Cervical-artery dissections: predisposing factors, diagnosis, and outcome

Headache attributed to cranial or cervical vascular disorders

Cranial or cervical vascular disease is commonly associated with headaches. The descriptions may range from a thunderclap onset of a subarachnoid hemorrhage to a phenotype similar to tension type headache. Occasionally, this may be the sole manifestation of a potentially serious underlying disorder like vasculitis. A high index of clinical suspicion is necessary to diagnose the disorder. Prompt recognition and treatment is usually needed for many conditions to avoid permanent sequelae that result in disability. Treatments for many conditions remain challenging and are frequently controversial due to paucity of well controlled studies. This is a review of the recent advances that have been made in the diagnosis or management of these secondary headaches.

Implicating the long styloid process in cervical carotid artery dissection

INTRODUCTION

To look for the presence and strength of association of cervical carotid artery dissection (CCAD) with a long styloid process.

METHODS

This case-control analysis included 35 patients with 37 affected carotid arteries. CT angiograms of these patients were analyzed by two raters blinded to clinical and radiological diagnosis. Parameters assessed were styloid process length, its proximity to the cervical internal carotid artery, and its medial and anterior angulations. The same parameters were assessed in 70 CT angiograms in age and sex matched controls.

RESULTS

Interrater correlations were 0.87, 0.40, 0.71, and 0.79 for styloid process length, contact distance, medial angulation, and anterior angulation, respectively. The mean styloid process length on the affected side was significantly more than on the contralateral side (37.8 vs. 34.6 mm, p = 0.006). There were also significant length and contact distance differences between the styloid processes ipsilateral to dissection and ipsilateral styloid processes of controls (38.9 vs. 36.2 mm, p = 0.05 and 3.1 vs. 5.0 mm, p = 0.05, respectively). There were increasing odds ratios (OR) for dissection with increasing styloid process length, with OR of 4.36 (95% CI = 1.04 to 18.4, p = 0.04) for length more than 50 mm. ORs for dissection increased with decreasing contact distance, with OR for distances less than 5 mm being 7.58 (95% CI = 0.93 to 62.1, p = 0.06). There was no significant association of CCAD with angulation of the styloid process.

CONCLUSION

Length and contact distance of the styloid process are risk factors for CCAD, suggesting mechanical impingement.

Blunt traumatic internal carotid artery dissection with delayed stroke in a young skydiver

We describe a case of a 33-year-old skydiver who presented to the emergency department after a traumatic landing following a parachuting episode. He initially presented with right knee pain secondary to a tibial plateau fracture. There were no neurological symptoms or signs at the initial assessment. While he was still in the emergency department, he suddenly developed headache and left-sided hemiplegia. An urgent work-up showed right middle cerebral artery thrombosis with right internal carotid thrombosis and dissection. We have discussed some possible mechanism of injury in skydiving that may have predisposed to the occurrence of cervical dissection in our patient.

Reversible cerebral vasoconstriction syndrome with concurrent bilateral carotid artery dissection

Background

The pathophysiological basis of reversible cerebral vasoconstriction syndrome is poorly understood but carotid artery dissection has been discussed as a rare possible cause. So far, only single cases of unilateral carotid artery dissection and reversible cerebral vasoconstriction syndrome have been reported.

Case

Here, we describe the case of a 54-year old patient presenting to the emergency department with right hemiparesis, hypaesthesia and dysarthria. Furthermore, he reported two episodes of thunderclap headache after autosexual activity. Cerebral imaging showed ischaemic infarcts, slight cortical subarachnoid haemorrhage, bilateral carotid artery dissection and fluctuating intracranial vessel irregularities, compatible with reversible cerebral vasoconstriction syndrome. An extensive diagnostic work-up was normal. No typical trigger factors of reversible cerebral vasoconstriction syndrome could be found. The patient received intravenous heparin and the calcium channel blocker nimodipine. Follow-up imaging revealed no vessel irregularities, the left internal carotid artery was still occluded.

Conclusion

This case supports the assumption that carotid artery dissection should be considered as a potential trigger of reversible cerebral vasoconstriction syndrome, possibly by altering sympathetic vascular tone.

