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determined Interesting, and of both therapeutic and diagnostic value, is the relief of pain afforded by corticosteroids in cervical and intracranial dissections, as mentioned above Most neurologists take the approach that warfarin, if used, may be discontinued after several months or a year, when angiography or MRA shows the lumen of the carotid artery to be patent, or at least reduced to no more that 50 percent of the normal diameter, and smooth-walled Vertebral Artery Dissection Dissection of these arteries is less common than dissection of the extracranial carotid artery but is being recognized with increasing frequency It may originate in the neck and extend into the intracranial portion of the vessel or remain isolated to either of these segments In both instances there is a tendency to form pseudoaneurysms, but this is more likely with the intracranial type, and only in the latter is there a risk of rupture through the adventitia, leading to a subarachnoid hemorrhage Rapid and extreme rotational movement of the neck is the most common identi able cause, as in turning the head to back up a car Chiropractic manipulation has been one precipitant Extending the neck to have one s hair washed, and swinging a golf club have also led to dissection Forceful coughing may also cause dissection, as in the carotid vessels There is no female predominance (in contrast to carotid dissection), but the previously cited intrinsic weaknesses of the vascular wall from Ehlers-Danlos disease and bromuscular dysplasia are risk factors The dissection usually originates in the C1-C2 segment of the vessel, where it is mobile but tethered as it leaves the transverse foramen of the axis and turns sharply to enter the cranium The symptoms, mainly vertigo, derive from the lateral medullary syndrome, often with additional features referable to the pons or midbrain, particularly diplopia and dysarthria The clinical manifestations in our experience have uctuated over minutes and hours, quite unlike the usual vertebrobasilar TIA Less common strokes include artery-to-artery embolism to the posterior cerebral territory or, a syndrome that has come to our attention several times in the past few years, a centrally placed infarction of the cervical spinal cord, presumably from occlusion of the anterior spinal artery The diagnosis of vertebral dissection should be suspected if persistent occipitonuchal pain is prominent and follows one of the known precipitants such as chiropractic manipulation of the neck, head trauma, or Valsalva straining or coughing activities but it may otherwise escape detection until the full-blown medullary or cerebellar stroke is established The latter may follow the inciting event by several days or weeks or even longer, obscuring the relationship Axial MRI images, particularly the T1-weighted sequences, show a double lumen in the dissected vessel, and skillful ultrasound investigation documents the same Mokri et al have found that some patients have evidence of spontaneous or traumatic dissection of multiple extracranial vessels; this also occurs as a consequence of dissection of the aortic arch from chest trauma Treatment This has usually been with heparin anticoagulation followed for a period by warfarin, but the precise duration of treatment is dif cult to determine and the same uncertainties as to effectiveness of anticoagulation and of stent placement discussed above in regard to carotid dissection pertain here Whether there is an inordinate risk of subarachnoid hemorrhage with intracranial dissection has not been settled The usual practice is to repeat an imaging or ultrasound study several months after the dissection and discontinue the anticoagulation if the vessel lumen has been reestablished suf ciently to allow good blood ow Pseudoaneu-
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rysms in the cervical portions of the vessels generally do not require speci c treatment As with other dissections, corticosteroids may relieve the initial associated pain Intracranial Arterial Dissection Dissections of intracranial arteries are less common than extracranial dissections and present in several ways A number of times we have misinterpreted the arteriographic appearance of a short segment of narrowing of the basilar or proximal middle cerebral arteries, assuming these changes to represent embolism or arteritis when in fact they proved to be dissections of the vessel wall In the case of purely intracranial dissection of the middle cerebral or basilar arteries, there is usually no preceding trauma, but a few patients have had minor head injuries, extreme coughing, or other Valsalva-producing events (eg, after childbirth) or they had used cocaine The typical picture is of uctuating symptoms referable to the affected circulation and severe cranial pain on the side of the occlusion retro-orbital in the case of middle cerebral dissection, occipital in the case of basilar dissection, occipital combined with supraorbital in the case of vertebral dissection (see above) A few have had sudden strokes that suggested embolic infarction, and a small number present with subarachnoid hemorrhage Treatment This is primarily with anticoagulation and follow-up arteriography It is notable that corticosteroids have relieved the cranial and retro-orbital pain in our cases, and dramatic relief of pain within an hour is a virtually diagnostic Endovascular revascularization has been attempted with mixed results, the main problem being catastrophic and usually fatal vessel rupture during angioplasty
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