855 1455LaPointe Leonard 072549 111006101619

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Published on January 23, 2008

Author: Riccardino

Source: authorstream.com

Arterial Dissection and Stroke: A Veiled Risk and Case Example:  Arterial Dissection and Stroke: A Veiled Risk and Case Example Kimberly R. Wilson, M.S. Leonard L. LaPointe, Ph.D. Charles G. Maitland, M.D. Dept. of Communication Disorders and TMH-FSU Neurolinguistic- Neurocognitive Research Center Tallahassee, Florida Purposes:  Purposes To alert clinicians to a relatively under-recognized cause of stroke and aphasia To present a background review on arterial dissection and CVA from environmental causes To present a case report of a 41 year old woman who suffered arterial dissection and aphasia after a prolonged period of neck extension during a root canal procedure Stroke Background:  Stroke Background Tissue death in the brain due to lack of oxygen or blood supply Typically associated with the elderly, but the young are not immune 2 types Hemorrhage Thromboembolic event 2 basic causes Genetic Environmental (We were surprised…) Genetic Risk Factors in Arterial Dissection:  Genetic Risk Factors in Arterial Dissection Similar to those that contribute to cerebrovascular accidents in the elderly Hypertension Carotid artery stiffness Hereditary connective tissue disease Differences in vertebral bony structures Estimated 2.9-10% of all strokes attributed to arterial dissection Up to 45% of CVAs in adults younger than 45 years old can be related to environmental factors Arterial Dissection:  Arterial Dissection Occurs when there is breakdown in the vessel wall of the artery causing blood to flow into the tissue layers instead of into the lamina and clot formation (Norris, Beletsky, & Nadareishvili, 2000) Typically, the subsequent stroke is secondary to the dissection Dissection in arterial wall causes clot to form with possible embolic event Types of Arterial Dissection:  Types of Arterial Dissection 2 specific types Carotid Artery Dissection (CAD) Vertebral Artery Dissection (VAD) Normal Dissected Arterial Dissection:  Arterial Dissection Unveiling the Risk:  Unveiling the Risk Head Position Dental procedures Ceiling Painting Sports Activities Wrestling Judo Treadmill running Accidents Motor vehicle accidents Falls Airbag or seatbelt trauma Neck Trauma Cervical manipulation Abuse Incredibly, even sea wave induced trauma Hand-held massager Leisure Activities Roller coasters Yoga Infection Narrowing of blood vessel Bouts of violent coughing These factors can cause an arterial dissection which result in a secondary stroke CAD (Campellone, 2004):  CAD (Campellone, 2004) 3-5 times more prevalent than VAD 75% of stroke cases in people 45 years old and younger Presenting signs and symptoms include: Unilateral headache Dysarthria Dysphagia Memory impairments Hemiparesis Visual impairment involving one field of vision VAD (Caplan, Zarins, & Hemmati, 1985):  VAD (Caplan, Zarins, & Hemmati, 1985) Relatively rare 15% of strokes in people 40 years old and younger Presenting symptoms include: Unilateral posterior headache Pain may radiate to neck and face Dysarthria Dysphagia Ataxia Double vision Limb or trunk numbness Diagnosing VAD/CAD:  Diagnosing VAD/CAD Computed tomography (CT) or magnetic resonance imaging (MRI) are not sensitive enough to detect arterial dissections Magnetic resonance angiography (MRA), carotid ultrasound, or digital subtraction angiography (DSA) are more sensitive Rarely administered unless physician suspects CAD/VAD Accurate diagnosis of CAD/VAD in adults 45 years old and younger is rare Physicians and patients are relatively unaware of the link between precipitating events and presenting signs/symptoms Treatment:  Treatment Aimed at preventing CVA Anticoagulation and antiplatelet therapy Surgery required in very few cases Bypass Stenting Patient prognosis is dependent on the timeliness of diagnosis and subsequent treatment (Saeed, Shuaib, Al-Sulaiti, & Emery, 2000) If the dissection is discovered early, patients have a excellent prognosis for recovery from symptoms Embolic or hemorrhagic event may be avoided completely The Case of K.S.:  The Case of K.S. 41 year old single mom of 6 year old twins No significant medical history or history of CVAs Smoked 1-2 packs a day Had a root canal 2 days prior to CVA Patient’s mom reports that K.S. was talking and laughing on the phone 1 day prior to CVA K.S. found unconscious by twins When twins were unable to wake her, they alerted a neighbor who called 911 CT showed large left Middle Carotid Artery CVA Carotid ultrasound showed large dissection on left carotid artery K.S. remained unconscious for 2 days following her admission to the hospital The Case of K.S.:  The Case of K.S. Upon awakening K.S. was: Unable to communicate in a meaningful way but could follow simple commands Significant right sided facial weakness and droop impacted attempts at speaking Unable to swallow any food or liquid safely Percutaneous endoscopic gastronomy (PEG) was conducted so that she could receive nutrition in non-oral form Unable to move limbs on right side due to hemiparesis Also had signs/symptoms of right neglect The Case of K.S.:  The Case of K.S. After comprehensive speech-language evaluation, K.S. diagnosed with: Mixed aphasia Western Aphasia Battery Aphasia Quotient: 34.8 Spontaneous Speech: 4 (including Fluency, Grammatical Competence, and Paraphasias) Auditory Comprehension: 8 Repetition: 2.4 Naming: 2.2 Apraxia of speech Moderate to severe oropharyngeal dysphagia Aspiration of all liquids and deep penetration of puree consistency In addition to speech therapy, K.S. also had intensive physical and occupational therapy Despite K.S.’s significant language deficits, she showed great potential for recovery of communicative skills At discharge from acute rehab (~8 weeks post onset) Effectively communicating with family and hospital staff via gestures and written choice Meeting nutritional needs via oral means on regular diet with thin liquids Preventative Measures:  Preventative Measures Avoid trauma to the head and neck Wear seatbelts when driving or riding in vehicles Take appropriate safety precautions for sporting events Helmet Padding Be aware that extended or extreme neck extension or cervical manipulation may increase risk for arterial dissection Implications:  Implications Community Education Target young as well as older adults in stroke education Include risk factors for dissection to raise awareness of causes and signs/symptoms of CAD/VAD Acute Care Change protocol for young adults who present with signs/symptoms History should include specific questions about possible environmental causes Treatment Goals Focus of goals shift from end-of-life to continuing life with appropriate interventions and compensations References:  References Campellone, J.V. (2004, July). Medical encyclopedia: Stroke secondary to carotid dissection. Medline Plus. Retrieved October 26, 2006, from http://www.nlm.nih.gov/medlineplus/ency/article/000732.htm Caplan, L.R., Zarins, C.K., & Hemmati, M. (1985). Spontaneous dissection of the extracranial vertebral arteries. Stroke, 16 (6), 1030-1038. Norris, J.W., Beletsky, V., & Nadareishvili, Z.G. (2000). Sudden neck movement and cervical artery dissection. Canadian Medical Association Journal, 163 (1), 38-40. Saeed, A.B., Shuaib, A., Al-Sulaiti, G., & Emery, D. (2000). Vertebral artery dissection: Warning symptoms, clinical features, and prognosis in 26 patients. Canadian Journal of Neurological Science, 27, 292-296.

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