POTD: Cervical Artery Dissection

Clinical Scenario:

A 25-year-old woman presents with neck pain, headache, nausea, left-sided facial numbness, and an unsteady gait. She says the headache began 7 days earlier shortly after a chiropractic treatment for chronic neck pain. Vital signs are normal; the unsteady gait is noted on ambulation. Noncontrast head CT findings are normal.

Which of these tests should be ordered next?

A. CT angiography of the neck with contrast

B. CT of the neck without contrast

C. Duplex ultrasonography of the carotid arteries

D. Duplex ultrasonography of the vertebral arteries.

The answer is A. 

Cervical Artery Dissection

What is it?

• Cervical artery dissections is the collective term for dissections of the carotid or vertebral arteries

  • internal carotid artery is most commonly affected

  • vertebral artery dissections are uncommon

• Dissection of the cervical arteries is a common cause of stroke among young and middle-aged persons. 

  • ~ 20% of strokes in the young are caused by carotid artery or vertebral artery dissections in the neck, compared to only 2.5% in older patients

• Caused by minor trauma in the setting of neck manipulation (e.g. by a chiropractor) or a minor sports injury. There are some case reports of these injuries occurring from riding roller coasters. 

• Seen more commonly in patients with connective tissue disorders or vascular pathologies (e.g. HTN, Marfan’s syndrome, fibrocystic dysplasia, etc)

Presentation

• Classic presentations include neck pain and headache that might precede development of neurologic symptoms (hemiplegia, hemisensory loss) by hours or up to 14 days.

• Vascular bruits (absence does not exclude dissection, e.g. present in only about 1/3 of carotid dissections)

• carotid dissection tends to present with some or all of the following:

  • frontal headache

  • anterior neck pain

  • eye, ear, or face pain

  • Ipsilateral Horner’s syndrome (due to expansion of the internal carotid artery with compression of sympathetic nerve fibers)

• vertebral artery dissectiontends to present with some or all of the following:

  • occipital headache

  • posterior neck pain

  • unilateral facial numbness, dizziness, ataxia, vision disturbances (diplopia), and nausea or vomiting

Evaluation

• Diagnosis is via CT angiography of the neck. Although it might take longer to obtain, MRA is also an acceptable diagnostic test. 

Treatment

• Anticoagulation with heparin intravenously followed by warfarin.

• tPA may be considered in some patients with stroke due to spontaneous extracranial dissection

• Endovascular therapies include stenting

  • usually used for extracranial carotid or vertebral artery dissection when medical management fails or is contraindicated

  • improved outcomes are associated with reconstitution of flow within 6 hours

References
PEER IX

https://lifeinthefastlane.com/ccc/cervical-artery-dissection/

POTD: Trauma Tuesdays - Concussions

Clinical scenario:

A 16-year-old boy presents after hitting his head in a collision with another player during a soccer game. He denies loss of consciousness but complains of a moderate headache, nausea, and difficulty concentrating. 

Which of the following represents appropriate next steps in management?

A. Admit the patient to the hospital for overnight observation

B. Clear the patient to play after 48 hours if his symptoms resolve

C. Discharge with instructions to get follow-up care and not return to play

D. Order a head CT to rule out the presence of an intracranial bleed or swelling

The correct answer is C. 

Concussions

What is a concussion?

The term "concussion" is often used in the medical literature as a synonym for mild TBI but more specifically describes a pathophysiological state that results in the characteristic symptoms and signs that individuals may experience after a mild TBI. 

Symptoms

Rapid-onset short-lived neurologic function impairment that resolves on its own. These symptoms reflect functional disturbance rather than structural injury.

Diagnosis

If one or more of the following:

• Symptoms, including somatic (headache, nausea, off balance), cognitive (“ in a fog,” slow), or emotional (rapidly changing)

• Physical signs, such as loss of consciousness, amnesia, although LOC is not required

• Behavior changes, such as irritability

• Cognitive impairment, such as slowed reaction times

• Sleep disturbance, such as insomnia

Evaluation

• Concussion is a clinical diagnosis, and there are a variety of sideline assessment tools (that are outside the scope of the ED) that include measurements of orientation, symptoms, gross cognition, and physical examination findings (e.g. Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), computerized neurocognitive testing, and the Sport Concussion Assessment Tool version 5 (SCAT5 or Child-SCAT5)).

• Physical exam should include: 

  • assessment of the cervical spine (+/- immobilization with c-collar if cervical spine injury suspected)

  • detailed neurologic assessment (including mental status, cognitive functioning, and gait/balance)

  • structural brain imaging (i.e. CT scan or MRI) if concern for structural injury (e.g. acute brain bleed)

Discharge Precautions

This is arguably the most important part of your role in the concussed patient. Thankfully, the CDC has a ton of great literature on the subject.

Pediatric Care Packets:

1. Pediatric Discharge Instructions

2. Symptom-Based Recovery Tips

3. Pediatric Care Plan

Adult Care Packets:

1. Adult Concussion Fact Sheet

2. Adult Concussion Brochure

3. Adult Care Plan

References:

PEER IX

http://www.emdocs.net/concussion-update/?fbclid=IwAR3KSyGMyb-55DTXUWRkTXRLBurnrvULl2zPhZb4xIyiJH8_idVktsaDTJA

https://www.uptodate.com/contents/acute-mild-traumatic-brain-injury-concussion-in-adults?search=concussion&sectionRank=3&usage_type=default&anchor=H25&source=machineLearning&selectedTitle=1~79&display_rank=1#H25

https://www.cdc.gov/HeadsUp/

POTD: Cerebral Venous Sinus Thrombosis (CVST)

Clinical Presentation:

An 18-year-old female student presented with a 7-day history of worsening frontal headache and 1 day history of vomiting. The patient described marked photophobia, but no fever or history of seizure. She was taking a combined oral contraceptive and had no other medical history. Physical examination showed no focal neurology, but fundoscopy revealed bilateral papilledema. 

Today, let’s learn about cerebral venous sinus thrombosis.

What is it?

Clot that forms within the major cerebral veins, such as the dural sinuses (super sagittal sinus, straight sinus, and transverse sinuses), cortical veins, vein of Galen, and jugular veins.

What causes it?

Thrombosis of either the cerebral veins or of the major cerebral sinuses.

Epidemiology

• More common in younger patients (median age = 38)

• More common in women

• Mortality of 10-30%

• Risk factors: 

  • Acquired: infections (otitis, mastoiditis), surgery, pregnancy, trauma, cancer, exogenous hormones

  • Genetic: inherited thrombophilia

Presentation

• Non-specific stroke-like symptoms: severe HA (90% of patients) that can be gradual in onset, weakness, paresthesias, blurred or double vision

• If increased ICP, can see mental status changes, lethargy, decreased consciousness, papilledema 

• If focal brain injury, can have seizures or focal neurological defecits

Diagnosis

• Variety of imaging modalities for diagnosis, typically can start with a non-contrast CT head and then progress to CT venogram (if MRI unavailable), or perform MR venography, MRI, or cerebral angiography

Management

• Manage seizures or herniations 

• Start anticoagulation

  • Unfractionated heparin (UFH)

  • Low molecular weight heparin (LMWH): 1 mg/kg SQ Q12 hours

• Other treatment modalities: systemic thrombolytics, cather-based interventions (thrombolytics and thrombectomy), decompressive craniectomy

References:

https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/cerebral_venous_sinus_thrombosis_134,69

https://coreem.net/core/cerebral-venous-thrombosis/

https://casereports.bmj.com/content/2015/bcr-2015-212437.full

https://lifeinthefastlane.com/ccc/cerebral-venous-thrombosis/