Spontaneous dissections of the carotid and vertebral arteries in the neck are a common cause of
stroke in young and middle-aged people. Moreover, they are increasingly recognized as the cause of a wide variety of other, more subtle,
neurologic signs and symptoms. The cause of these
arterial dissections largely remains unexplained but probably involves a combination of genetic and environmental factors. Magnetic resonance imaging has largely surpassed angiography as the imaging study of choice. The treatment of carotid and
vertebral artery dissections is based on rather incomplete evidence. Anticoagulation with
heparin followed by
warfarin remains the treatment of choice in most major medical centers and is supported by the demonstration of emboli as the most common cause of
stroke in these patients. The burgeoning interest in
endovascular techniques has resulted in many patients being treated for carotid and
vertebral artery dissections with percutaneous angioplasty and
stent deployment. Although the treatment of dissections is generally well tolerated and the radiographic results are impressive, most dissections heal spontaneously and the associated
aneurysms never
rupture and rarely cause delayed ischemic symptoms. Surgical treatment of dissections, consisting of an in situ interposition graft or extracranial-intracranial bypass, is indicated only for those patients with persistent symptoms refractory to maximal medical
therapy who are not candidates for endovascular treatment.