Neurosonographic monitoring of haemodynamic changes in tandem middle cerebral and internal carotid artery occlusion due to arterial dissection

A middle-aged man with pain in the right eye and right side of the neck was brought to the emergency department one hour after the onset of left-sided weakness. Computed tomography (CT) showed hyperdense right middle cerebral artery (MCA). On transcranial Doppler (TCD), occlusion of the right MCA and right internal carotid artery (ICA) was found. Thirty minutes after thrombolytic therapy was initiated, engagement of collateral circulation through the anterior communicating artery (AComA) was shown by TCD. Caro-tid duplex examination confirmed occlusion of the right ICA with intimal flap and intramural haematoma. CT angiography revealed flame-like occlusion of the right ICA, and occlusion of the right MCA with collateral supply from the left to right anterior cerebral artery through the AComA. Recanalization of the MCA and ICA was evident on both CT and ultrasound. Frequent ultrasound monitoring is useful for haemodynamic evaluation of carotid artery dissection, while TCD plays an important role in real-time monitoring of flow changes of intracranial vasculature.

Functional outcome in young adult ischemic stroke: impact of lipoproteins

AIM

To determine the functional outcome in a cohort of young adults with ischemic stroke patients, focusing on components of lipid profile.

METHODS

In our registry including consecutive patients with first-ever ischemic stroke aged 15-49 from 1994 to 2007, we analyzed predictors of 3-month functional outcome (modified Rankin Scale, mRS). Infarct size fell into small, medium, large posterior, or large anterior. Stroke severity was assessed with NIH Stroke Scale (NIHSS). Serum lipids were measured within 72 h after admission. Binary, multinomial ordinal, and Poisson regressions allowed revealing factors associated with size of infarct, stroke severity, and unfavorable outcome or death (mRS, 2-6) or mRS as an ordinal measure.

RESULTS

In the 968 patients included (mean age, 41.3 ± 7.6; 62.6% men; 49.5% with mRS 0-1), factors associated with unfavorable outcome after multivariable analysis were increasing age (odds ratio, 1.03 per year; 95% confidence interval, 1.01-1.05), higher NIHSS score (1.23 per point, 1.17-1.29), large anterior (4.37, 2.26-8.42) or posterior (1.73, 1.05-2.85) infarcts, bilateral lesions (2.28, 1.30-3.98), internal carotid artery dissection (ICAD) (3.65, 1.41-9.47), and inversely high-density lipoprotein (HDL) levels (0.58 per unit increase, 0.38-0.86). Increasing HDL associated with smaller infarct size (0.71, 0.51-0.98). Both higher total and HDL cholesterol associated with lower NIHSS score (0.96, 0.93-0.98 for total cholesterol and 0.82, 0.75-0.88 for HDL) and lower 3-month mRS (0.87, 0.78-0.97 for total cholesterol and 0.65, 0.47-0.90 for HDL).

CONCLUSION

In addition to known prognosticators, ICAD and lower HDL levels were independently associated with adverse clinical outcomes in our young adult stroke cohort.

Predictors of Delayed Stroke in Patients with Cervical Artery Dissection

Background

Stroke in patients with acute cervical artery dissection may be anticipated by initial transient ischemic or nonischemic symptoms.

Aim

Identifying risk factors for delayed stroke upon cervical artery dissection.

Methods

Cervical artery dissection patients from the multicenter Cervical Artery Dissection and Ischemic Stroke Patients study were classified as patients without stroke ( n = 339), with stroke preceded by nonstroke symptoms (delayed stroke, n = 244), and with stroke at onset ( n = 382). Demographics, clinical, and vascular findings were compared between the three groups.

Results

Patients with delayed stroke were more likely to present with occlusive cervical artery dissection ( P < 0·001), multiple cervical artery dissection ( P = 0·031), and vertebral artery dissection ( P < 0·001) than patients without stroke. No differences were observed in age, smoking, arterial hypertension, hypercholesterolemia, migraine, body mass index, infections during the last week, and trauma during the last month, but patients with delayed stroke had less often transient ischemic attack ( P < 0·001) and local signs (Horner syndrome and cranial nerve palsy; P < 0·001).

