⚠️

DRAFT - Pending Review

This plan requires physician review before clinical use.

Cervical Artery Dissection

VERSION: 1.1 CREATED: January 30, 2026 REVISED: January 30, 2026 STATUS: Draft - Pending Review

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DIAGNOSIS: Cervical Artery Dissection (Carotid and Vertebral)

ICD-10: I77.71 (Dissection of carotid artery), I77.74 (Dissection of vertebral artery), I67.0 (Dissection of cerebral arteries, nonruptured), I63.00 (Cerebral infarction due to thrombosis of unspecified precerebral artery), I63.20 (Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries), I63.139 (Cerebral infarction due to embolism of unspecified carotid artery), G43.909 (Migraine, unspecified — sentinel headache misdiagnosis code)

CPT CODES: 70496 (CTA head), 70498 (CTA neck), 70553 (MRI brain with and without contrast), 70547 (MRA neck without contrast), 70549 (MRA neck with and without contrast), 93880 (Carotid duplex ultrasound), 36224 (Conventional cerebral angiography), 93886 (Transcranial Doppler), 85025 (CBC), 85610 (PT/INR), 85730 (aPTT), 80048 (BMP), 86140 (CRP)

SYNONYMS: Cervical artery dissection, carotid dissection, carotid artery dissection, vertebral artery dissection, vertebral dissection, internal carotid artery dissection, ICA dissection, extracranial dissection, intracranial dissection, cervical dissection, arterial dissection neck, spontaneous dissection, traumatic dissection, CeAD, CAD (carotid artery dissection), VAD (vertebral artery dissection), ICAD, young stroke, dissection stroke, Horner syndrome stroke, neck pain stroke, chiropractic stroke, post-traumatic dissection, dissecting aneurysm carotid, dissecting aneurysm vertebral, intimal tear carotid, intimal tear vertebral, intramural hematoma carotid, intramural hematoma vertebral

SCOPE: Acute and subacute cervical artery dissection (carotid and vertebral) in adults — covers spontaneous and traumatic etiologies, initial evaluation, imaging diagnosis (CTA, MRA with fat saturation, conventional angiography), antithrombotic therapy (anticoagulation vs. antiplatelet), stroke prevention, pseudoaneurysm monitoring, and long-term follow-up. Excludes intracranial dissection with subarachnoid hemorrhage (see SAH template), aortic dissection, and management of completed large territory ischemic stroke (see Acute Ischemic Stroke template for thrombolysis/thrombectomy protocols).

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
CBC with differential (CPT 85025)	Baseline hematologic assessment; thrombocytopenia affects antithrombotic choice; anemia evaluation	Normal platelets (>100,000); normal hemoglobin	STAT	STAT	ROUTINE	STAT
BMP (Na, K, Cr, glucose, BUN) (CPT 80048)	Electrolyte assessment; renal function for contrast imaging and medication dosing	Normal electrolytes; eGFR adequate for contrast	STAT	STAT	ROUTINE	STAT
PT/INR (CPT 85610)	Baseline coagulation; INR required before initiating anticoagulation; affects tPA eligibility if stroke present	INR <1.7 for tPA eligibility; baseline before anticoagulation	STAT	STAT	ROUTINE	STAT
aPTT (CPT 85730)	Baseline coagulation; required before heparin initiation	Normal range	STAT	STAT	-	STAT
Point-of-care glucose (CPT 82962)	Hypoglycemia mimics stroke; required before tPA if stroke symptoms present	>60 mg/dL	STAT	STAT	-	STAT
Troponin (CPT 84484)	Cardiac ischemia evaluation; stress cardiomyopathy with acute stroke	Normal	STAT	STAT	-	STAT
Lipid panel (fasting or non-fasting) (CPT 80061)	Vascular risk assessment; statin decision-making for secondary prevention	Baseline for treatment decisions	-	ROUTINE	ROUTINE	-
HbA1c (CPT 83036)	Diabetes screening; vascular risk stratification	<7.0% (individualized)	-	ROUTINE	ROUTINE	-

1B. Extended Workup (Second-line)

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
ESR (CPT 85652)	Inflammatory or vasculitic etiology; fibromuscular dysplasia workup	Normal (<20 mm/h)	-	ROUTINE	ROUTINE	-
CRP (CPT 86140)	Inflammatory marker; vasculitis screen in young stroke workup	Normal (<3 mg/L)	URGENT	ROUTINE	ROUTINE	URGENT
Hepatic function panel (AST, ALT, albumin) (CPT 80076)	Liver function affects anticoagulant metabolism and dosing	Normal	-	ROUTINE	ROUTINE	-
TSH (CPT 84443)	Thyroid dysfunction as cardiovascular risk factor	Normal	-	ROUTINE	ROUTINE	-
Pregnancy test (beta-hCG) (CPT 84703)	Affects imaging choices (gadolinium contrast) and antithrombotic selection; pregnancy-associated dissection recognized etiology	Negative	STAT	STAT	ROUTINE	STAT
Urine drug screen (CPT 80307)	Sympathomimetic use (cocaine, amphetamines) as dissection trigger	Negative	URGENT	ROUTINE	-	URGENT
Fibrinogen (CPT 85384)	Coagulopathy evaluation; DIC screening if multi-organ involvement	Normal (200-400 mg/dL)	URGENT	ROUTINE	-	URGENT
D-dimer (CPT 85379)	Elevated in acute dissection; may support diagnosis when imaging equivocal; not diagnostic alone	Normal (though often elevated in acute dissection)	URGENT	ROUTINE	-	URGENT
Type and screen (CPT 86900)	Blood products availability if interventional procedure or hemorrhagic complication	On file	STAT	ROUTINE	-	STAT

1C. Rare/Specialized (Refractory or Atypical)

