Risk factors and clinical presentation of craniocervical arterial dissection: A prospective study

BACKGROUND Craniocervical arterial dissection is a major cause of ischaemic stroke in young adults. The pathogenesis is not fully understood but is thought to be related to a combination of an intrinsic weakness in the arterial wall and an external trigger. Intrinsic susceptibility is thought to be a generalised arteriopathy, vascular anomaly or genetic predisposition. Proposed extrinsic factors include recent viral infection and minor mechanical trauma to the neck, including neck manipulation, which has raised concerns amongst manual practitioners in particular as to the appropriate screening of patients and avoidance of more vigorous therapeutic techniques. The presenting features of dissection may mimic a musculoskeletal presentation, creating a diagnostic dilemma for primary care practitioners. Early recognition is critical so that appropriate management can be commenced.The aims of this study are to prospectively investigate young patients ≤55 years admitted to hospital with radiologically diagnosed craniocervical arterial dissection compared to matched controls with stroke but not dissection, to identify risk factors and early presenting clinical features, so these may be more readily identified by primary care practitioners. METHODS Patients ≤ 55 years presenting to hospital with craniocervical arterial dissection and controls will have their medical records reviewed and be interviewed and questioned about possible risk factors, preceding events to admission such as recent neck trauma, and presenting clinical features including any preceding transient ischaemic features. Clinical assessment will include a connective tissue screening examination to identify subclinical connective tissue disorders. Radiology and blood screening will be reviewed for typical features and inflammatory markers. Functional outcome will be reviewed to determine the burden of the stroke. DISCUSSION This study will provide descriptive and comparative data on intrinsic and extrinsic risk factors for craniocervical arterial dissection and outline the typical clinical presentation, including the nature of early presenting features which might assist practitioners to identify those patients for whom vigorous manual therapy of the neck is inappropriate and alert them to those for whom immediate urgent medical care should be sought.