Conclusions

Occlusive cervical artery dissection, multiple cervical artery dissection, and vertebral artery dissection were associated with an increased risk for delayed stroke. No other risk factors for delayed stroke were identified. Immediate cervical imaging of cervical artery dissection patients without ischemic stroke is needed to identify patients at increased risk for delayed ischemia.

Spontaneous dissection of the coronary and vertebral arteries post-partum: case report and review of the literature

Background

Spontaneous coronary and vertebral artery dissections are rare events occurring most commonly in otherwise healthy women during pregnancy or the post-partum period.

Case presentation

This report describes a 35-year-old female who presented with an acute inferior ST elevation myocardial infarction 7 months post-partum secondary to spontaneous dissection of the left obtuse marginal coronary artery. Despite appropriate medical therapy with dual anti-platelet therapy, the patient presented four weeks later with a spontaneous dissection of the right vertebral artery.

Conclusion

We review the presentation, diagnosis, and management of spontaneous dissections of the vasculature in the peri-partum period.

3D fast spin-echo T1 black-blood imaging for the diagnosis of cervical artery dissection

SUMMARY

We performed non-contrast-enhanced 3D fast spin-echo T1 imaging with variable flip angles (CUBE T1) at 3T in 11 patients with CAD. CUBE T1 allowed easy diagnosis of CAD, owing to its comprehensive neck coverage, high spatial resolution enabling multiplanar reformations, fat saturation, and BB effect, the latter also allowing lumen patency to be studied. This sequence may replace 2D axial T1WI for the diagnosis of CAD.

A replication of the study 'Adverse effects of spinal manipulation: a systematic review'

Objective

To assess the significance of adverse events after spinal manipulation therapy (SMT) by replicating and critically reviewing a paper commonly cited when reviewing adverse events of SMT as reported by Ernst (J Roy Soc Med 100:330–338, 2007).

Method

Replication of a 2007 Ernst paper to compare the details recorded in this paper to the original source material. Specific items that were assessed included the time lapse between treatment and the adverse event, and the recording of other significant risk factors such as diabetes, hyperhomocysteinemia, use of oral contraceptive pill, any history of hypertension, atherosclerosis and migraine.

Results

The review of the 32 papers discussed by Ernst found numerous errors or inconsistencies from the original case reports and case series. These errors included alteration of the age or sex of the patient, and omission or misrepresentation of the long term response of the patient to the adverse event. Other errors included incorrectly assigning spinal manipulation therapy (SMT) as chiropractic treatment when it had been reported in the original paper as delivered by a non-chiropractic provider (e.g. Physician).

The original case reports often omitted to record the time lapse between treatment and the adverse event, and other significant clinical or risk factors. The country of origin of the original paper was also overlooked, which is significant as chiropractic is not legislated in many countries. In 21 of the cases reported by Ernst to be chiropractic treatment, 11 were from countries where chiropractic is not legislated.

Conclusion

The number of errors or omissions in the 2007 Ernst paper, reduce the validity of the study and the reported conclusions. The omissions of potential risk factors and the timeline between the adverse event and SMT could be significant confounding factors. Greater care is also needed to distinguish between chiropractors and other health practitioners when reviewing the application of SMT and related adverse effects.

Beware of "old" Horner syndrome

PURPOSE

Chronic Horner syndrome is a rare clinical condition, the etiology of which often remains undiscovered. A patient is presented with an 8-year history of Horner syndrome who was diagnosed with multiple cervical artery dissections.

CASE REPORT

A 42-year-old woman presented to our emergency department with a severe occipital headache that woke her up from sleep 3 days earlier. She had a history of headaches and recalled one in particular dating back to 2003. At that time, she sought medical attention at general practitioner's office because of the terrible headache and a noticeable disparity of her pupils. She was told that she had miosis of the right pupil. The examination conducted in 2011 revealed Horner syndrome with right miosis and ptosis. A four-vessel cerebral angiography revealed an occlusion of the right internal carotid artery. The morphology of stenosis and pseudoaneurysm of C1 segment of left internal carotid artery, as well as a pseudoaneurysm of V3/V4 junction of left vertebral artery indicated a probable dissective etiology.

