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– 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 DysfunctionNon 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 DysfunctionNon 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 DysfunctionIschemic 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 DysfunctionNon 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 DysfunctionIschemic 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

– 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