Carotid Dissection ================== þ Bottom Line: Carotid Dissection - Unilateral headache + partial Horner’s or TIA/CVA is a carotid dissection until proven otherwise - Anticoagulation is the treatment of choice and will not extend the dissection þ Epidemiology - 1:20,000 cases of chiropractic neck manipulation þ Presentation - Classic Triad + unilateral head, face or neck pain; up to 4 days later: + partial Horner's Syndrome : no anhydrosis + retinal or cerebral CVA - All three present in less than one-third of patients. - 2/3 “strongly” suggests the diagnosis. - 1/4 have history of migraines and feelsn similar - anticoagulate to prevent thromboembolism; doesn't extent the dissection - ASA and heparin/Coumadin about the same risk of CVA - May also present with cranial nerve abnormalities (12% of patients). 3, 5, 7, 12 are most common. Impairment of taste in 10%. - Pulsatile tinnitus is reported in ¼ of patients. Bruit may be present - Ischemic symptoms in 50-95% of patients. TIA may precede, but 1/5 have CVA without warning signs. þ Diagnostic Tests - Angiography has traditionally been gold standard, but is being replaced by MRI - Ultrasound may show an abnormal pattern of flow (90%), but the site of dissection is generally not seen - CTA is comparable to MRI/A þ Treatment - Anticoagulation (heparin/coumadin) to prevent thromboembolic complications because 90% of infarcts due to dissection are thromboembolic - Theory that this treatment (or TPA) may extend the dissection appears to be unfounded - Usually anticoagulation is continued for 6 months