CONCLUSIONS

This case illustrates that Horner syndrome with a chronic presentation can be as potentially dangerous as its acute counterpart and should be judiciously investigated.

Risk factors and clinical presentation of craniocervical arterial dissection: a prospective study

Background

Craniocervical arterial dissection is a major cause of ischaemic stroke in young adults. The pathogenesis is not fully understood but is thought to be related to a combination of an intrinsic weakness in the arterial wall and an external trigger. Intrinsic susceptibility is thought to be a generalised arteriopathy, vascular anomaly or genetic predisposition. Proposed extrinsic factors include recent viral infection and minor mechanical trauma to the neck, including neck manipulation, which has raised concerns amongst manual practitioners in particular as to the appropriate screening of patients and avoidance of more vigorous therapeutic techniques. The presenting features of dissection may mimic a musculoskeletal presentation, creating a diagnostic dilemma for primary care practitioners. Early recognition is critical so that appropriate management can be commenced.

The aims of this study are to prospectively investigate young patients ≤55 years admitted to hospital with radiologically diagnosed craniocervical arterial dissection compared to matched controls with stroke but not dissection, to identify risk factors and early presenting clinical features, so these may be more readily identified by primary care practitioners.

Methods

Patients ≤ 55 years presenting to hospital with craniocervical arterial dissection and controls will have their medical records reviewed and be interviewed and questioned about possible risk factors, preceding events to admission such as recent neck trauma, and presenting clinical features including any preceding transient ischaemic features. Clinical assessment will include a connective tissue screening examination to identify subclinical connective tissue disorders. Radiology and blood screening will be reviewed for typical features and inflammatory markers. Functional outcome will be reviewed to determine the burden of the stroke.

Discussion

This study will provide descriptive and comparative data on intrinsic and extrinsic risk factors for craniocervical arterial dissection and outline the typical clinical presentation, including the nature of early presenting features which might assist practitioners to identify those patients for whom vigorous manual therapy of the neck is inappropriate and alert them to those for whom immediate urgent medical care should be sought.

Traumatic and spontaneous carotid and vertebral artery dissection in a level 1 trauma center

This study aimed to compare traumatic and spontaneous carotid artery dissection (CAD) and vertebral artery dissection (VAD) with respect to age, pre-morbid risk factors, and site of dissection. Chart review was performed for 49 patients with CAD and VAD admitted to Westchester Medical Center, a level 1 trauma center, from 1999 to 2007. Presentation was categorized into traumatic (n=28, 57%) or spontaneous dissection (n=21, 43%). Pre-morbid risk factors were analyzed. Location of dissection was identified and categorized into four possible segments. Patients with spontaneous dissection were likely to be over the age of 50 years (p<0.05), and had significantly higher proportions of coronary artery disease (33% compared to 7%, p<0.05), hypertension (57% compared to 18%; p<0.01), and hypercholesterolemia (29% compared to 0%; p<0.01). Of the 49 patients, 42 had imaging studies available for segmental analysis. In both traumatic CAD and VAD, dissection at Segment III (corresponds with the first and second cervical vertebrae), was the most common site (37.5% and 50%, respectively, p<0.05). In contrast, Segment I (origin of the vessel to the fifth cervical vertebrae) was the most common site for spontaneous CAD and VAD (55% and 77%, respectively, p<0.05). This cross-sectional study suggests that etiology plays an important role in the location of dissection. Traumatic CAD and VAD occur most commonly in Segment III. Spontaneous CAD and VAD occur most commonly in Segment I and are associated with increasing age and premorbid cerebrovascular risk factors.

Cervical carotid artery dissection: current review of diagnosis and treatment

Carotid artery dissection is a cause of stroke, especially in young and middle-aged patients. A dissection occurs when there is an intimal tear or rupture of the vasa vasorum, leading to an intramural hematoma, which is thought to result from trauma or can occur spontaneously, and is likely multifactorial, involving environmental and intrinsic factors. The clinical diagnosis of carotid artery dissection can be challenging, with common presentations including pain, partial Horner syndrome, cranial nerve palsies, or cerebral ischemia. With the use of noninvasive imaging, including magnetic resonance and computed tomography angiography, the diagnosis of carotid dissection has increased in frequency. Treatment options include thrombolysis, antiplatelet or anticoagulation therapy, endovascular or surgical interventions. The choice of appropriate therapy remains controversial as most carotid dissections heal on their own and there are no randomized trials to compare treatment options.

