Correspondence

Spontaneous Dissection of the Carotid and Vertebral Arteries

N Engl J Med 2001; 345:467August 9, 2001

Article

To the Editor:

In the review article on spontaneous dissection of the carotid and vertebral arteries (March 22 issue),1 Dr. Schievink recommends therapeutic anticoagulation unless the dissection extends intracranially. Intraarterial angiography is often necessary to establish whether such an extension is present. It is believed that there is an increased risk of intracranial bleeding on anticoagulation of an intracranial arterial dissection. However, there is no good evidence to support this view. In the absence of hard data, this approach is largely empirical. It would be appropriate to qualify this recommendation until better data are available.

Robert Kalb, M.D.
Yale University School of Medicine, New Haven, CT 06520-8018
rgk2@email.med.yale.edu

1 References

1
Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001;344:898-906
Full Text | Web of Science | Medline

To the Editor:

Although the title of Schievink's review of cervical arterial dissection uses the words “spontaneous dissection,” the author includes “minor precipitating event[s],” such as sudden neck movements, as causes of dissection. We believe that in the context of dissection the word “spontaneous” is a misnomer, since this diagnosis is entirely dependent on the patient's history.

In a prospective study being undertaken by the Canadian Stroke Consortium,1 careful history taking in patients with so-called spontaneous dissection has invariably revealed minor trauma. Most people experience sudden inadvertent neck movements during everyday activities, but the hallmark of dissection seen so far in 99 of 119 of our patients (83 percent) is sudden, often severe, and immediate neck pain over the site of the dissection. These arterial tears are often surprisingly painful.

There is clearly a spectrum of injury, varying from trivial injuries, such as those due to swinging a golf club, to serious, direct trauma to the neck. Underlying congenital arterial abnormalities, such as fibromuscular dysplasia, are very relevant. Such abnormalities were seen on 21 of 119 angiograms (18 percent) in our cases, but subtle changes in the arterial wall not visible on angiography are probably more common.

Vadim Beletsky, M.D., Ph.D.
John W. Norris, M.D.
University of Toronto, Toronto, ON M4N 3M5, Canada
neuroteam@netscape.net

for the Canadian Stroke Consortium

1 References

1
Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical arterial dissection. CMAJ 2000;163:38-40
Web of Science | Medline

Author/Editor Response

Dr. Schievink replies:

To the Editor: Dr. Kalb is correct in stating that I do not recommend anticoagulation in patients with intracranial extension of a carotid-artery or vertebral-artery dissection. Because there is no external elastic lamina in intracranial arteries and because the media in these arteries is attenuated as compared with that of extracranial arteries, anticoagulation is likely to increase the risk of intracranial bleeding. This approach to therapy is largely empirical, and better data are certainly needed. In my experience, arteriography is generally not necessary to show intracranial extension of a dissection, since it is often better visualized by magnetic resonance imaging.

Drs. Beletsky and Norris object to the use of the term “spontaneous.” As I state in my article, there is a distinction between minor precipitating events, such as coughing and sneezing, and the serious head or neck injuries encountered in motor vehicle crashes. It is likely that the etiology and pathogenesis of spontaneous carotid-artery and vertebral-artery dissections are multifactorial and that mechanical factors, such as sudden neck movements, and underlying arteriopathy have a role. The underlying arteriopathy may be transient and may be related to a recent infection, or the arteriopathy may be related to a genetic abnormality.

Wouter I. Schievink, M.D.
Cedars–Sinai Medical Center, Los Angeles, CA 90048
schievinkw@cshs.org

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