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Homocysteine (CPT 83090)	Hyperhomocysteinemia as connective tissue and vascular risk factor in young dissection	Normal (<15 micromol/L)	-	ROUTINE	ROUTINE	-
Connective tissue disorder panel (COL3A1 gene testing for vascular Ehlers-Danlos)	Recurrent dissections, family history of dissection, vascular fragility, easy bruising, thin translucent skin	Negative for pathogenic variants	-	EXT	EXT	-
ANA (CPT 86235)	Autoimmune vasculopathy screen in young stroke or recurrent dissection	Negative	-	EXT	EXT	-
Antiphospholipid antibody panel (lupus anticoagulant, anticardiolipin, beta2-glycoprotein I)	Thrombophilia screening in young stroke with dissection; recurrent events	Negative	-	EXT	EXT	-
Hypercoagulable panel (protein C, protein S, antithrombin III, Factor V Leiden, prothrombin gene mutation)	Young stroke workup; recurrent dissection or thrombosis history; family history of thrombophilia	Normal	-	EXT	EXT	-
Alpha-1 antitrypsin level and phenotype	Alpha-1 antitrypsin deficiency associated with cervical artery dissection and connective tissue fragility	Normal level and MM phenotype	-	EXT	EXT	-
Skin biopsy with electron microscopy	Suspected vascular Ehlers-Danlos syndrome; evaluates collagen structure	Normal collagen architecture	-	-	EXT	-
RPR/VDRL (CPT 86592)	Syphilitic arteritis in young stroke workup	Negative	-	ROUTINE	ROUTINE	-

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
CT head without contrast (CPT 70450)	Immediate (door-to-CT <25 min if stroke symptoms)	Exclude hemorrhage; identify early ischemic changes; rule out SAH from intracranial extension	Pregnancy (relative)	STAT	STAT	-	STAT
CT angiography head and neck (CTA) (CPT 70496, 70498)	Immediate with CT head; first-line for dissection diagnosis	Intimal flap, double lumen sign, tapered stenosis ("flame-shaped" occlusion), mural thickening, pseudoaneurysm, string sign	Contrast allergy (premedicate); eGFR <30 (benefit outweighs risk in acute setting)	STAT	STAT	ROUTINE	STAT
MRI brain with DWI (CPT 70553)	Within 24h if stroke symptoms; STAT if diagnosis uncertain	Acute ischemic infarct on DWI (restricted diffusion); infarct pattern suggesting artery-to-artery embolism; watershed vs embolic pattern	Pacemaker, metallic implants, severe claustrophobia	URGENT	URGENT	ROUTINE	URGENT
ECG (12-lead) (CPT 93000)	Immediate	Rule out atrial fibrillation as alternative cardioembolic source; acute MI	None	STAT	STAT	ROUTINE	STAT

2B. Extended

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRA neck with fat saturation (CPT 70547, 70549)	Within 24-48h; gold standard for intramural hematoma	Crescent sign (intramural hematoma on axial T1 fat-sat); vessel wall expansion; dissection flap; pseudoaneurysm	Same as MRI	URGENT	URGENT	ROUTINE	URGENT
MRA head (intracranial) (CPT 70544)	Within 24-48h	Intracranial extension of dissection; tandem lesion; distal embolism	Same as MRI	-	URGENT	ROUTINE	URGENT
CT perfusion (CTP) (CPT 0042T)	With CTA if extended stroke window (6-24h) or wake-up stroke	Ischemic penumbra assessment; mismatch between core infarct and hypoperfused tissue for thrombectomy decision	Same as CTA	STAT	URGENT	-	STAT
Carotid duplex ultrasound (CPT 93880)	Within 24-48h; follow-up imaging at 3-6 months	High-resistance flow pattern; absent or reduced flow; intimal flap; vessel wall hematoma (less sensitive than CTA/MRA)	None significant	-	ROUTINE	ROUTINE	-
Transcranial Doppler (TCD) (CPT 93886)	Within 24-48h	Intracranial stenosis; distal flow changes; microembolic signals (HITS) on monitoring suggesting active embolization	Absent temporal bone window (~10% of patients)	-	ROUTINE	ROUTINE	-
Transthoracic echocardiogram (TTE) (CPT 93306)	Within 48h	Rule out cardioembolism as alternative or concurrent etiology; PFO; valvular disease	None significant	-	ROUTINE	ROUTINE	-
Continuous cardiac telemetry (CPT 93228)	Minimum 24-48h	Rule out atrial fibrillation as alternative stroke mechanism	None	STAT	STAT	-	STAT
CTA or MRA neck follow-up (3-6 months)	3-6 months after diagnosis	Recanalization (complete or partial), pseudoaneurysm stability or resolution, residual stenosis	Same as initial study	-	-	ROUTINE	-

2C. Rare/Specialized

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
Conventional cerebral angiography (DSA) (CPT 36224)	If CTA/MRA equivocal; planned endovascular intervention	Definitive vessel lumen assessment; intimal flap; double lumen; string-of-beads (FMD); pseudoaneurysm; stent planning	Contrast allergy; severe renal impairment; coagulopathy; vessel fragility (vascular Ehlers-Danlos — relative contraindication)	-	EXT	EXT	EXT
MRI vessel wall imaging (high-resolution)	If intracranial dissection vs. atherosclerosis vs. vasculitis unclear	Vessel wall enhancement pattern; intramural hematoma; eccentric wall thickening distinguishes dissection from atherosclerosis	Same as MRI	-	EXT	EXT	-
CTA/MRA full aorta	If connective tissue disorder suspected; multi-vessel dissection	Additional dissections; aneurysms of aorta, renal, iliac arteries suggesting systemic arteriopathy	Same as CTA/MRA	-	EXT	EXT	-
Renal artery duplex or CTA abdomen	If fibromuscular dysplasia suspected (especially young women)	Renal artery FMD (string-of-beads pattern); renal artery aneurysm	Same as CTA	-	EXT	EXT	-