Carotid artery dissection presenting with isolated headache and Horner syndrome after minor head injury

A woman aged 31 years presented to the emergency department after a minor head injury. She reported mild headache and a metallic taste in her mouth. Full neurologic examination was remarkable only for left-sided Horner syndrome. Left internal carotid artery dissection was confirmed on magnetic resonance imaging. She was treated with aspirin. Symptoms and signs persisted 3 months later, but there was no additional neurologic deficit. We stress the importance of early detection of Horner syndrome to minimize the risk of disabling stroke.

Copy number variation in patients with cervical artery dissection

Cervical artery dissection (CeAD) occurs in healthy young individuals and often entails ischemic stroke. Skin biopsies from most CeAD-patients show minor connective tissue alterations. We search for rare genetic deletions and duplication that may predispose to CeAD. Forty-nine non-traumatic CeAD-patients with electron microscopic (EM) alterations of their dermal connective tissue (EM+ patients) and 21 patients with normal connective tissue in skin biopsies (EM- patients) were analyzed. Affymetrix 6.0 microarrays (Affymetrix) from all patients were screened for copy number variants (CNVs). CNVs absent from 403 control subjects and from 2402 published disease-free individuals were considered as CeAD-associated. The genetic content of undentified CNVs was analyzed by means of the Gene Ontology (GO) Term Mapper to detect associations with biological processes. In 49 EM+ patients we identified 13 CeAD-associated CNVs harboring 83 protein-coding genes. In 21 EM- patients we found five CeAD-associated CNVs containing only nine genes (comparison of CNV gene density between the groups: Mann-Whitney P=0.039). Patients' CNVs were enriched for genes involved in extracellular matrix organization (COL5A2, COL3A1, SNTA1, P=0.035), collagen fibril organization COL5A2, COL3A1, (P=0.0001) and possibly for genes involved in transforming growth factor beta (TGF)-beta receptor signaling pathway (COL3A1, DUPS22, P=0.068). We conclude that rare genetic variants may contribute to the pathogenesis of CeAD, in particular in patients with a microscopic connective tissue phenotype.

Spontaneous bilateral carotid artery dissection following cervical manipulation

We report an autopsy case of a bilateral carotid artery dissection, following cervical manipulation by a chiropractor. To establish the etiology of a cervical artery dissection is important in view of possible legal implications and to exclude hereditary disorders, since cervical artery dissection has been linked to several arteriopathies. The underlying arteriopathy in the presented case was an idiopathic cystic medial degeneration. This report emphasizes the role of the pathologist in defining the underlying arteriopathy in carotid artery dissection.

Carotid artery dissection-related intracranial aneurysm development: case report

BACKGROUND AND IMPORTANCE

We analyzed the physiopathology of the association between cervical artery dissections (CADs), intracranial aneurysms (IAs), and aneurysmal subarachnoid hemorrhage.

CLINICAL PRESENTATION

A 43-year-old woman presented with diffuse subarachnoid hemorrhage (Fisher 3; Hunt-Hess 1). computed tomography angiography revealed a cervical internal carotid artery dissection and 2 IAs: right paraclinoid and right posterior communicating artery. The patient underwent surgical clipping of the 2 aneurysms. CAD was managed conservatively. Postoperative course was initially uneventful. After 24 hours, digital subtraction angiography (DSA) documented the exclusion of the aneurysms and an improvement of the CAD. After 3 days, the patient's neurological condition suddenly worsened; CT scan documented a subarachnoid rebleeding (Hunt-Hess 4) and DSA revealed the recurrence of CAD and a new right internal carotid artery aneurysm. The patient underwent clipping of the new aneurysm and decompressive craniectomy because of severe brain swelling. Postoperative neurological conditions remained poor. DSA showed the exclusion of the aneurysms and improvement of CAD. Three days later, CT scan performed after a sudden raise in intracranial pressure documented a wide intracerebral hematoma. Computed tomography angiography did not show new vascular malformations. Surgical removal of the hematoma was performed, but poor neurological conditions persisted.

