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DIAGNOSTIC CONSIDERATIONS IN CERVICAL AND INTRACRANIAL ARTERIAL DISSECTIONS THROUGH A CASE SERIES STUDY

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INTRODUCTION: Cervical and intracranial vessels dissections are often misdiagnosed given their symptoms heterogeneity. Headache, partial Horner Syndrome and focal deficits are important clinical features. OBJECTIVE: Report epidemiological and clinical features of 6 patients diagnosed with arterial dissections in a neurology emergency department. METODOLOGIA: We have retrospectively studied six cases of cervical and intracranial arterial dissections and extracted information regarding age, symptoms, vaccine status, covid-19 infection and radiological aspects of the dissections. RESULTADOS: Medium age of onset was 43 years-old. Five patients had headaches, in which two cases were occipital/cervical pain, one orgasm-associated headache, one headache plus transient expression aphasia and one new-onset bilateral frontal headache. New headache pattern was the main red flag for further investigation. Unresponsiveness to usual analgesics led to the diagnosis in a patient with migraine. Direct trauma caused an extensive carotid bulb dissection complicated with distal embolization and ipsilateral M1 occlusion in a patient. The mean time to diagnosis was 4.8 days. Diagnosis was achieved with angiotomography or magnetic resonance angiography. Anterior circulation was stricken in 2 cases, with a carotid bulb dissection related to trauma and a bilateral carotid spontaneous dissection. Extracranial vertebral dissections were seen in 3 cases, plus 1 case of intracranial V4 dissection. Four patients had had respiratory viral infections or vaccine shots within 30 days of symptoms onset. Five patients were discharged with no disability. No deaths occurred. DISCUSSION: Cervical arterial dissections are present in up to 20% of strokes in young patients. Intimal damage or vasa vasorum rupture are proposed mechanisms. Hypertension, migraines, recent infections and direct trauma are established risk factors for arterial dissections, which usually occur after carotid bifurcations. This case series highlights important pitfalls in diagnosing arterial dissections: (1) unresponsive and new occipital or cervical headaches prompt further investigation with contrasted images. (2) Infections and vaccines may cause transient endothelial inflammation, weakening the arterial wall, with further risk of dissection. (3) Neurologic focal deficits arising from both anterior and posterior circulations can be subtle and should be carefully searched in patients presenting with high-risk headaches.