Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Dissections of brain-supplying arteries

Abstract

Arterial dissections involving arteries in the neck and head are being identified increasingly readily because of growing awareness of their clinical features, along with advances in imaging technologies. Dissections are caused mostly by stretching and tearing of arteries, which leads to bleeding within the arterial wall. Dissections of brain-supplying arteries are invariably accompanied by headache and other forms of pain. Subintimal dissections cause mostly brain and eye ischemia, whereas subadventitial dissections lead to formation of aneurysms and pseudoaneurysms and, if the dissection is intracranial, subarachnoid hemorrhage. Dissections are most effectively visualized by conventional angiography, but they can also be imaged by CT or magnetic resonance angiography, fat-saturated MRI cross sections, and ultrasound. Treatment for arterial dissections has not been studied with randomized trial methodology, but most clinicians prescribe antithrombotic medications as prophylaxis. The recurrence rate of infarction or arterial dissections is very low.

Key Points

  • Arterial dissections are caused by stretching and tearing of arteries, leading to bleeding within the arterial wall

  • Headache and other forms of pain almost invariably accompany arterial dissections

  • Sudden-onset strokes are caused by propagation or embolization of thrombus formed in the region of arterial dissection

  • Patients with intracranial dissections present with either brain infarction or subarachnoid hemorrhage

  • Magnetic resonance brain and vascular imaging can be used to confirm a diagnosis of arterial dissection

  • Treatment of arterial dissections should include an antithrombotic agent

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Schematic drawing of an internal carotid artery dissection.
Figure 2: Imaging findings in a patient with a carotid artery dissection.
Figure 3: MRI findings in a young woman who sustained an arterial dissection after chiropractic manipulation.
Figure 4: Imaging of false lumens in carotid artery dissections.

Similar content being viewed by others

References

  1. Watson A (1956) Dissecting aneurysm of arteries other than the aorta. J Pathol Bacterial 72: 439–449

    Article  Google Scholar 

  2. Wolman L (1959) Cerebral dissecting aneurysms. Brain 82: 276–291

    Article  CAS  Google Scholar 

  3. Ojemann RG et al. (1972) Spontaneous dissecting aneurysms of the internal carotid artery. Stroke 3: 434–440

    Article  CAS  Google Scholar 

  4. Ehrenfeld WK and Wylie EG (1976) Spontaneous dissection of the internal carotid artery. Arch Surg 111: 294–330

    Article  Google Scholar 

  5. Fisher CM et al. (1978) Spontaneous dissection of cervico-cerebral arteries. Can J Neurol Sci 5: 9–19

    Article  CAS  Google Scholar 

  6. Caplan LR et al. (1985) Spontaneous dissection of the extracranial vertebral artery. Stroke 16: 1030–1038

    Article  CAS  Google Scholar 

  7. Mokri B (2001) Cervicocephalic arterial dissections. In Uncommon Causes of Stroke, 211–229 (Eds Bogousslavsky J and Caplan LR) Cambridge: Cambridge University Press

    Google Scholar 

  8. Bogousslavsky J et al. (1987) Spontaneous carotid dissection with acute stroke. Arch Neurol 44: 137–140

    Article  CAS  Google Scholar 

  9. Baumagartner RW and Bogousslavsky J (2005) Clinical manifestations of carotid dissection. In Handbook on Cerebral Artery Dissection, 70–76 (Eds Baumgartner RW et al.) Basel: Karger

    Chapter  Google Scholar 

  10. Caplan LR (1996) Posterior Circulation Disease: Clinical Findings, Diagnosis, and Management. Boston: Blackwell

    Google Scholar 

  11. Chaves C et al. (2002) Spontaneous intracranial internal carotid artery dissection. Arch Neurol 59: 977–981

    Article  Google Scholar 

  12. Pessin MS et al. (1989) Spontaneous intracranial carotid artery dissection. Stroke 20: 1100–1113

    Article  CAS  Google Scholar 

  13. Caplan LR et al. (1988) Dissection of the intracranial vertebral artery. Neurology 38: 868–877

    Article  CAS  Google Scholar 

  14. Caplan LR et al. (2006) Dissection of the posterior cerebral arteries. Arch Neurol 62: 1138–1143

    Article  Google Scholar 

  15. Ohkuma H et al. (2003) Neuroradiologic and clinical features of arterial dissection of the anterior cerebral artery. AJNR Am J Neuroradiol 24: 691–699

