醫學筆記匯整 ED Notes

- Uncommon but important cause of young stroke (10% to 25% of cases)
  在年輕型腦中風占了很重要的角色
- Especially in young and middle-aged patients

- Prominent risk factor : history of neck trauma in the days to weeks prior to presentation
  除了外傷也可能是運動傷害, 頸部按摩 
 
  Other risk factor : 
  Connective tissue disease, history of migraine, large vessel arteriopathies and hypertension.
  據統計有 1/4 的頸動脈剝離的患者以前曾有偏頭痛的病史
  很多論文提到病人會抱怨這次頭痛與之前不同
  此類病患與偏頭痛的病患最大的差異, 就是脖子會有頸部血管按壓的疼痛（Carotidynia）
  甚至有病人的脖子會痛到無法讓醫師碰觸或轉動脖子

- 先有 Unilateral headache (68%), neck pain (39%), or face pain (10%)
  Symptoms may be transient or persistent
  以上 Preceding symptoms 再發展出 neurologic symptoms 可能是 hours to 14 days
  典型的發作模式是先疼痛數日後發生中風, 期間可能伴隨局部神經學症狀

 

 Carotid Artery Dissection 

 - The headache is most commonly in the frontotemporal region 
 - Due to its variable quality and severity, may mimic SAH (thunderclap headache),
   temporal arteritis, or preexisting migraine.

 - A partial Horner's syndrome  (miosis and ptosis)
   has traditionally been linked to carotid artery dissection, but in reality,
   it occurs in only about 25% of patients and is a sign accompanying other disorders besides stroke.
   支配臉部汗腺的交感神經是沿外頸動脈而上
   若內頸動脈剝離約有不到一半的病人會出現瞳孔縮小及眼瞼下垂, 卻不會有臉部無汗
   所以特稱為 Partial Horner syndrome

 - Associated cranial nerve palsies have been reported in 12% of carotid artery dissections.
   最常見的為味覺喪失 (dysgeusia) 及疼痛性的耳鳴

 - Carotid dissection can progress to cause cerebral ischemia or, rarely, retinal infarction.
   中風前多半先會出現暫時性腦缺血或是黑矇症 amaurosis fugax
   中風在 MRI 多呈現 embolic pattern
 

 Vertebral Artery Dissection   

- Neck pain (66%) and headache (65%), both of which can be unilateral or bilateral
  很容易被誤認為肌肉或是骨頭關節的疼痛

- headache typically occipital, but can rarely present with pain on an
  entire side of the head or in the frontal region.

- Unilateral facial paresthesia, dizziness, vertigo, N/V, diplopia and other visual
  disturbances, ataxia, limb weakness, numbness, dysarthria, and hearing loss.

- Cervical radiculopathy (typically a peripheral motor deficit at the C5 level)
  is a rare presentation (1%). 

- Untreated vertebral artery dissection may result in infarction in posterior circulation.
  中風方面最典型的表現為 Wallenberg syndrome 

 

- MRI/magnetic resonance angiography and CT/CT angiography are
  the diagnostic modalities of choice for suspected carotid, vertebral, or basilar artery dissection.
  血管攝影

​​​​​​​- Choice of study is usually determined by consultation
   with the neurologist and radiologist. Color duplex US may
   not detect important vascular lesions.
 

 Treatment 

​​​​​​​- Traditionally treated with IV heparin followed by warfarin