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Cervical Artery Dysfunction
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Vascular Anatomy
• Posterior system (20%)– Vertebrobasilar arterial
• Tethering at C2, C1 and atlanto-occipital membrane
• Right angled bends
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Vascular Anatomy
• Anterior system (80%) – Internal and External carotid arteries
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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
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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
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Mechanism of Injury
• Traumatic– Coughing– Sneezing– Head turning– RTC
• Insidious– Atherosclerosis– Inflammation– Connective tissue disease– Upper cervical instability
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Associated Pathologies
• Cervical instability• Whiplash Associated Disorders• Diabetes• Hypertension• Cardiac Disease• Hypercholesterolemia• Blood Clotting Disorders
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Classification
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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
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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
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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
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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
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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
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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
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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
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Special Tests
• Blood Pressure Testing• Cranial Nerve Testing• Special Tests not useful
and more likely to cause injury
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Further Investigation
• Ultrasound Doppler• Arteriography• Magnetic Resonance
Angiography
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General Management
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Conservative - Management
• Medic Led• Monitor BP• Statins, Anti coagulants• No physical therapy