TM, Debette S, Pezzini A, Kloss M, Grond-Ginsbach C, Majersik JJ, Worrall BB, Leys D, Baumgartner R, Caso V, Béjot Y, Compter A, Reiner P, Thijs V, Southerland AM, Bersano A, Brandt T, Gensicke H, Touzé E, Martin JJ, Chabriat H, Tatlisumak T, Lyrer P, Arnold M, Engelter ST, CADISP-Plus Study Group. Cervical artery dissection in patients ≥60 years: Often painless, few mechanical triggers. Neurology. 2017;88(14):1313–20. https://doi.org/10.1212/WNL.0000000000003788. Epub 2017 Mar 3. PMID: 28258079.

  9. Markus HS, Levi C, King A, Madigan J, Norris J, Cervical Artery Dissection in Stroke Study (CADISS) Investigators. Antiplatelet therapy vs anticoagulation therapy in cervical artery dissection: the Cervical Artery Dissection in Stroke Study (CADISS) randomized clinical trial final results. JAMA Neurol. 2019;76(6):657–64. https://doi.org/10.1001/jamaneurol.2019.0072. PMID: 30801621; PMCID: PMC6563567.

  10. Debette S, Metso TM, Pezzini A, Engelter ST, Leys D, Lyrer P, Metso AJ, Brandt T, Kloss M, Lichy C, Hausser I, Touzé E, Markus HS, Abboud S, Caso V, Bersano A, Grau A, Altintas A, Amouyel P, Tatlisumak T, Dallongeville J, Grond-Ginsbach C, CADISP-group. CADISP-genetics: an international project searching for genetic risk factors of cervical artery dissections. Int J Stroke. 2009;4(3):224–30. https://doi.org/10.1111/j.1747-4949.2009.00281.x. PMID: 19659826.

  11. Berntsen EM. Cervical artery dissection - choice of diagnostic imaging. Tidsskr Nor Laegeforen. 2017;137(3):166. English, Norwegian. https://doi.org/10.4045/tidsskr.16.1087. PMID: 28181743.

  12. Stapczynski JS. Strangulation injuries. Emerg Med Rep. 2010;31(17):193–203.

    Google Scholar 

  13. SalehiOmran S, Parikh NS, Poisson S, Armstrong J, Merkler AE, Prabhu M, Navi BB, Riley LE, Fink ME, Kamel H. Association between pregnancy and cervical artery dissection. Ann Neurol. 2020;88(3):596–602. https://doi.org/10.1002/ana.25813. Epub 2020 Jul 13 PMID: 32525238.

  14. Chaibi A, Russell MB. A risk-benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Ann Med. 2019;51(2):118–27. https://doi.org/10.1080/07853890.2019.1590627.

  15. Chung CLR, Côté P, Stern P, L'Espérance G. The association between cervical spine manipulation and carotid artery dissection: a systematic review of the literature. J Manipulative Physiol Ther. 2015;38(9):672–76. https://doi.org/10.1016/j.jmpt.2013.09.005. Epub 2014 Jan 3. PMID: 24387889.

  16. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ; American College of Cardiology Foundation; American Stroke Association; 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; Society for Vascular Surgery. 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 Jul 26;124(4):489-532. https://doi.org/10.1161/CIR.0b013e31820d8d78. Epub 2011 Jan 31. Erratum in: Circulation. 2011 Jul 26;124(4):e145. Dosage error in article text. PMID: 21282505.

  17. Hanning U, Sporns PB, Schmiedel M, Ringelstein EB, Heindel W, Wiendl H, Niederstadt T, Dittrich R. CT versus MR techniques in the detection of cervical artery dissection. J Neuroimaging. 2017;27(6):607–12. https://doi.org/10.1111/jon.12451. Epub 2017 Jun 2 PMID: 28574627.

  18. Delgado Almandoz JE, Schaefer PW, Kelly HR, Lev MH, Gonzalez RG, Romero JM. Multidetector CT angiography in the evaluation of acute blunt head and neck trauma: a proposed acute craniocervical trauma scoring system. Radiology. 2010;254(1):236–44. https://doi.org/10.1148/radiol.09090693.

  19. Sporns PB, Niederstadt T, Heindel W, Raschke MJ, Hartensuer R, Dittrich R, Hanning U. Imaging of spontaneous and traumatic cervical artery dissection : comparison of typical CT angiographic features. Clin Neuroradiol. 2019;29(2):269–75. https://doi.org/10.1007/s00062-018-0666-4.

  20. Edelman RR, Koktzoglou I. Noncontrast MR angiography: an update. J Magn Reson Imaging. 2019;49(2):355–73. https://doi.org/10.1002/jmri.26288. Epub 2018 Dec 19. PMID: 30566270; PMCID: PMC6330154.

