Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 12 Sept 2026Clinical review pending
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Dissection with acute cerebral ischaemia
A current retinal or hemispheric deficit from extracranial carotid dissection is a hyperacute stroke emergency, while thunderclap headache or meningism raises intracranial extension and subarachnoid haemorrhage.
Action: Activate the stroke pathway, record last-known-well, obtain non-contrast brain imaging plus head-and-neck angiography and assess thrombolysis or thrombectomy under standard specialist criteria.
Synopsis
Recognise carotid dissection before stroke, obtain complete arterial imaging and choose acute reperfusion and antithrombotic management safely.
Treat any current retinal or hemispheric deficit as acute stroke: obtain brain imaging and complete head-and-neck angiography without delaying standard reperfusion assessment.
Painful partial Horner syndrome, new unilateral neck or orbital pain with ptosis and miosis, is a same-day carotid imaging indication even without limb weakness.
Thunderclap headache, meningism or intracranial extension raises subarachnoid haemorrhage; exclude bleeding before antithrombotic treatment.
Key red flags
Ongoing weakness, aphasia, visual loss, neglect or reduced consciousness requires immediate hyperacute stroke assessment and reperfusion imaging.
Painful partial Horner syndrome needs same-day cervical and intracranial arterial imaging even before weakness or speech disturbance appears.
Thunderclap headache, meningism or subarachnoid blood suggests intracranial dissection or rupture and changes antithrombotic safety completely.
Progressive dysphagia, airway symptoms or multiple lower cranial neuropathies may indicate an enlarging dissecting aneurysm with compression.
Recurrent ischaemia despite prescribed treatment needs repeat imaging and neurovascular review rather than empirical addition of more antithrombotic drugs.
Painful partial Horner syndrome
New ipsilateral ptosis and miosis with orbital, facial or neck pain strongly suggests internal carotid dissection; facial sweating may be preserved.
Retinal or hemispheric ischaemia
Transient monocular loss, retinal infarction, aphasia, neglect or contralateral motor and sensory deficits may follow artery-to-artery embolism.
Investigation priorities
01
CT angiography of head and neckFirst step
Demonstrate luminal and wall-related signs while assessing intracranial vessels and potential stroke targets.
Management branches
LOCALPainful local carotid syndrome
Unilateral head or neck pain accompanies partial Horner syndrome, pulsatile tinnitus or lower cranial neuropathy.
Perform urgent neurological, pupillary and cranial-nerve examination and ask specifically about transient monocular loss, language disturbance and recent trauma.
Arrange same-day CTA or MRA of the head and neck rather than relying on auscultation, routine Doppler or symptom resolution.
Key medicines
AspirinWhen an antiplatelet strategy is selected after acute ischaemic stroke, give 300 mg orally or rectally once daily after haemorrhage is excluded, continuing for fourteen days before the documented long-term regimen; if thrombolysed, start only after the twenty-four-hour scan excludes bleeding.Check allergy, active bleeding, ulcer risk and concomitant anticoagulation; intracranial dissection with subarachnoid haemorrhage requires a different pathway.
Specialist-selected oral anticoagulantNo universal licensed dissection dose exists; the stroke specialist selects a named oral agent and its product-specific regimen, documents whether use is off label, and sets a three-month reassessment.Exclude subarachnoid and intracranial haemorrhage; consider infarct size, intracranial extension, renal and hepatic function, trauma, bleeding, pregnancy, interactions and planned procedures before selecting the agent.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 12 Sept 2026; clinical approval remains outstanding.