Clinical Features

• Non-ischemic features

  • Ipsilateral headache and facial/neck pain (constant, severe, throbbing or sharp)

  • Partial horner syndrome: ptosis and miosis

  • Pulse-synchronous tinnitus

  • Neck swelling

  • Reduced taste sensation

  • Cranial nerve lesions, usually caudal nerves (VI–XII)

• Ischemic features

  • Symptomatic middle cerebral artery infarction (see “Stroke”)

  • Amaurosis fugax (ischemic retina)

• Non-ischemic features

  • Occipital headache

  • Posterior nuchal pain

• Ischemic features: vertebrobasilar insufficiency (leads to stroke resembling lateral medullary dysfunction, e.g., Wallenberg syndrome)

  • Ipsilateral loss of taste and facial pain and numbness (most common symptom)

  • Contralateral pain relief and reduced temperature sensation

  • Vertigo

  • Ataxia

  • Central Horner syndrome

  • Dysphagia and dysarthria or hoarseness

  • Nausea, vomiting

• Duplex ultrasonography: high resistance flow or complete absence of flow in affected artery

• Helical CT angiography (replacing MRI as diagnostic modality of choice )

  • Changed caliber of vessel

  • Oval or slit-like cross-section of vessel

• MR angiography

  • Intramural blood

  • Mural expansion

  • Irregular vessel margins

  • Filling defects [4]

  • Extravasation of contrast [5]

  • Caliber changes of vessel

• Conventional angiography

  • Intimal flap

  • Double lumen

  • Long tapered segment of contrast in distal portion of internal carotid artery

Baseline monitoring parameters (e.g., INR, PT, aPPT) should be performed before administering anticoagulant therapy.

• Treatment should be initiated after an intracerebral hemorrhage has been ruled out.

  • Heparin therapy followed by oral anticoagulation for 3–6 months and/or

  • Antiplatelet agents for 1 year

• Possibly angioplasty/stenting or surgical intervention may be warranted in severe cases

Asymptomatic pseudoaneurysms do not usually require treatment and most dissections heal spontaneously.