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3. TREATMENT

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
IV alteplase (tPA)	IV	Acute ischemic stroke within 4.5h of last known well due to dissection-related embolism	0.9 mg/kg :: IV :: once :: 0.9 mg/kg IV (max 90 mg); 10% as bolus over 1 min, remaining 90% infused over 60 min. Dissection is NOT a contraindication to IV tPA if within window	Standard tPA exclusions: >4.5h from last known well; BP >185/110 despite treatment; platelets <100K; INR >1.7; active bleeding; intracranial hemorrhage; intracranial dissection with SAH	Neuro checks q15min during infusion, q30min x 6h, then q1h x 18h; BP q15min x 2h, q30min x 6h; hold anticoagulants/antiplatelets 24h post-tPA	STAT	STAT	-	STAT
Tenecteplase IV	IV	Acute ischemic stroke with LVO from dissection; preferred if thrombectomy planned	0.25 mg/kg :: IV :: once :: 0.25 mg/kg IV single bolus (max 25 mg); preferred over alteplase if LVO planned for thrombectomy	Same as alteplase	Same as alteplase	STAT	STAT	-	STAT
Endovascular thrombectomy	Endovascular	Large vessel occlusion from dissection-related embolism or in-situ thrombosis; within 24h if eligible per DAWN/DEFUSE-3 criteria	N/A :: Endovascular :: once :: Mechanical thrombectomy for LVO (ICA, M1, basilar); stenting of dissection considered on case-by-case basis	Large established infarct (ASPECTS <6 in 0-6h window); no LVO; poor premorbid function (mRS >2)	Continuous neuro-ICU monitoring post-procedure; groin check; BP per post-thrombectomy protocol	STAT	STAT	-	STAT
Heparin IV infusion (therapeutic)	IV	Acute dissection with high embolic risk: free-floating thrombus, crescendo TIA, recurrent embolic events despite antiplatelet, critical flow-limiting stenosis	60-80 units/kg :: IV :: continuous :: Bolus 60-80 units/kg (max 5000 units); then infusion 12-18 units/kg/h; target aPTT 1.5-2.5x control (typically 60-80 sec)	Active hemorrhagic infarct; intracranial dissection with SAH; large completed infarct (hemorrhagic transformation risk); uncontrolled BP; active bleeding	aPTT q6h until stable, then q12-24h; platelets q3 days (HIT surveillance); daily neuro checks; signs of bleeding	STAT	STAT	-	STAT
Aspirin loading dose	PO	Acute dissection without stroke or with minor ischemic stroke; first-line antiplatelet per CADISS trial	325 mg :: PO :: once :: 325 mg PO/PR loading dose; if tPA was given, wait 24h and obtain CT head before starting. Transition to maintenance 81-325 mg daily	Active GI bleeding; true aspirin allergy; within 24h of tPA (wait for post-tPA CT)	GI symptoms; bleeding signs	STAT	STAT	-	STAT
Labetalol IV	IV	BP control in acute dissection with stroke; target BP <185/110 if tPA candidate; permissive hypertension if no tPA	10-20 mg :: IV :: q10-20min PRN :: 10-20 mg IV over 1-2 min; may repeat q10-20min; max 300 mg. Target: <185/110 pre-tPA; <180/105 post-tPA; <220/120 if no tPA	Heart block (2nd/3rd degree); severe bradycardia; decompensated HF; asthma/severe COPD	Heart rate; BP continuous monitoring	STAT	STAT	-	STAT
Nicardipine IV	IV	Continuous BP control in acute dissection with stroke or severe hypertension	5 mg/h :: IV :: continuous :: 5 mg/h IV infusion; increase by 2.5 mg/h q5-15min; max 15 mg/h	Severe aortic stenosis	BP continuous monitoring; headache and flushing common	STAT	STAT	-	STAT
IV normal saline	IV	Isotonic fluid resuscitation and maintenance in acute dissection	125-150 mL/h :: IV :: continuous :: Isotonic fluids; avoid hypotonic solutions (cerebral edema risk); avoid dextrose-containing fluids (hyperglycemia worsens ischemic outcomes)	Volume overload	I/O; electrolytes	STAT	STAT	-	STAT
Supplemental oxygen	INH	Maintain oxygenation in acute stroke from dissection	2-4 L/min :: INH :: continuous :: Only if SpO2 <94%; nasal cannula or mask as needed; target SpO2 >=94%	Not applicable	SpO2 continuous monitoring; avoid routine supplemental O2 if normoxic	STAT	STAT	-	STAT

3B. Symptomatic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Acetaminophen	PO	Headache and neck pain from dissection; fever management (temperature >38C worsens ischemic outcomes)	650-1000 mg :: PO :: q6h PRN :: 650-1000 mg PO q6h PRN; max 4g/day (2g if hepatic impairment)	Severe hepatic disease	Temperature; LFTs if prolonged use; pain assessment	STAT	STAT	ROUTINE	STAT
Ibuprofen	PO	Headache and neck pain from dissection if not on anticoagulation; short-term use only	400-600 mg :: PO :: q6-8h PRN :: 400-600 mg PO q6-8h PRN with food; max 2400 mg/day; limit to <7 days	Concurrent anticoagulation (increased bleeding risk); GI bleeding history; renal impairment; concurrent aspirin (may reduce antiplatelet efficacy)	GI symptoms; renal function; bleeding signs	URGENT	ROUTINE	ROUTINE	-
Gabapentin	PO	Neuropathic pain (Horner syndrome-associated pain, persistent neck/face pain)	300 mg :: PO :: qHS :: Start 300 mg PO qHS; titrate by 300 mg q1-3 days; target 900-1800 mg/day divided TID; max 3600 mg/day	Renal impairment (adjust dose for CrCl <60)	Sedation; dizziness; peripheral edema; renal function	-	ROUTINE	ROUTINE	-
Ondansetron	IV	Nausea and vomiting (vertebral dissection with posterior circulation symptoms)	4 mg :: IV :: q6h PRN :: 4 mg IV/PO q6h PRN nausea	QT prolongation; serotonin syndrome risk	QTc if risk factors	URGENT	ROUTINE	ROUTINE	URGENT
Meclizine	PO	Vertigo from vertebral artery dissection with posterior circulation ischemia	25 mg :: PO :: q6-8h PRN :: 25 mg PO q6-8h PRN vertigo; short-term use only (may mask central symptoms)	Glaucoma; urinary retention	Sedation; anticholinergic effects; monitor for central vertigo signs	URGENT	ROUTINE	ROUTINE	-
Enoxaparin (prophylactic)	SC	DVT prophylaxis if not on therapeutic anticoagulation and limited mobility	40 mg :: SC :: daily :: 40 mg SC daily; start within 24-48h; hold if on therapeutic anticoagulation	Active bleeding; platelets <50K; CrCl <30 (use UFH 5000 units SC q8-12h instead)	Platelets q3 days; renal function	-	ROUTINE	-	ROUTINE
Pneumatic compression devices	Mechanical	DVT prophylaxis (non-pharmacologic); use in addition to or instead of pharmacologic prophylaxis	N/A :: Mechanical :: continuous :: Apply to both lower extremities immediately on admission	Acute DVT in lower extremity; severe peripheral vascular disease	Skin checks daily	STAT	STAT	-	STAT
Pantoprazole	PO	GI prophylaxis for patients on antithrombotic therapy; stress ulcer prevention	40 mg :: PO :: daily :: 40 mg IV/PO daily	C. difficile risk with prolonged use	GI symptoms	-	ROUTINE	ROUTINE	ROUTINE

