Spontaneous Cervical Artery Dissection: A Case Series

Cervical artery dissection refers to dissection of the vertebral or carotid arteries, and accounts for up to 20% of strokes in those under 45. Antithrombotic therapy is therefore essential to limit thrombosis at the site of injury and distal neuronal damage. However, the exact choice of drugs, timing and duration of therapy remain a challenging decision. A review of data was conducted on three cases of unprovoked cervical dissection at our stroke center between 2017 and 2020. They include bilateral internal carotid artery dissection, right vertebral artery dissection, and left internal carotid artery dissection. Three key outcomes were identified: narrowing, occlusion and pseudoaneurysm; such outcomes dictated our management approach. Two patients were given antiplatelet therapy for at least one year. The patient with bilateral dissection was perceived to have higher thromboembolic risk, due to the presence of a free-floating thrombus. Thus, he was anticoagulated for a year, and thereafter given antiplatelet therapy. The evidence behind long-term management of carotid artery dissection remains equivocal. There is no strong evidence favouring anticoagulation over antiplatelets or vice versa. Anticoagulation tends to be preferred in cases of severe stenosis, occlusion or pseudoaneurysm, to reduce the risk of thromboembolic phenomena. Anti-platelets are preferred where there is a high risk of haemorrhagic transformation or contraindication to anticoagulation. The duration of secondary prevention is similarly unclear. Advances in radiology and increased follow-up have resulted in uncertainty on the management of incomplete healing at the six-month point. Varying clinical practice has been identified and there is a lack of a clear guideline. We propose continuing antithrombotic therapy in cases of incomplete healing, as in our case series. Nevertheless, we require more data on the subject and thus suggest an initial nation-wide survey to compare the different management strategies followed by large-scale retrospective analyses comparing long-term outcomes.