Cervical Artery Dysfunction

Vascular Anatomy Posterior system (20%)– Vertebrobasilar arterial Tethering at C2, C1 and atlanto-occipital membrane Right angled bends

Vascular Anatomy Anterior system (80%) – Internal and External carotid arteries

Pathology Cervical Artery Dysfunction is an umbrella term to describe injury to the arteries within the neck Includes a range of pathologies and not just “Dissection” Injury to the arteries can alter blood flow to the brain, head, neck and face Signs generally categorised into Ischemic and Retinal Non Ischemic

Pathophysiology Often a dissection, but not always A small tear Blood penetrates vessel wall Causing aneurysms and/or false lumen Causing stenosis, inflammation of tissue (vascular and local) Nociceptors in blood vessels Stenosis restricts blood flow Atherosclerosis increases risk of dissection

Mechanism of Injury Traumatic Insidious Coughing Sneezing Head turning RTC Insidious Atherosclerosis Inflammation Connective tissue disease Upper cervical instability

Associated Pathologies Cervical instability Whiplash Associated Disorders Diabetes Hypertension Cardiac Disease Hypercholesterolemia Blood Clotting Disorders

Classification

Internal Carotid Artery Dysfunction Non Ischemic Signs Horner’s Syndrome- 82% of cases Dropping eyelid (ptosis) Sunken eye (enophthalmia) Small constricted pupil (miosis) Facial Dryness (anhidrosis) The superior cervical sympathetic ganglion supplying the eye are found in the carotid sheath and follow the course of the carotid artery

Internal Carotid Artery Dysfunction Non Ischemic Signs Lower Cranial Nerve Dysfunction (IX – XII) Glossopharyngeal (Palate Elevation and Gag Reflex) Vagus (Palate Elevation and Gag Reflex) Accessory (Resisted Cervical Rotation and Shoulder Shrug) Hypoglossal (Stick Tongue out and into sides of mouth) Acute onset head or neck pain like no other Ipsilateral neck and facial pain

Internal Carotid Artery Dysfunction Ischemic Signs Signs of Cerebral Stroke or Retinal Ischemia Transient Ischemic Attack Ischemic Stroke Retinal Ischemia Painless episodic loss of vision Localized/patchy blurring of vision Weakness of eye muscles Protrusion of eye Swelling of the eye Unlikely to present in a physiotherapy clinic, however be aware of Retinal Ischemic changes

Vertebral Artery Dysfunction Non Ischemic Signs Ipsilateral posterior neck pain and occipital headaches C5/6 Nerve root impairment (rare) Weakness Wrist Extension Weakness Elbow Flexion Sensation change thumb side hand, wrist and forearm

Vertebral Artery Dysfunction Ischemic Signs 5D’s and 3N’s Ataxia Vomiting Vascular Dizziness is very common with Vertebral artery dysfunctions Does not improve with repeated rotations

Subjective Mechanism of Injury History of Migraine type headache Traumatic usually History of Migraine type headache Cranial Nerve Dysfunction PMH Cardiac and/or Vascular Disease Hypertension Hypercholesterolemia Diabetes Blood clotting disorders Anticoagulant therapy Long term steroid use Family History Vascular and Cardiac disease in family

Objective Potential Red Flags massively affect the order of your objective examination Diagnostic Medical Work UP Blood Pressure Cranial Nerve Testing Active ROM Passive ROM Never continue the examination if you suspect serious pathology is present or you do not possess the skills to perform relevant examinations (e.g cranial nerves, BP) Always REFER ON when necessary

Special Tests Blood Pressure Testing Cranial Nerve Testing Special Tests not useful and more likely to cause injury

Further Investigation Ultrasound Doppler Arteriography Magnetic Resonance Angiography

General Management

Conservative - Management Medic Led Monitor BP Statins, Anti coagulants No physical therapy