3C. Second-line/Refractory

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Aspirin + Clopidogrel (DAPT)	PO	High-risk dissection with minor stroke (NIHSS <=3) or recurrent TIA on single antiplatelet; short-term use (21-90 days)	81 mg + 75 mg :: PO :: daily :: Aspirin 81 mg daily + Clopidogrel 75 mg daily x 21-90 days; load clopidogrel 300 mg if not previously on it; then transition to single antiplatelet	Major stroke (NIHSS >3); high bleeding risk; planned surgery	Bleeding signs; CBC monthly	-	URGENT	ROUTINE	-
Enoxaparin (therapeutic)	SC	Bridge from IV heparin to oral anticoagulation; alternative to IV heparin in stable dissection with embolic risk	1 mg/kg :: SC :: q12h :: 1 mg/kg SC q12h; adjust for renal function (1 mg/kg daily if CrCl 15-30); bridge to warfarin if needed	Active bleeding; CrCl <15; HIT; large hemorrhagic infarct	Anti-Xa levels (target 0.5-1.0 IU/mL); platelets q3 days; renal function	-	ROUTINE	ROUTINE	ROUTINE
Warfarin	PO	Dissection with high embolic risk when anticoagulation chosen over antiplatelet; CADISS trial showed equivalent outcomes	5 mg :: PO :: daily :: Start 5 mg PO daily (2-3 mg if elderly, low weight, or drug interactions); target INR 2.0-3.0; overlap with heparin bridge until INR therapeutic x 2 consecutive days	Active bleeding; pregnancy (teratogenic); severe hepatic disease; inability to monitor INR	INR daily until stable, then weekly, then monthly; diet counseling (vitamin K consistency); bleeding signs	-	ROUTINE	ROUTINE	-
Carotid/vertebral artery stenting	Endovascular	Refractory ischemia despite optimal antithrombotic therapy; symptomatic recurrent stenosis; expanding pseudoaneurysm with embolic events	N/A :: Endovascular :: once :: Endovascular stenting of dissected segment; case-by-case basis; dual antiplatelet pre- and post-procedure	Active hemorrhage; vascular Ehlers-Danlos (extreme caution — vessel fragility); vessel too tortuous for access	Post-procedure: continuous neuro monitoring x 24h; dual antiplatelet compliance; follow-up imaging at 1, 3, 6 months	-	EXT	-	EXT
Mannitol 20%	IV	Acute cerebral edema from large territory infarct due to dissection-related stroke	1-1.5 g/kg :: IV :: once :: 1-1.5 g/kg IV bolus for acute herniation; then 0.25-0.5 g/kg q4-6h maintenance	Anuria; severe dehydration	Serum osmolality (hold if >320 mOsm/kg); osmolar gap; renal function; I/O	-	-	-	STAT
Hypertonic saline 23.4%	IV	Acute herniation from massive stroke due to dissection-related occlusion	30 mL :: IV :: once :: 30 mL IV bolus via central line over 10-20 min for acute herniation	No central access for 23.4%; hypokalemia	Serum sodium (target 145-155 mEq/L); osmolality; central line integrity	-	-	-	STAT
Decompressive craniectomy	Surgical	Malignant MCA infarction from carotid dissection with complete ICA occlusion and poor collaterals	N/A :: Surgical :: once :: Surgery within 48h of onset; age <60 preferred; >50% MCA territory infarct; reduces mortality from 70-80% to ~20%	Bilateral infarcts; hemorrhagic transformation; age >60 (relative)	Post-operative neuro checks; ICP monitoring; wound care	-	-	-	STAT