CONCLUSION

CAD-related hemodynamic changes may play a role in the development of IAs. The presence of IAs must be screened carefully in case of CAD, because the dynamic behavior of CAD definitively increases the risk of IA formation, enlargement, and rupture.

The course of unilateral intracranial arteriopathy in young adults with arterial ischemic stroke

BACKGROUND AND PURPOSE

Unilateral intracranial focal nonprogressive arteriopathy is often found in children with arterial ischemic stroke. We aimed to investigate the course of unilateral intracranial arteriopathy in young adults.

METHODS

We searched the Utrecht Stroke Database for patients between 16 and 50 years of age diagnosed with anterior circulation arterial ischemic stroke and a nonatherosclerotic, unilateral intracranial large-artery arteriopathy between 1991 and 2005. We assessed clinical features, potential causes, risk factors, extent of infarction and arteriopathy at presentation, long-term angiographic course, and clinical outcome.

RESULTS

Of 356 patients with anterior circulation arterial ischemic stroke, 17 (5%) had a documented unilateral intracranial arteriopathy, of whom 14 could be included for follow-up investigations (median age, 34 years; range, 27-49 years). Median duration of follow-up was 8.8 years (range, 1.7-12.8 years). In 11 patients, onset of symptoms was not abrupt. The arteriopathy normalized completely in 5 and improved in 3 patients; in none of the patients did the arteriopathy worsen. Two of 14 patients had recurrent symptoms. Ten patients (71%) had a good outcome (modified Rankin Scale score≤2).

CONCLUSIONS

In young adults, arterial ischemic stroke is rarely caused by a unilateral intracranial arteriopathy. Similar to children, onset of symptoms in young adults is often not abrupt and the arteriopathy may improve over time. Late recurrences were rare. Possibly, a monophasic inflammatory process, as has been suggested for childhood intracranial focal nonprogressive arteriopathies, also occurs in young adults.

Age-dependent differences in cervical artery dissection

The goal of this work was to explore age-dependent differences in cervical artery dissection (CeAD). This study is based on the Cervical Artery Dissection and Ischemic Stroke Patients population comprising 983 consecutive CeAD patients and 658 control patients with a non-CeAD ischemic stroke (IS), frequency-matched for age and gender. Patients were divided into three age categories: ≤33 (for CeAD, n = 150), 34-54 (n = 688), and ≥55 (n = 145) years, and the youngest and oldest groups were compared. The youngest patients were mostly women and the oldest men. The frequency of internal carotid artery dissection (ICAD) versus vertebral artery dissection (VAD) increased with age from 44 to 75 %. This age-related shift remained significant after adjustment for sex. The frequency of a transient ischemic event as the CeAD symptom declined from 33 % in the youngest age group, to 19 % in the oldest. Vascular risk factors increased in frequency with advancing age in both groups, but for hypertension the increase was steeper for non-CeAD IS patients. For CeAD patients, but not for patients with non-CeAD IS, preceding infection was more common in the oldest group. The youngest non-CeAD IS patients had better functional outcome (modified Rankin Scale 0-1) than the oldest, while the similar trend was not statistically significant among CeAD patients. Younger age seems to be associated with VAD and female gender, and older age with ICAD and male gender. Age-related changes in the frequencies of hypertension and recent infection were different between the CeAD and non-CeAD IS groups. Age does not seem to be an important outcome predictor in CeAD strokes.

Therapeutic and diagnostic implication of inadequate circle of willis in a patient with acute spontaneous bilateral internal carotid artery dissection: case report and review of the literature

Background and Purpose

Emphasizing the therapeutic and diagnostic implications of concomitant inadequate collaterals from the circle of Willis in a rare case of spontaneous acute bilateral internal carotid artery dissection (BICAD) following 5 days of isolated rigorous cough (pertussis like).

Case Description

A 45-year-old male has been referred to our department with rapid neurological deterioration consisting of dysarthria and severe left hemiparesis following 5 days of isolated rigorous cough. CTA demonstrated BICAD, a tiny anterior communicating artery and no bilateral posterior communicating artery. The patient had no personal or familial risk factors. Infectious, traumatic, vascular and connective tissue diseases were ruled out.

