Synopsis
Recognise cervical artery dissection from painful local and cerebral ischaemic clues, obtain complete head-and-neck arterial imaging, and coordinate reperfusion and specialist antithrombotic treatment safely.
- Cervical artery dissection is an important cause of stroke in younger adults and can occur spontaneously or after seemingly minor neck strain, coughing, sport, trauma or manipulation.
- Internal carotid dissection classically causes unilateral head, face or neck pain with partial Horner syndrome, pulsatile tinnitus, retinal ischaemia or hemispheric TIA or stroke.
- Vertebral dissection more often causes occipital or posterior neck pain followed by vertigo, diplopia, dysarthria, ataxia, nystagmus, sensory change or other posterior circulation signs.
- Pain can precede cerebral ischaemia by hours or days, so a normal initial limb examination does not make a new painful Horner syndrome or suspicious posterior neck syndrome benign.
- Urgent CTA or MRA should cover head and neck vessels; carotid Doppler alone can miss high cervical, vertebral and intracranial disease and should not be used to exclude dissection.
- Treat an acute disabling ischaemic stroke with the usual thrombolysis and thrombectomy pathways when eligible; dissection itself is not an automatic reperfusion contraindication.
- For extracranial dissection, antiplatelet therapy or anticoagulation may be selected because no clear overall superiority has been established; current UK stroke guidance recommends antithrombotic treatment for at least 3 months, with any continuation beyond that reassessed by the specialist team.
- Intracranial extension, dissecting aneurysm, subarachnoid haemorrhage or recurrent ischaemia despite therapy changes the risk and requires urgent neurovascular multidisciplinary management.
Key red flags
Ongoing or fluctuating focal deficit, aphasia, disabling posterior signs or reduced consciousness requires immediate acute-stroke activation and reperfusion imaging.
Painful Horner syndrome is a same-day arterial-imaging indication because cerebral embolism can occur after the local syndrome begins.
Thunderclap headache, meningism or intracranial dissection raises subarachnoid haemorrhage and changes antithrombotic safety completely.
Progressive dysphagia, airway symptoms or multiple lower cranial neuropathies may indicate an expanding pseudoaneurysm requiring urgent neurovascular review.
Recurrent ischaemic events despite confirmed therapeutic treatment needs repeat imaging and specialist endovascular discussion rather than unsupervised drug stacking.
Investigation priorities
Demonstrate tapered stenosis, occlusion, intimal abnormality, pseudoaneurysm or mural change and assess intracranial vessels.
Management branches
New unilateral head or neck pain occurs with partial Horner syndrome, pulsatile tinnitus or lower cranial neuropathy.
- Perform urgent neurological, pupillary and cranial-nerve examination and ask about transient retinal or cerebral symptoms and recent neck stress or injury.
- Arrange same-day CTA or MRA of the head and neck rather than relying on carotid Doppler or waiting for weakness.
- Discuss confirmed or strongly suspected dissection with stroke or neurology to determine antithrombotic treatment and whether brain MRI is needed.
- Give emergency return advice for visual loss, speech change, imbalance or weakness and advise against further neck manipulation during evaluation.