3D. Disease-Modifying / Chronic Therapies

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Aspirin (maintenance)	PO	Long-term secondary stroke prevention post-dissection; first-line per CADISS trial equivalence data	81 mg :: PO :: daily :: 81 mg PO daily preferred for long-term use; 325 mg daily acceptable; duration minimum 3-6 months; many neurologists continue indefinitely if vascular risk factors present	Baseline CBC; renal function	Active GI bleeding; true aspirin allergy	GI symptoms; annual CBC; bleeding assessment at follow-up	-	ROUTINE	ROUTINE	-
Clopidogrel (maintenance)	PO	Alternative antiplatelet for aspirin-intolerant patients; long-term secondary prevention post-dissection	75 mg :: PO :: daily :: 75 mg PO daily; duration minimum 3-6 months; if aspirin intolerant, may use long-term	Baseline CBC	Active pathologic bleeding; hypersensitivity to clopidogrel	CBC; bleeding assessment; bruising	-	ROUTINE	ROUTINE	-
Apixaban	PO	Dissection with concurrent atrial fibrillation; alternative anticoagulant if warfarin not preferred	5 mg :: PO :: BID :: 5 mg PO BID standard dose; 2.5 mg BID if >=2 of: age >=80, weight <=60 kg, Cr >=1.5; for concurrent AF or physician preference for anticoagulation strategy	Renal function; hepatic function; CBC	Active pathologic bleeding; prosthetic heart valve	Renal function q6-12 months; bleeding signs; CBC	-	ROUTINE	ROUTINE	-
Atorvastatin	PO	Vascular risk reduction; secondary stroke prevention in dissection patients with atherosclerotic risk factors	40-80 mg :: PO :: daily :: 40-80 mg PO daily; high-intensity statin therapy for secondary stroke prevention	Baseline LFTs; lipid panel	Active liver disease; pregnancy; breastfeeding	LFTs at 12 weeks then annually; lipid panel at 4-12 weeks; CK if myalgia	-	ROUTINE	ROUTINE	-
Lisinopril	PO	Blood pressure management for secondary stroke prevention; target BP <130/80 after acute phase	5-10 mg :: PO :: daily :: Start 5-10 mg PO daily; titrate to 20-40 mg daily; target BP <130/80	Baseline Cr; K+	Bilateral renal artery stenosis; angioedema history; pregnancy	Cr and K+ at 1-2 weeks; BP at follow-up visits	-	ROUTINE	ROUTINE	-
Amlodipine	PO	Alternative or adjunctive antihypertensive for secondary stroke prevention	5 mg :: PO :: daily :: Start 5 mg PO daily; max 10 mg daily	None required	Severe aortic stenosis (relative)	BP; peripheral edema	-	ROUTINE	ROUTINE	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Neurology consultation (stroke team) for dissection confirmation, antithrombotic strategy, and stroke workup coordination	STAT	STAT	ROUTINE	STAT
Neurointerventional/endovascular consultation for large vessel occlusion thrombectomy or stenting consideration in refractory dissection	STAT	STAT	-	STAT
Neurosurgery consultation for malignant cerebral edema, posterior fossa stroke with hydrocephalus, or expanding pseudoaneurysm requiring surgical management	URGENT	URGENT	-	STAT
Vascular neurology follow-up in 2-4 weeks for antithrombotic reassessment and follow-up imaging planning	-	ROUTINE	ROUTINE	-
Genetics consultation if suspected connective tissue disorder (vascular Ehlers-Danlos, Marfan, Loeys-Dietz) given recurrent dissections, family history, or clinical features	-	ROUTINE	ROUTINE	-
Rheumatology consultation if vasculitis or autoimmune arteriopathy suspected based on lab findings or imaging	-	ROUTINE	ROUTINE	-
Cardiology consultation for newly detected atrial fibrillation or PFO evaluation if concurrent cardioembolic source suspected	-	ROUTINE	ROUTINE	-
Speech-language pathology (SLP) for dysphagia screening before PO intake if stroke present; also evaluate for lower cranial nerve palsy (vagus, hypoglossal) from carotid dissection	URGENT	STAT	ROUTINE	URGENT
Physical therapy for early mobilization (24-48h), gait training, and balance assessment if stroke-related deficits present	-	URGENT	ROUTINE	URGENT
Occupational therapy for ADL assessment, upper extremity function, and adaptive strategies if stroke-related deficits present	-	URGENT	ROUTINE	URGENT
Ophthalmology or neuro-ophthalmology referral if persistent Horner syndrome for ptosis evaluation and baseline assessment	-	ROUTINE	ROUTINE	-
Pain management referral for refractory neck/head pain not responding to standard analgesics	-	ROUTINE	ROUTINE	-
Social work for discharge planning, insurance coordination, DME, and caregiver support	-	ROUTINE	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD	ICU
Call 911 immediately if new or worsening symptoms: sudden weakness, numbness, vision changes, speech difficulty, severe headache, loss of balance (may indicate stroke from dissection)	STAT	STAT	ROUTINE	-
Do NOT drive until cleared by neurology (minimum 2 weeks; Horner syndrome may affect vision)	URGENT	URGENT	ROUTINE	-
Take all antithrombotic medications exactly as prescribed; do NOT stop aspirin, clopidogrel, or anticoagulant without medical advice (stopping increases stroke risk)	URGENT	URGENT	ROUTINE	-
Avoid high-risk neck activities: vigorous chiropractic manipulation, extreme cervical extension/rotation, contact sports, roller coasters, heavy lifting with Valsalva (may worsen dissection or cause recurrence)	URGENT	URGENT	ROUTINE	-
Report new neck pain, headache (especially pulsatile), drooping eyelid, double vision, or pulsatile tinnitus as these may indicate dissection extension or new dissection	URGENT	ROUTINE	ROUTINE	-
If on warfarin: maintain consistent vitamin K intake; attend all INR monitoring appointments; report any signs of bleeding (bruising, blood in stool/urine, gum bleeding)	-	ROUTINE	ROUTINE	-
Follow-up imaging (CTA or MRA neck) scheduled at 3-6 months to assess vessel healing; do NOT skip this appointment	-	ROUTINE	ROUTINE	-
Follow-up appointment with neurology in 2-4 weeks for treatment reassessment; primary care in 4 weeks for vascular risk factor management	-	ROUTINE	ROUTINE	-
Avoid straining and heavy lifting (>20 lbs) for 4-6 weeks to reduce risk of dissection propagation	URGENT	ROUTINE	ROUTINE	-
Gradual return to light exercise after 2-4 weeks with physician clearance; avoid high-impact sports for 3-6 months minimum	-	ROUTINE	ROUTINE	-