    PubMed  Google Scholar 

  16. Koyama S et al. (1996) Spontaneous dissecting aneurysm of the anterior cerebral artery: report of two cases. Surg Neurol 46: 55–61

    Article  CAS  Google Scholar 

  17. Caplan LR and Hennerici MG (1998) Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 55: 1475–1482

    Article  CAS  Google Scholar 

  18. Caplan LR et al. (2006) Is hypoperfusion an important cause of strokes? If so, how? Cerebrovasc Dis 21: 145–153

    Article  Google Scholar 

  19. Biousse V et al. (1995) Time course of symptoms in extracranial carotid artery dissections: a series of 80 patients. Stroke 26: 235–239

    Article  CAS  Google Scholar 

  20. Pozzali E et al. (1989) Blunt traumatic carotid dissection with delayed symptoms. Stroke 20: 412–416

    Article  Google Scholar 

  21. Caplan LR and Biousse V (2004) Cervicocranial arterial dissections. J Neuroophthalmol 24: 299–305

    Article  Google Scholar 

  22. Mokri B et al. (1988) Spontaneous dissections of the vertebral arteries. Neurology 38: 880–885

    Article  CAS  Google Scholar 

  23. Silbert PL et al. (1995) Headache and neck pain in spontaneous internal carotid and vertebral artery dissection. Neurology 45: 1517–1522

    Article  CAS  Google Scholar 

  24. Saeed AB et al. (2000) Vertebral artery dissection: warning symptoms, clinical features, and prognosis in 26 patients. Can J Neurol Sci 27: 292–296

    Article  CAS  Google Scholar 

  25. Arnold M and Bousser MG (2005) Clinical manifestations of vertebral artery dissection. In Handbook on Cerebral Artery Dissection, 77–86 (Eds Baumgartner RW et al.) Basel: Karger

    Chapter  Google Scholar 

  26. Arnold M et al. (2006) Vertebral artery dissection: presenting findings and predictors of outcome. Stroke 37: 2499–2503

    Article  Google Scholar 

  27. Dubard T et al. (1994) Upper limb peripheral deficits due to extracranial vertebral artery dissection. Cerebrovasc Dis 4: 88–91

    Article  Google Scholar 

  28. Crum B et al. (2000) Spinal manifestations of vertebral artery dissection. Neurology 55: 304–306

    Article  CAS  Google Scholar 

  29. Yonas H et al. (1977) Dissecting intracranial aneurysms. Surg Neurol 8: 407–415

    CAS  PubMed  Google Scholar 

  30. Anson J and Crowell RM (1991) Cervicocranial arterial dissection. Neurosurgery 29: 89–96

    Article  CAS  Google Scholar 

  31. O'Connell B et al. (1985) Dissecting aneurysms of head and neck. Neurology 35: 993–997

    Article  CAS  Google Scholar 

  32. Pelkonen O et al. (1998) Intracranial arterial dissection. Neuroradiology 40: 442–447

    Article  CAS  Google Scholar 

  33. Manz HJ and Luessenhop AJ (1982) Dissecting aneurysms of the intracranial vertebral artery. J Neurol 230: 25–35

    Article  Google Scholar 

  34. Berkovic SF et al. (1983) Basilar artery dissection. J Neurol Neurosurg Psychiatry 46: 126–129

    Article  CAS  Google Scholar 

  35. Alexander CB et al. (1979) Dissecting aneurysms of the basilar artery in 2 patients. Stroke 10: 294–299

    Article  CAS  Google Scholar 

  36. Bugiani O et al. (1983) Nontraumatic dissecting aneurysm of the basilar artery. Eur Neurol 22: 256–260

    Article  CAS  Google Scholar 

  37. Berger MS and Wilson CB (1984) Intracranial dissecting aneurysms of the posterior circulation. J Neurosurg 61: 882–894

    Article  CAS  Google Scholar 

  38. Friedman AH and Drake CG (1984) Subarachnoid hemorrhage from intracranial dissecting aneurysm. J Neurosurg 60: 325–334

    Article  CAS  Google Scholar 

  39. Schievink WI et al. (1988) Heritable connective tissue disorders in cervical artery dissections: a prospective study. Neurology 50: 1166–1169

