A 38-year-old woman arrives holding the left side of her neck, her voice quieter than usual. She describes sudden neck pain after a yoga maneuver yesterday, followed this morning by a “curtain” over her left eye and clumsiness in her right hand. Her blood pressure is 168/94, and the left pupil seems slightly smaller than the right. The CT scanner is ready, but the next decision has not yet been made.

— What’s your move? Read on.

Before you read
  • When is reperfusion therapy appropriate?
  • Antiplatelet or anticoagulation—and for how long?

When to Think of It

Entertain the diagnosis with acute unilateral neck pain, headache, facial pain, partial Horner syndrome, retinal ischemia, or focal neurologic symptoms—especially after neck trauma, manipulation, coughing, or exertion. Vertebral dissection may cause posterior headache, vertigo, ataxia, diplopia, dysarthria, or posterior-circulation stroke.

Sick or Not Sick

The key fork is disabling or evolving neurologic ischemia now versus an intact, stable patient. Activate the stroke pathway immediately for persistent focal deficits, large-vessel-occlusion syndrome, or disabling symptoms; do not wait for confirmatory vascular imaging before considering reperfusion.

The First Fifteen Minutes

  • ABCs, bedside glucose, cardiac monitor, two IVs, frequent neurologic reassessment, and last-known-well time.
  • Suspected acute ischemic stroke with disabling deficit and no hemorrhage/contraindication → tenecteplase 0.25 mg/kg IV push, maximum 25 mg within the accepted treatment window, or alteplase 0.9 mg/kg IV (maximum 90 mg; 10% bolus, remainder over 60 minutes) per local stroke protocol. Fibrinolysis restores flow before irreversible infarction; verify dosing with institutional stroke protocol.
  • Large-vessel occlusion on CTA → immediate neurointerventional consultation for mechanical thrombectomy; do not delay transfer for additional testing.
  • Blood pressure above 185/110 mm Hg when thrombolysis is planned → labetalol 10–20 mg IV over 1–2 minutes, repeat once, or nicardipine 5 mg/h IV infusion, titrating by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h. Lowering pressure permits safer thrombolysis.
  • No thrombolysis and BP below 220/120 mm Hg → generally avoid acute BP reduction, because cerebral perfusion may be pressure-dependent.
  • Confirmed ischemic stroke without thrombolysis and hemorrhage excluded → aspirin 325 mg PO or rectally once; it reduces early recurrent embolic events. Do not give antiplatelet therapy before excluding intracranial hemorrhage.

Definitive Care & Disposition

Obtain noncontrast head CT plus CTA head and neck from aortic arch through intracranial circulation; MRI/MRA can clarify small infarcts or equivocal findings but should not delay acute treatment. Admit symptomatic patients to a stroke unit or ICU depending on deficits, infarct burden, blood pressure, and intervention. For extracranial dissection with ischemic stroke, antiplatelet therapy is commonly favored; anticoagulation is individualized and generally avoided with intracranial dissection, large infarct, hemorrhagic transformation, or intracranial bleeding risk. Continue secondary prevention and arrange vascular-neurology follow-up with repeat imaging, often at 3–6 months.

How This One Kills

The dangerous error is labeling unilateral headache or neck pain as migraine or muscle strain while a thromboembolic stroke is developing; the artery may look deceptively normal on a routine noncontrast head CT.
The Differential — What Else Looks Like This
  • Migraine with aura — stereotyped positive symptoms and gradual spread; confusing it with dissection delays vascular imaging and stroke treatment.
  • Carotid sinus or cervical muscle injury — local pain without retinal or focal neurologic ischemia; missing dissection risks embolization.
  • Subarachnoid hemorrhage — thunderclap headache, meningismus, or reduced consciousness; treating presumed dissection without hemorrhage exclusion can worsen bleeding.
  • Cerebral venous thrombosis — headache with seizures, papilledema, or diffuse deficits; the vascular territory and treatment strategy differ.

The Second-Day Story

Older patients may present with isolated dizziness, transient monocular visual loss, neck pain, or nonspecific headache rather than a dramatic stroke. Prior analgesics may blunt pain, and a normal initial examination does not exclude an unstable lesion. Ask specifically about recent neck movement or trauma, inspect for ptosis/miosis, compare pulses and blood pressures when appropriate, and obtain CTA when the symptom pattern is vascular.
Back to Our Patient
Back to the 38-year-old woman: her acute neck pain, transient monocular visual loss, partial Horner syndrome, and right-hand weakness trigger recognition of cervical artery dissection with cerebral ischemia. She is stable in airway and circulation but has a potentially disabling, evolving neurologic deficit, so the stroke team is activated and CTA head/neck is obtained without delaying evaluation for reperfusion. CT excludes hemorrhage; CTA demonstrates a left internal carotid dissection with an intracranial occlusion, and she receives protocol-directed reperfusion followed by neurointerventional assessment. She is admitted to a stroke ICU for monitoring, antithrombotic planning, and repeat vascular imaging.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“Thirty-eight-year-old woman with sudden left neck pain after yoga yesterday now has transient left monocular vision loss and right-hand clumsiness, with last-known-well this morning. She has no seizure, fever, trauma, anticoagulant use, or prior similar headache; examination shows mild right-hand drift and left partial ptosis and miosis. Glucose is normal, and she is protecting her airway with BP 168/94. I’m concerned for left cervical internal carotid dissection causing acute ischemic stroke. I’m activating the stroke team, obtaining noncontrast head CT and CTA head/neck, and will pursue reperfusion if eligible while avoiding unnecessary BP reduction.”

Study Directive

  • Draw the carotid and vertebral dissection presentations from memory, including Horner syndrome and posterior-circulation symptoms.
  • Review your institutional thrombolysis and thrombectomy inclusion/exclusion criteria.
  • Practice a 60-second stroke activation presentation using last-known-well, deficit, glucose, BP, and anticoagulant status.
  • Complete five cases distinguishing migraine, dissection, subarachnoid hemorrhage, and cerebral venous thrombosis.

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