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD	ICU
Avoid chiropractic cervical manipulation permanently given dissection history (recurrence risk)	URGENT	ROUTINE	ROUTINE	-
Blood pressure target <130/80 mmHg for secondary stroke prevention	-	ROUTINE	ROUTINE	-
Smoking cessation (absolute) as smoking impairs vascular healing and increases recurrence risk	-	ROUTINE	ROUTINE	-
Moderate alcohol use only (<=1 drink/day women, <=2 drinks/day men); excess alcohol increases bleeding risk on antithrombotics	-	ROUTINE	ROUTINE	-
Mediterranean or DASH diet for vascular risk reduction	-	ROUTINE	ROUTINE	-
Regular moderate-intensity aerobic exercise (30-40 min, 3-5 days/week) after medical clearance; avoid contact sports and extreme neck positions	-	-	ROUTINE	-
Weight management (BMI 18.5-24.9) for vascular risk reduction	-	ROUTINE	ROUTINE	-
Glycemic control (HbA1c <7%) if diabetic to reduce vascular risk	-	ROUTINE	ROUTINE	-
Avoid oral contraceptives or hormone replacement therapy without neurology input given vascular event history	-	ROUTINE	ROUTINE	-
Home blood pressure monitoring with log for physician review at follow-up visits	-	ROUTINE	ROUTINE	-
Stress management and emotional support; anxiety and depression common after young stroke diagnosis	-	ROUTINE	ROUTINE	-

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Atherosclerotic carotid/vertebral stenosis	Older patient; vascular risk factors (HTN, DM, hyperlipidemia, smoking); calcified plaque on imaging; gradual onset; no neck pain	CTA/MRA (calcified plaque vs. intimal flap/hematoma); MRI fat-sat (no intramural hematoma)
Fibromuscular dysplasia (FMD)	Young-middle aged women; "string-of-beads" appearance on angiography; may coexist with dissection; renal artery involvement	CTA/MRA (string-of-beads vs. smooth tapering); renal artery imaging; FMD can cause dissection
Carotid web (atypical FMD)	Shelf-like projection in posterior carotid bulb; recurrent stroke in young patients; no neck pain or Horner syndrome	CTA sagittal reformats (shelf lesion); DSA
Vasculitis (CNS or systemic)	Multifocal stenoses; constitutional symptoms (fever, weight loss, arthralgias); elevated ESR/CRP; multi-territory strokes	ESR, CRP, ANA, ANCA; vessel wall MRI (concentric enhancement vs. eccentric in dissection); possible brain/meningeal biopsy
Reversible cerebral vasoconstriction syndrome (RCVS)	Thunderclap headache; multifocal segmental vasoconstriction; triggered by vasoactive drugs, postpartum; spontaneous resolution	CTA/MRA (diffuse segmental narrowing vs. focal dissection); serial imaging showing resolution at 12 weeks
Intracranial aneurysm (unruptured or ruptured)	Acute headache (worst headache if rupture); focal mass effect; SAH on CT	CT head (SAH); CTA (saccular aneurysm vs. dissecting pseudoaneurysm); LP
Migraine with aura	Episodic; visual or sensory aura preceding headache; family history; stereotyped attacks; young patient	Clinical history (recurrent stereotyped episodes); normal MRI DWI (no infarct); dissection can mimic migraine
Cluster headache	Periorbital pain with autonomic features (tearing, conjunctival injection, rhinorrhea, partial Horner); episodic pattern	Clinical pattern (brief attacks in clusters); Horner syndrome in cluster is transient; CTA/MRA to exclude dissection if first presentation
Cardioembolic stroke (atrial fibrillation, PFO)	Irregular rhythm; multiple vascular territory infarcts; no neck pain or local signs	ECG/telemetry (AF); TTE/TEE (PFO, thrombus); CTA neck (normal vessels, no dissection)
Venous sinus thrombosis	Headache, papilledema, seizures; may have focal deficits; hypercoagulable state; postpartum	CT/MR venography (venous thrombosis); CTA arterial phase normal
Carotidynia (TIPIC syndrome)	Self-limited neck pain and tenderness over carotid; no neurologic deficits; perivascular inflammation on imaging	Ultrasound/CTA (perivascular inflammation without intimal flap or intramural hematoma); self-resolves in 2 weeks
Neck musculoskeletal strain	Neck pain after trauma/exertion; no neurologic deficits; no Horner syndrome; normal vascular imaging	Clinical exam (muscular tenderness, full neuro exam normal); CTA/MRA if dissection concern

6. MONITORING PARAMETERS

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Neurologic exam (NIHSS, cranial nerves, Horner syndrome)	q1h x 24h acutely, then q4h x 48h, then q shift; outpatient at each visit	Stable or improving deficits; resolution of Horner	If NIHSS increases >=4: STAT CT head; call stroke team; reassess antithrombotic strategy	STAT	STAT	ROUTINE	STAT
Blood pressure	q1h x 24h, then q4h; outpatient at each visit	<185/110 pre-tPA; <180/105 post-tPA x 24h; <130/80 chronic	Titrate antihypertensives; avoid SBP <100 (hypoperfusion risk in stenosed vessel)	STAT	STAT	ROUTINE	STAT
Heart rate and rhythm (telemetry)	Continuous x 48-72h minimum	Detect paroxysmal atrial fibrillation as concurrent etiology	Cardiology consult; anticoagulation if AF detected	STAT	STAT	-	STAT
aPTT (if on IV heparin)	q6h until stable, then q12-24h	1.5-2.5x control (typically 60-80 sec)	Adjust heparin infusion rate per protocol	STAT	STAT	-	STAT
INR (if on warfarin)	Daily until stable, then weekly, then monthly	2.0-3.0	Adjust warfarin dose; bridge with heparin if subtherapeutic and high risk	-	ROUTINE	ROUTINE	-
Platelet count (HIT surveillance if on heparin)	q3 days while on heparin	Platelets >150,000; >50% drop triggers HIT workup	HIT screen (PF4 antibody); switch to argatroban or bivalirudin if positive	-	ROUTINE	-	ROUTINE
Follow-up vascular imaging (CTA or MRA neck)	3-6 months post-diagnosis; then 12 months if residual abnormality	Recanalization (complete or partial); stable or resolving pseudoaneurysm; no new stenosis	If worsening: neurovascular conference; consider intervention; adjust antithrombotic	-	-	ROUTINE	-
Renal function (Cr, BUN)	q24-48h if contrast given; q3-6 months if on DOAC	Stable eGFR	Hydration; adjust medication dosing; hold nephrotoxic agents	-	ROUTINE	ROUTINE	-
Blood glucose	q6h x 48h (q1h if insulin drip) if stroke present	140-180 mg/dL; avoid <60 mg/dL	Insulin adjustment; D50W for hypoglycemia	STAT	STAT	-	STAT
Swallowing screen	Before any PO intake	Pass screening (water swallow test)	NPO until formal SLP evaluation; consider NG tube	URGENT	STAT	-	URGENT
Lipid panel	Fasting within 24-48h; repeat at 4-12 weeks on statin	LDL <70 mg/dL	Intensify statin; add ezetimibe	-	ROUTINE	ROUTINE	-
Depression and anxiety screening (PHQ-9, GAD-7)	At 1 month, 3 months, then annually	PHQ-9 <5; GAD-7 <5	SSRI initiation; psychology/psychiatry referral; peer support	-	-	ROUTINE	-