  21. Günther A, Witte OW, Freesmeyer M, Drescher R. Clinical presentation, magnetic resonance angiography, ultrasound findings, and stroke patterns in patients with vertebral artery dissection. Eur Neurol. 2016;76(5–6):284–94. https://doi.org/10.1159/000452303. Epub 2016 Nov 1 PMID: 27798932.

  22. • Almohammad M, Dadak M, Götz F, Donnerstag F, Tryc AB, Mahmoudi N, Wattjes MP. The potential role of diffusion weighted imaging in the diagnosis of early carotid and vertebral artery dissection. Neuroradiology. 2021. https://doi.org/10.1007/s00234-021-02842-4. Epub ahead of print. PMID: 34773479. Small, single center study evaluating the ability of diffusion weighted imaging (DWI)-MRI to detect CeADs and their associated intramural hematomas early in patient presentation for symptoms. They found DWI-MRI had good sensitivity for early detection of these findings.

  23. Li Q, Wang J, Chen H, Gong X, Ma N, Gao K, He L, Guan M, Chen Z, Li R, Mi D, Yuan C, Zhao X, Zhao XH. Characterization of craniocervical artery dissection by simultaneous MR noncontrast angiography and intraplaque hemorrhage imaging at 3T. AJNR Am J Neuroradiol. 2015;36(9):1769–75. https://doi.org/10.3174/ajnr.A4348. Epub 2015 Jun 4. PMID: 26045573; PMCID: PMC7968754.

  24. • Huang RJ, Lu Y, Zhu M, Zhu JF, Li YG. Simultaneous non-contrast angiography and intraplaque haemorrhage (SNAP) imaging for cervical artery dissections. Clin Radiol. 2019;74(10):817.e1-817.e7. https://doi.org/10.1016/j.crad.2019.06.018. Feasibility study of 53 patients looking at a new technique called “simultaneous non-contrast angiography and intraplaque haemorrhage (SNAP) sequence” for evaluating CeADs. Found good agreement between this technique and established techniques for diagnosing CeADs.

  25. Kanoto M, Hosoya T. Diagnosis of intracranial artery dissection. Neurol Med Chir (Tokyo). 2016;56(9):524–33. https://doi.org/10.2176/nmc.ra.2015-0294.

  26. Montorfano MA, Pla F, Vera L, Cardillo O, Nigra SG, Montorfano LM. Point-of-care ultrasound and Doppler ultrasound evaluation of vascular injuries in penetrating and blunt trauma. Crit Ultrasound J. 2017;9(1):5. https://doi.org/10.1186/s13089-017-0060-5. Epub 2017 Feb 16. PMID: 28211004; PMCID: PMC5313497.

  27. Binder T. Chapter 7. Imaging the vertebral arteries. 123 Sonography. 2021. Retrieved February 8, 2022, from https://123sonography.com/imaging-vertebral-arteries#article_13438

  28. Yang L, Ran H. Extracranial vertebral artery dissection: findings and advantages of ultrasonography. Medicine (Baltimore). 2018;97(9):e0067. https://doi.org/10.1097/MD.0000000000010067.

  29. • Brunser AM, Lavados PM, Cavada G, Muñoz-Venturelli P, Olavarría VV, Navia V, Mansilla E, Díaz V. Transcranial Doppler as a predictor of ischemic events in vertebral artery dissection. J Neuroimaging. 2020;30(6):890–5. https://doi.org/10.1111/jon.12773. Epub 2020 Aug 28. PMID: 32857896. Small study of 88 patients showing that specific transcranial doppler findings in patients with known vertebral artery dissection may predict future ischemic events.

  30. Brunser AM, Lavados PM, Hoppe A, Muñoz-Venturelli P, Sujima E, López J, Mansilla E, Cárcamo D, Díaz V. Transcranial Doppler as a predictor of ischemic events in carotid artery dissection. J Neuroimaging. 2017;27(2):232–6. https://doi.org/10.1111/jon.12379. Epub 2016 Aug 5 PMID: 27491878.

  31. Fullerton HJ, Johnston SC, Smith WS. Arterial dissection and stroke in children. Neurology. 2001;57(7):1155–60. https://doi.org/10.1212/wnl.57.7.1155. PMID: 11601431.

  32. Rafay MF, Armstrong D, Deveber G, Domi T, Chan A, MacGregor DL. Craniocervical arterial dissection in children: clinical and radiographic presentation and outcome. J Child Neurol. 2006;21(1):8–16. https://doi.org/10.1177/08830738060210010101. PMID: 16551446.