Results

Neurological deterioration persisted despite immediate provision of continuous ‘full-heparinization’ with concomitant rigorous control of blood pressure. Endovascular treatment consisting of bilateral stenting was undertaken. Ten days later, the patient was discharged with mild hemiparesis and resuming normal activity after 3 months.

Conclusions

BICAD with concomitant inadequate collaterals from the circle of Willis may predispose to hypoperfusion which might not respond to the usual conservative treatment prompting for flow reestablishment. Moreover, isolated rigorous cough can cause acute spontaneous BICAD even among patients without any risk factors.

[Facial and eye pain - Neurological differential diagnosis]

Head and facial pain are common in neurological practice and the pain often arises in the orbit or is referred into the eye. This is due to the autonomic innervation of the eye and orbit. There are acute and chronic pain syndromes. This review gives an overview of the differential diagnosis and treatment. Idiopathic headache syndromes, such as migraine and cluster headache are the most frequent and are often debilitating conditions. Trigemino-autonomic cephalalgias (SUNCT and SUNA) have to be taken into account, as well as trigeminal neuralgia. Trigemino-autonomic headache after eye operations can be puzzling and often responds well to triptans. Every new facial pain not fitting these categories must be considered symptomatic and a thorough investigation is mandatory including magnetic resonance imaging. Infiltrative and neoplastic conditions frequently lead to orbital pain. As a differential diagnosis Tolosa-Hunt syndrome and Raeder syndrome are inflammatory conditions sometimes mimicking neoplasms. Infections, such as herpes zoster ophthalmicus are extremely painful and require rapid therapy. It is important to consider carotid artery dissection as a cause for acute eye and neck pain in conjunction with Horner's syndrome and bear in mind that vascular oculomotor palsy is often painful. All of the above named conditions should be diagnosed by a neurologist with special experience in pain syndromes and many require an interdisciplinary approach.

Considerations in the physical rehabilitation of patients with whiplash-associated disorders

STUDY DESIGN

Review of research identifying physical impairments in the neuromuscular system in subjects with whiplash-associated disorders.

OBJECTIVE

Review the impairments in movement and neuromuscular function toward constructing research informed exercise programs.

SUMMARY OF BACKGROUND DATA

Pain and injury to the musculoskeletal system result in loss of motion and impaired neuromuscular function which impacts on functional activities, work and quality of life. Therapeutic exercise is a mainstay of rehabilitation, but the nature of the exercises prescribed are currently various and the effect sizes of current programs for patients with whiplash-associated disorders are modest at best.

METHODS

A review was undertaken of research investigating the changes in cervical motion and neuromuscular function to better inform exercise prescription and identify areas for future research. RESULTS.: Reduced range of movement as well as pathological movement patterns (reduced acceleration and velocity, reduced smoothness and irregular axes of neck movement) have been documented in subjects with whiplash-associated disorders. In relation to neuromuscular control, changes have been demonstrated in neck muscles' spatial and temporal relationships as well as in their strength and endurance. The presence or not and the extent of changes is highly variable between individuals and appears to have some relationship to pain intensity. It appears that there is a need for specificity in exercise prescription to address particular impairments rather than the use of generic programs. High pain intensity can modify effects of a therapeutic exercise program.

CONCLUSION

Pain and injury result in reorganization of the motor control strategies of neck muscles and movement. Further research is required to determine if outcomes after a whiplash injury can be improved by using research informed, individually prescribed exercise programs matched to the individual's presentation. Research into best methods of pain management is also required to facilitate physical rehabilitation.

Age determination of vessel wall hematoma in spontaneous cervical artery dissection: a multi-sequence 3T cardiovascular magnetic resonance study

BACKGROUND

Previously proposed classifications for carotid plaque and cerebral parenchymal hemorrhages are used to estimate the age of hematoma according to its signal intensities on T1w and T2w MR images. Using these classifications, we systematically investigated the value of cardiovascular magnetic resonance (CMR) in determining the age of vessel wall hematoma (VWH) in patients with spontaneous cervical artery dissection (sCAD).