7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	Dissection without stroke or with minor stroke (NIHSS 0-3); stable exam over 24h observation; antithrombotic therapy initiated and tolerated; adequate home support; reliable outpatient follow-up arranged; imaging follow-up scheduled; prescriptions filled; patient education complete
Admit to stroke unit/floor	Dissection with moderate stroke (NIHSS 4-15); dissection requiring IV heparin initiation and aPTT monitoring; new dissection requiring observation for stroke development; incomplete workup; dysphagia requiring NPO or modified diet; pain requiring IV medications
Admit to ICU/neuro-ICU	Post-tPA monitoring (first 24h); post-thrombectomy; large territory infarct with edema risk; bilateral dissections with hemodynamic compromise; posterior fossa stroke with herniation risk; unstable BP requiring IV antihypertensive infusion; declining neurologic exam; respiratory compromise
Transfer to higher level of care	LVO requiring thrombectomy not available at current facility (transfer to comprehensive stroke center); need for neurointerventional stenting; need for neurosurgical decompression not available; suspected vascular Ehlers-Danlos requiring specialized genetics and vascular care
Outpatient management	Incidental dissection found on imaging without symptoms; chronic dissection with complete healing on follow-up; stable pseudoaneurysm on long-term monitoring

8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
Antiplatelet vs. anticoagulation equivalent for stroke prevention in cervical dissection	Class I, Level B-R	CADISS trial (Markus et al. Lancet Neurology 2015)
CADISS extended follow-up: no difference in recurrent stroke or death at 1 year	Class II, Level B-R	CADISS investigators (J Neurol Neurosurg Psychiatry 2019)
IV tPA safe and effective in dissection-related stroke; cervical dissection is NOT a contraindication	Class IIa, Level C	AHA/ASA 2019 Guidelines (Powers et al.); observational data
Antithrombotic therapy recommended for at least 3-6 months post-dissection	Class I, Level C	AHA/ASA 2014 Stroke Prevention Guidelines; Expert consensus
CTA and MRA with fat saturation are first-line imaging for cervical dissection diagnosis	Class I, Level B-NR	Debette et al. Lancet Neurology 2015 (review); Provenzale and Sarikaya Radiology 2009
Intramural hematoma best seen on T1 fat-saturated MRI (crescent sign)	Class IIa, Level B-NR	Debette and Leys NEJM 2009
Fibromuscular dysplasia is the most common arteriopathy associated with cervical dissection	Class II, Level B-NR	Olin et al. Circulation 2011; Debette et al. Lancet Neurology 2015
Vascular Ehlers-Danlos syndrome (COL3A1 mutations) increases dissection risk; avoid catheter angiography if possible	Class IIa, Level C	Pepin et al. NEJM 2000; Byers Ehlers-Danlos Syndrome Vascular Type (GeneReviews)
Thrombectomy for LVO from dissection follows standard acute stroke criteria	Class I, Level A	AHA/ASA 2019 Guidelines; MR CLEAN, DAWN, DEFUSE-3 trials (dissection etiology subgroup data)
Dual antiplatelet therapy (aspirin + clopidogrel) for minor stroke/high-risk TIA applicable to dissection-related minor stroke	Class I, Level A	CHANCE trial (Wang et al. NEJM 2013); POINT trial
Cervical dissection accounts for 10-25% of ischemic strokes in young adults (<50 years)	Observational	Debette and Leys NEJM 2009; Schievink NEJM 2001
Annual recurrence rate of cervical dissection is approximately 1% per year	Observational	Schievink et al. Neurology 1994; Debette et al. Stroke 2011
Chiropractic cervical manipulation associated with increased cervical dissection risk	Class III, Level C	Cassidy et al. Spine 2008; Rothwell et al. Stroke 2001 (association debated but avoidance recommended)
Pseudoaneurysm monitoring with serial imaging; most stabilize; intervention for symptomatic expansion	Class IIb, Level C	Expert consensus; Touze et al. Stroke 2001
Follow-up vascular imaging at 3-6 months to assess recanalization and guide antithrombotic duration	Class IIa, Level C	AHA/ASA guidelines; expert consensus
Permissive hypertension (up to 220/120 if no tPA) in dissection-related stroke without thrombolysis	Class I, Level B-R	AHA/ASA 2019 Guidelines
Horner syndrome (miosis, ptosis, anhidrosis) is a classic presentation of carotid dissection; present in ~50% of carotid dissections	Observational	Mokri et al. Ann Neurol 1986; Debette and Leys NEJM 2009
Decompressive craniectomy for malignant MCA edema from dissection-related ICA occlusion follows standard protocols	Class I, Level A (age <60)	DESTINY, DECIMAL, HAMLET pooled analysis
Pregnancy and postpartum period are recognized risk factors for cervical artery dissection	Observational	Kelly et al. Neurology 2014; Arnold et al. Neurology 2006
High-intensity statin therapy for secondary stroke prevention in patients with atherosclerotic risk factors post-dissection	Class I, Level A	SPARCL trial (Amarenco et al. NEJM 2006); AHA/ASA 2021

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CHANGE LOG

v1.1 (January 30, 2026) - Fixed structured dosing format across all treatment sections (3A, 3B, 3C, 3D) to use proper [dose] :: [route] :: [frequency] :: [instructions] format - Fixed Gabapentin dosing: corrected malformed dosing field (was missing frequency, had multiple doses in dose field) - Fixed Acetaminophen, Ibuprofen, Ondansetron, Meclizine dosing: separated dose from frequency in structured fields - Fixed Heparin IV dosing: clean bolus dose in first field with infusion details in instructions - Fixed Apixaban dosing: standard dose (5 mg) in first field; reduced dose in instructions - Fixed Lisinopril dosing: starting dose (5-10 mg) in first field; titration in instructions - Fixed Amlodipine dosing: starting dose (5 mg) in first field; max in instructions - Fixed Aspirin maintenance dosing: standard dose (81 mg) in first field - Fixed Atorvastatin dosing: dose range in first field with instructions in fourth field - Fixed Mannitol dosing: bolus dose in first field; maintenance in instructions - Fixed DAPT row: cleaned dosing format for combined regimen - Fixed Enoxaparin therapeutic dosing: separated dose from frequency - Added structured dosing format to procedure rows (thrombectomy, stenting, craniectomy, pneumatic compression) using N/A for dose field - Added ICU column to Section 4B (Patient Instructions) for venue consistency - Added ICU column to Section 4C (Lifestyle & Prevention) for venue consistency - Simplified treatment names: removed "Blood pressure management:" prefix from Labetalol and Nicardipine; removed "Osmotherapy:" prefix from Mannitol - Updated version to 1.1; added REVISED date

v1.0 (January 30, 2026) - Initial template creation - Comprehensive coverage of carotid and vertebral artery dissection - Includes spontaneous and traumatic etiologies - CADISS trial-informed antithrombotic guidance (antiplatelet vs. anticoagulation equivalence) - Full imaging workup including CTA, MRA with fat saturation, vessel wall imaging - Young stroke workup context and connective tissue disorder screening - Thrombolysis and thrombectomy considerations for dissection-related stroke - Pseudoaneurysm monitoring protocol - Structured dosing format v3.0 compliant

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APPENDIX A: CLINICAL PRESENTATION PATTERNS

Dissection Type	Classic Presentation	Key Features
Carotid (anterior circulation)	Unilateral head/neck/face pain + ipsilateral Horner syndrome + contralateral hemispheric stroke symptoms	Ipsilateral partial Horner (miosis, ptosis, NO anhidrosis if postganglionic); pulsatile tinnitus; cranial nerve palsies (CN XII hypoglossal most common); amaurosis fugax
Vertebral (posterior circulation)	Posterior neck pain/occipital headache + posterior circulation stroke symptoms	Vertigo, diplopia, dysarthria, ataxia, nausea/vomiting; lateral medullary syndrome (Wallenberg); may present as isolated neck/occipital pain
Bilateral carotid	Bilateral headache/neck pain + bilateral hemispheric signs	Rare; consider connective tissue disorder; FMD; recent trauma
Multiple vessel	Pain in multiple distributions + multi-territory ischemia	Strong indicator of underlying arteriopathy (vascular EDS, FMD, Loeys-Dietz)

APPENDIX B: ANTITHROMBOTIC DECISION GUIDE

Clinical Scenario	Recommended Strategy	Duration	Evidence
Dissection WITHOUT stroke or TIA	Antiplatelet (aspirin 81-325 mg daily)	3-6 months minimum	CADISS trial; expert consensus
Dissection WITH minor stroke (NIHSS <=3)	Antiplatelet (aspirin 81-325 mg daily) OR DAPT x 21 days then single agent	3-6 months minimum	CADISS; CHANCE/POINT extrapolation
Dissection WITH moderate stroke	Antiplatelet preferred; anticoagulation if high embolic features	3-6 months; reassess with follow-up imaging	CADISS; AHA/ASA guidelines
Free-floating thrombus in lumen	IV heparin then warfarin (INR 2-3)	Until thrombus resolves on imaging (typically 3-6 months)	Expert consensus; observational data
Recurrent TIA on antiplatelet	Switch to anticoagulation (heparin bridge to warfarin)	3-6 months; reassess	Expert consensus
Pseudoaneurysm (stable)	Continue antiplatelet	Monitor with imaging q6-12 months until stable x 2 studies	Expert consensus
Pseudoaneurysm (expanding/symptomatic)	Anticoagulation; consider endovascular stenting	Until resolved or stabilized	Expert consensus; case series
Healed dissection on follow-up imaging	May discontinue antithrombotic if no other indication; discuss with patient	Reassess vascular risk factors	Expert consensus

APPENDIX C: DISSECTION RISK FACTORS

Category	Risk Factors
Connective tissue disorders	Vascular Ehlers-Danlos syndrome (type IV), Marfan syndrome, Loeys-Dietz syndrome, fibromuscular dysplasia, osteogenesis imperfecta
Mechanical/traumatic	Chiropractic cervical manipulation, motor vehicle accident, sports injury (contact sports, skiing), roller coaster, prolonged neck extension (dental work, surgery, painting ceilings), coughing/sneezing/vomiting
Vascular	Hypertension, migraine with aura, fibromuscular dysplasia, prior dissection
Hormonal/metabolic	Pregnancy and postpartum, oral contraceptive use, hyperhomocysteinemia, alpha-1 antitrypsin deficiency
Infectious/inflammatory	Recent upper respiratory infection (proposed association), vasculitis
Idiopathic	Approximately 30-40% of cervical dissections have no identifiable risk factor