  33. Stence NV, Fenton LZ, Goldenberg NA, Armstrong-Wells J, Bernard TJ. Craniocervical arterial dissection in children: diagnosis and treatment. Curr Treat Options Neurol. 2011;13(6):636–48. https://doi.org/10.1007/s11940-011-0149-2. PMID: 21979145; PMCID: PMC3297486.

  34. Nash M, Rafay MF. Craniocervical arterial dissection in children: pathophysiology and management. Pediatr Neurol. 2019;95:9–18. https://doi.org/10.1016/j.pediatrneurol.2019.01.020. Epub 2019 Feb 2 PMID: 30955992.

  35. Camacho A, Villarejo A, de Aragón AM, Simón R, Mateos F. Spontaneous carotid and vertebral artery dissection in children. Pediatr Neurol. 2001;25(3):250–3. https://doi.org/10.1016/s0887-8994(01)00294-6. PMID: 11587883.

  36. Basso A, Desrumaux A, Lametery E, Bouzat P, Mortamet G. Transcranial Doppler as a useful tool in the detection of cervical steno-occlusive arteriopathy in infants. Arch Pediatr. 2019;26(7):415–8. https://doi.org/10.1016/j.arcped.2019.09.007. Epub 2019 Oct 17 PMID: 31630904.

  37. Hakimi R, Sivakumar S. Imaging of carotid dissection. Curr Pain Headache Rep. 2019;23(1):2. https://doi.org/10.1007/s11916-019-0741-9. PMID: 30661121.

  38. •• Markus HS, Levi C, King A, Madigan J, Norris J, Cervical Artery Dissection in Stroke Study (CADISS) Investigators. Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection: The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA Neurol. 2019;76(6):657–64. https://doi.org/10.1001/jamaneurol.2019.0072. PMID: 30801621; PMCID: PMC6563567. RCT which showed the risk for stroke following CeAD is overall low (2.5% at 1 year) and there is no benefit of one over the other between anticoagulation and antiplatelet therapies at further reducing the risk of stroke at one year.

  39. Kennedy F, Lanfranconi S, Hicks C, et al. Antiplatelets vs anticoagulation for dissection: CADISS nonrandomized arm and meta-analysis. Neurology. 2012;79(7):686–9.

    Article  CAS  Google Scholar 

  40. Menon R, Kerry S, Norris JW, Markus HS. Treatment of cervical artery dissection: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2008 Oct 1;79(10):1122-7.

  41. • Strunk D, Schwindt W, Wiendl H, Dittrich R, Minnerup J. Long-term sonographical follow-up of arterial stenosis due to spontaneous cervical artery dissection. Front Neurol. 2022;3(12):792321. https://doi.org/10.3389/fneur.2021.792321. PMID:35185752;PMCID: PMC8850833. Analysis of a neurology department database of CeAD patients that were followed for an average of 21 months with duplex ultrasound evaluation of their dissections. Found decreased stenosis and recanalization of about half of their included patients within the first year. Supports long term monitoring of arterial changes in CeAD patients for at least the first year.

  42. • Traenka C, Streifler J, Lyrer P, Engelter ST. Clinical usefulness of serial duplex ultrasound in cervical artery dissection patients. Cerebrovasc Dis. 2020;49(2):206–15. https://doi.org/10.1159/000507485. Single center, observational study looking at duplex ultrasound findings during regular follow ups for patients with known CeADs. Study found that multiple patients had observable changes within their arteries including recanalization and delayed occlusion, and were often symptomatic due to these changes.

Download references

Author information

Authors and Affiliations

  1. University of Kansas Medical Center, 4000 Cambridge St, Center Kansas City, KS, 66160, USA

    Adrienne Malik, Stephanie Thom, Kristi Bernath, Elspeth Pearce & Brittany Hudson-Walsh

  2. Saint Luke’s Health Center, 4401 Wornall Rd, Kansas City, MO, 64111, USA

    Kayla Donnawell

Authors
  1. Adrienne Malik
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stephanie Thom
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kristi Bernath
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Elspeth Pearce
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kayla Donnawell
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Brittany Hudson-Walsh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Adrienne Malik.

Ethics declarations

Conflict of Interest

Adrienne Malik, Stephanie Thom, Kristi Bernath, Elspeth Pearce, Kayla Donnawell, and Brittnay Hudson-Walsh declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of Topical Collection on Neurologic Emergencies

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Malik, A., Thom, S., Bernath, K. et al. Identification of Cervical Artery Dissections: Imaging Strategies and Literature Review. Curr Emerg Hosp Med Rep 10, 45–53 (2022). https://doi.org/10.1007/s40138-022-00247-y

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40138-022-00247-y

Keywords

Search

Navigation