Carotid dissections causing neuro deficit... stroke mimicker

[pinipig523]

So what is your practice with these patients? Patients who come in with a carotid artery dissection - either intracranial or extracranially?

I read a few months ago - so pardon me if I'm rusty - on EB Medicine, that if it is intracranial, you need to give antiplatelet but heparinize the patient if it is extracranial. The literature that supported said that tpa extracranially was controversial.

Reason I ask is that I had a patient yesterday who had RUE and RLE weakness, he was out of tpa range but had no headache or neck stiffness or pain and there was no trauma... so CTH plain and was normal, out of tpa range because >5h, and then gave aspirin and admitted. Now, MRA shows dissection.

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[name?]

I wouldn't do anything different other than do and document what neuro asked me to do after it was identified. Emergently you're not going to make any difference with initiating more aggressive therapy as far as I understand. I thought it was more secondary prevention to anti coagulate these guys beyond the typical ASA for non-tpa strokes

 

[Rendar5]

The truth is that heparin vs. ASA is controversial and there is no well-established answer either way. As above, talk to neuro, let them decide. At this point, it's a CVA admission: the goal is to find the all fixable causes of a stroke and treat them to prevent further strokes. Cervical artery dissection is just one thing you look for, and if it happens to pop up on the ED portion of the workup (which is rare unless you're MRI-ing and MRA-ing routinely prior to admission), then you talk to your inpatient team and do things their way and document it as such.

 

[future_dr_house]

How many people are routinely ordering CTA head and neck with perfusion studies? It's what we do at my academic center.

 

[Birdstrike]

So what is your practice with these patients? Patients who come in with a carotid artery dissection - either intracranial or extracranially?

I read a few months ago - so pardon me if I'm rusty - on EB Medicine, that if it is intracranial, you need to give antiplatelet but heparinize the patient if it is extracranial. The literature that supported said that tpa extracranially was controversial.

Reason I ask is that I had a patient yesterday who had RUE and RLE weakness, he was out of tpa range but had no headache or neck stiffness or pain and there was no trauma... so CTH plain and was normal, out of tpa range because >5h, and then gave aspirin and admitted. Now, MRA shows dissection.

These are rare but I've seen 3, I think. Classically, there are stroke symptoms with some sore of atypical head and/or neck pain.

Pain + neuro deficit = Think VASCULAR

As far as treatment, just call neuro.

 

[southerndoc]

How many people are routinely ordering CTA head and neck with perfusion studies? It's what we do at my academic center.

Our stroke protocol is non-contrast CT for symptoms <3 hrs, non-con followed by CTA head/neck for symptoms 3-6 hours (because our neurointerventionalist will take the patient to the lab if there is evidence of a clot).