METHODS

35 consecutive patients (mean age 43.6 ± 9.8 years) with sCAD received a cervical multi-sequence 3T CMR with fat-saturated black-blood T1w-, T2w- and TOF images. Age of sCAD was defined as time between onset of symptoms (stroke, TIA or Horner's syndrome) and the CMR scan. VWH were categorized into hyperacute, acute, early subacute, late subacute and chronic based on their signal intensities on T1w- and T2w images.

RESULTS

The mean age of sCAD was 2.0, 5.8, 15.7 and 58.7 days in patients with acute, early subacute, late subacute and chronic VWH as classified by CMR (p < 0.001 for trend). Agreement was moderate between VWH types in our study and the previously proposed time scheme of signal evolution for cerebral hemorrhage, Cohen's kappa 0.43 (p < 0.001). There was a strong agreement of CMR VWH classification compared to the time scheme which was proposed for carotid intraplaque hematomas with Cohen's kappa of 0.74 (p < 0.001).

CONCLUSIONS

Signal intensities of VWH in sCAD vary over time and multi-sequence CMR can help to determine the age of an arterial dissection. Furthermore, findings of this study suggest that the time course of carotid hematomas differs from that of cerebral hematomas.

Pathologic evaluation of the cervical spine following surgical and chiropractic interventions

When patients die after chiropractic or surgical interventions of the cervical spine, pathologists tasked with the autopsy are frequently overwhelmed by the complicated anatomy, laborious dissections, complex operative procedures and surgical hardware, and the necessity to differentiate artifacts from trauma and disease. However, abundant data can be obtained from careful evaluation of the cervical spine in situ; extensive postmortem diagnostic imaging procedures; detailed dissections of the removed, formalin-fixed and decalcified spine; and histology. This study presents a regimented, stepwise approach to the evaluation of the cervical spine in these difficult cases, promotes uniform assessment, facilitates diagnoses, and supports the accumulation of otherwise hard-to-come-by reference material that can be of value in future cases. The resultant detailed autopsy findings may prove useful in the medico-legal death investigation process. Autopsy findings may also be of great value to health care providers involved in quality assurance processes.

Treatment of Spontaneous Intradural Vertebral Artery Dissections

Spontaneous intradural vertebral artery dissections may cause subarachnoid hemorrhage and often result in devastating damage. Increased use of noninvasive imaging studies has allowed larger numbers of patients to be diagnosed. In addition, intracranial vertebral artery dissection tends to induce multiple lesions affecting both intracranial vertebral arteries recurrently. Although unruptured dissections in this area usually have a benign nature, some authors have reported on the incidence of rupture from this lesion. Once hemorrhage from a dissecting vessel wall has occurred, it needs to be treated in the acute phase because of the high risk of rebleeding resulting in high morbidity and mortality. From December 2004 to July 2010, we managed 47 patients with spontaneous vertebral artery dissection, 31 patients were ruptured and 16 were unruptured. All patients who suffered from subarachnoid hemorrhage were treated with endovascular procedures. Most of the patients with unruptured dissection received medical therapy, but if the aneurysmal dilatation persisted or grew, surgical interventions were performed. Stenting with or without coils was deployed for 13 patients with posterior inferior cerebellar artery involvement at the site of dissection and/or were affected on the dominant side. In some patients, stenting was performed even if they were in the acute phase. For other ruptured patients, internal coil trappings were performed. Six patients died due to severe initial subarachnoid hemorrhage and one patient, who underwent stent deployment with coils for the dominant vertebral artery, with bilateral dissection continuing to the basilar artery died due to rerupture while the next additional coiling was planning. There were two cases of complications related to the intervention. During the follow-up period no bleeding occurred in any of the patients except for the previously mentioned patient. In conclusion, internal coil trapping or stent placement with or without coils was effective in preventing rebleeding of ruptured vertebral artery dissection. If the dissection is unruptured, it is necessary to detect the risk of bleeding with careful watching and when progress appears to be made, patients should be treated promptly. Stent-assisted therapy for preserving the patency of the parent artery and major branches is a promising treatment for vertebral artery dissection, even in the acute stage of subarachnoid hemorrhage. However, the risk of acute rerupture and recurrence remains even with the porous stent placement with or without coils.