    Article  Google Scholar 

  40. Brandt T et al. (1998) Ultrastructural connective tissue abnormalities in patients with spontaneous cervicocerebral artery dissections. Ann Neurol 44: 281–285

    Article  CAS  Google Scholar 

  41. Schievink WI et al. (1994) Alpha 1-antitrypsin deficiency in intracranial aneurysms and cervical artery dissections. Lancet 343: 452–453

    Article  CAS  Google Scholar 

  42. Martin JJ et al. (2006) Familial cervical artery dissections: clinical, morphologic, and genetic studies. Stroke 37: 2924–2929

    Article  Google Scholar 

  43. D'Anglejan-Chatillon J et al. (1989) Migraine—a risk factor for dissection of cervical arteries. Headache 29: 560–561

    Article  CAS  Google Scholar 

  44. Tzourio C et al. (2002) Migraine and the risk of cervical artery dissection: a case–control study. Neurology 59: 435–437

    Article  CAS  Google Scholar 

  45. Schievink WI et al. (1994) Recurrent spontaneous cervical-artery dissection. N Engl J Med 330: 393–397

    Article  CAS  Google Scholar 

  46. Dittrich R et al. (2007) Polyarterial clustered recurrence of cervical artery dissection seems to be the rule. Neurology 69: 180–186

    Article  CAS  Google Scholar 

  47. Leclerc X et al. (1998) Helical CT for the follow-up of cervical internal carotid artery dissections. AJNR Am J Neuroradiol 19: 831–837

    CAS  PubMed  Google Scholar 

  48. Bui LN et al. (1993) Magnetic resonance angiography of cervicocranial dissection. Stroke 24: 126–131

    Article  Google Scholar 

  49. Kasner SE et al. (1997) Magnetic resonance angiography demonstrates vascular healing of carotid and vertebral artery dissections. Stroke 28: 1993–1997

    Article  CAS  Google Scholar 

  50. Sturzenegger M (1995) Ultrasound findings in carotid artery dissection: analysis of 43 patients. Neurology 45: 691–698

    Article  CAS  Google Scholar 

  51. Sturzenegger M et al. (1993) Ultrasound findings in spontaneous extracranial vertebral artery dissection. Stroke 24: 1910–1921

    Article  CAS  Google Scholar 

  52. Bartels E and Flugel KA (1996) Evaluation of extracranial vertebral artery dissections with duplex color-flow imaging. Stroke 27: 290–295

    Article  CAS  Google Scholar 

  53. Bartels E (2006) Dissection of the extracranial vertebral artery: clinical findings and early noninvasive diagnosis in 24 patients. J Neuroimaging 16: 24–33

    Article  Google Scholar 

  54. Engelter ST et al. (2000) Long-term follow-up after extracranial internal carotid artery dissection. Eur Neurol 44: 199–204

    Article  CAS  Google Scholar 

  55. Touze E et al. (2003) Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology 61: 1347–1351

    Article  CAS  Google Scholar 

  56. Lyrer P and Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD000255. 10.1002/14651858.CD000255

  57. Dreier JP et al. (2004) Delayed occlusion after internal carotid artery dissection under heparin. Cerebrovasc Dis 18: 296–303

    Article  CAS  Google Scholar 

  58. Engelter ST et al. (2007) Antiplatelets versus anticoagulation in cervical artery dissection. Stroke 38: 2605–2611

    Article  Google Scholar 

  59. Engelter S and Lyrer P (2005) Antithrombotic therapy for cervical artery dissection. In Handbook on Cervical Artery Dissection, 147–159 (Eds Baumgartner RW et al.) Basel: Karger

    Chapter  Google Scholar 

  60. Georgiadis D and Baumgartner RW (2005) Thrombolysis in cervical artery dissection. In Handbook on Cervical Artery Dissection, 140–146 (Eds Baumgartner RW et al.) Basel: Karger

    Chapter  Google Scholar 

  61. Kadkhodayan Y et al. (2005) Angioplasty and stenting in carotid dissection with and without pseudoaneurysm. AJNR Am J Neuroradiol 26: 2328–2335

    PubMed  Google Scholar 

Download references

Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

Author information

Authors and Affiliations

Authors

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Caplan, L. Dissections of brain-supplying arteries. Nat Rev Neurol 4, 34–42 (2008). https://doi.org/10.1038/ncpneuro0683

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpneuro0683

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing