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Long B, Pelletier J, Koyfman A, Bridwell RE. High risk and low prevalence diseases: Spontaneous cervical artery dissection. Am J Emerg Med 2024; 76:55-62. [PMID: 37995524 DOI: 10.1016/j.ajem.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Spontaneous cervical artery dissection (sCAD) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of sCAD, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION sCAD is a condition affecting the carotid or vertebral arteries and occurs as a result of injury and compromise to the arterial wall layers. The dissection most commonly affects the extracranial vessels but may extend intracranially, resulting in subarachnoid hemorrhage. Patients typically present with symptoms due to compression of local structures, and the presentation depends on the vessel affected. The most common symptom is headache and/or neck pain. Signs and symptoms of ischemia may occur, including transient ischemic attack and stroke. There are a variety of risk factors for sCAD, including underlying connective tissue or vascular disorders, and there may be an inciting event involving minimal trauma to the head or neck. Diagnosis includes imaging, most commonly computed tomography angiography of the head and neck. Ultrasound can diagnose sCAD but should not be used to exclude the condition. Treatment includes specialist consultation (neurology and vascular specialist), consideration of thrombolysis in appropriate patients, symptomatic management, and administration of antithrombotic medications. CONCLUSIONS An understanding of sCAD can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA
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Trager RJ, Daniels CJ, Scott ZE, Perez JA. Pregnancy and spontaneous cervical artery dissection: A propensity-matched retrospective cohort study. J Stroke Cerebrovasc Dis 2023; 32:107384. [PMID: 37742385 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107384] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVES We hypothesized that pregnant women would have an increased risk of spontaneous cervical artery dissection (sCeAD) affecting the carotid or vertebral arteries over one-year follow-up after the first trimester ultrasound compared to matched non-pregnant controls. MATERIALS AND METHODS We queried a United States research network (TriNetX, Inc.) of de-identified medical records of >111 million patients, with data spanning 2008-2023. We included women aged ≥18 and excluded those with trauma and conditions potentially causative of sCeAD. Women were divided into cohorts based on a1 first trimester ultrasound and subsequent labor, delivery, or full-term pregnancy, or2 gynecological examination and no pregnancy. We used propensity matching to control for variables associated with sCeAD and calculated the risk ratio (RR) of sCeAD occurring over one-year follow-up from the index date of ultrasound or gynecological exam. RESULTS After matching, the incidence rate of sCeAD in the pregnancy cohort was 8.0 (95% CI: 8.0-8.1) per 100,000 person-years, compared to 3.9 (95% CI: 3.9-3.9) per 100,000 person-years in the non-pregnancy cohort, yielding an RR (95% CI) of 2.06 (1.17-3.61; P= .0104). A cumulative incidence graph suggested that most cases of sCeAD in the pregnancy cohort occurred during pregnancy rather than the postpartum period. CONCLUSIONS Our findings demonstrate that women have a twofold increased risk of sCeAD during pregnancy and the postpartum period compared to non-pregnant women. Further research is needed to determine whether maternal comorbidities such as preeclampsia account for these findings, and clarify when sCeAD occurs in relation to pregnancy or the postpartum period.
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Affiliation(s)
- Robert J Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland OH, USA.
| | - Clinton J Daniels
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA
| | - Zachary E Scott
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA
| | - Jaime A Perez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Trager RJ, Cupler ZA, Theodorou EC, Dusek JA. COVID-19 Does Not Increase the Risk of Spontaneous Cervical Artery Dissection. Cureus 2023; 15:e47524. [PMID: 38022016 PMCID: PMC10664733 DOI: 10.7759/cureus.47524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Case reports have raised the possibility of an association between coronavirus disease 2019 (COVID-19) and spontaneous cervical artery dissection (sCeAD), yet no large studies have examined this association. We hypothesized that adults with confirmed COVID-19 would have an increased risk of sCeAD over the subsequent six months compared to test-negative controls after adjusting for confounding variables. Methods We obtained data from a United States medical records network (TriNetX, Inc., Cambridge, MA) of >106 million patients, providing adequate power needed for this rare outcome. We identified two cohorts of adults meeting the criteria of (1) test-confirmed COVID-19 or (2) non-COVID-19 test-negative controls, from April 1, 2020, to December 31, 2022. Patients with previous COVID-19 or conditions predisposing to sCeAD were excluded. Propensity matching was used to control for variables associated with sCeAD and markers of healthcare utilization. Results The number of patients reduced from before matching (COVID-19: 491,592; non-COVID-19: 1,472,895) to after matching, resulting in 491,115 patients per cohort. After matching, there were 22 cases of sCeAD in the COVID-19 cohort (0.0045%) and 20 cases in the non-COVID-19 cohort (0.0041%), yielding a risk ratio of 1.10 (95% CI: 0.60-2.02; P = 0.7576). Both cohorts had a median of five healthcare visits during follow-up. Conclusions Our results suggest that COVID-19 is not a risk factor for sCeAD. This null finding alleviates the concern raised by initial case reports and may better direct future research efforts on this topic.
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Affiliation(s)
- Robert J Trager
- Department of Chiropractic, Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, USA
- Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, USA
- Department of Biostatistics and Bioinformatics, Clinical Research Training Program, Duke University School of Medicine, Durham, USA
| | - Zachary A Cupler
- Physical Medicine & Rehabilitative Services, Butler VA (Veterans Affairs) Health Care System, Butler, USA
- Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Elainie C Theodorou
- Science Research and Engineering Program, Hathaway Brown School, Cleveland, USA
| | - Jeffery A Dusek
- Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, USA
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Salehi Omran S. Cervical Artery Dissection. Continuum (Minneap Minn) 2023; 29:540-565. [PMID: 37039409 DOI: 10.1212/con.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Cervical artery dissection is a common cause of stroke in young adults. This article reviews the pathophysiology, etiology and risk factors, evaluation, management, and outcomes of spontaneous cervical artery dissection. LATEST DEVELOPMENTS Cervical artery dissection is believed to be a multifactorial disease, with environmental factors serving as possible triggers in patients who have a genetic predisposition to dissection formation. Cervical artery dissection can cause local symptoms or ischemic events, such as ischemic stroke or transient ischemic attack. Neuroimaging is used to confirm the diagnosis; classic findings include a long tapered arterial stenosis or occlusion, dissecting aneurysm, intimal flap, double lumen, or intramural hematoma. Patients with cervical artery dissection who present with an acute ischemic stroke should be evaluated for IV thrombolysis, endovascular therapy eligibility, or both. Antithrombotic therapy with either anticoagulation or antiplatelet treatment is used to prevent stroke from cervical artery dissection. The risk of recurrent ischemia appears low and is mostly limited to the first two weeks after symptom onset. ESSENTIAL POINTS Cervical artery dissection is a known cause of ischemic strokes. Current data show no difference between the benefits and risks of anticoagulation versus antiplatelet therapy in the acute phase of symptomatic extracranial cervical artery dissection, thereby supporting the recommendation that clinicians can prescribe either treatment. Further research is warranted to better understand the pathophysiology and long-term outcomes of cervical artery dissection.
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Xiao S, Zhang J, Wang L, Zhang H. Analysis of a delayed diagnosis of carotid artery aneurysm presenting as a parapharyngeal space infection. EAR, NOSE & THROAT JOURNAL 2022:1455613221113811. [PMID: 36189632 DOI: 10.1177/01455613221113811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
It is very rare for extracranial carotid artery dissection to present as a carotid pseudoaneurysm. A delayed diagnosis and delayed treatment will lead to rupture of carotid pseudoaneurysm and massive hemorrhage and death. In this paper, we reviewed the progress of the disease in one patient and reviewed the relevant literature reports to understand the characteristics of the disease. The patient had two consultations within the otolaryngology department. The patient later showed signs of infection in the parapharyngeal space and then died of an aneurysmal rupture and massive hemorrhage.
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Affiliation(s)
- Shufen Xiao
- Departments of Otorhinolaryngology-Head and Neck Surgery, Bethune International Peace Hospital, Shijiazhuang, China
| | - Juan Zhang
- Department of Pharmacy, The Affiliated Hospital of Hebei University of Engineering, Handan, Hebei, China
| | - Ling Wang
- Departments of Otorhinolaryngology-Head and Neck Surgery, Bethune International Peace Hospital, Shijiazhuang, China
| | - Hong Zhang
- Departments of Otorhinolaryngology-Head and Neck Surgery, The Affiliated Hospital of Hebei University of Engineering, Handan, China
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Keser Z, Chiang CC, Benson JC, Pezzini A, Lanzino G. Cervical Artery Dissections: Etiopathogenesis and Management. Vasc Health Risk Manag 2022; 18:685-700. [PMID: 36082197 PMCID: PMC9447449 DOI: 10.2147/vhrm.s362844] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/19/2022] [Indexed: 11/23/2022] Open
Abstract
Cervical Artery Dissection (CeAD) is a frequent stroke etiology for patients younger than 50 years old. The most common immediate complications related to CeAD are headache and neck pain (65–95%), TIA/ischemic stroke (>50%), and partial Horner’s syndrome (25%). The prevailing hypothesis regarding the pathogenesis of sCeAD is that the underlying constitutional vessel wall weakness of patients with sCeAD is genetically determined and that environmental factors could act as triggers. The stroke prevention treatment of CeAD remains controversial, involving anticoagulation or antiplatelet therapy and potentially emergent stenting and/or thrombectomy or angioplasty for selected cases of carotid artery dissection with occlusion. The treatment of headache associated with CeAD depends on the headache phenotype and comorbidities. Radiographically, more than 75% of CeAD cases present with occlusion or non-occlusive stenosis. Many patients demonstrate partial and complete healing, more commonly in the carotid arteries. One-fifth of the patients develop dissecting pseudoaneurysm, but this is a benign clinical entity with an extremely low rupture and stroke recurrence risk. Good recovery is achieved in many CeAD cases, and mortality remains low. Family history of CeAD, connective tissue disorders like Ehlers-Danlos syndrome type IV, and fibromuscular dysplasia are risk factors for recurrent CeAD, which can occur in 3–9% of the cases. This review serves as a comprehensive, updated overview of CeAD, emphasizing etiopathogenesis and management.
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Affiliation(s)
- Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Correspondence: Zafer Keser, Department of Neurology – Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA, Email
| | | | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
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Arning C, Hanke-Arning K, Eckert B. The Clinical Features of Dissection of the Cervical Brain-Supplying Arteries. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:581-587. [PMID: 35734920 PMCID: PMC9749844 DOI: 10.3238/arztebl.m2022.0238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/04/2022] [Accepted: 05/17/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Dissections of the cervical brain-supplying arteries are a leading cause of ischemic stroke in young adults, with an annual incidence of 2.5-3 / 100 000 for carotid artery dissection and 1-1.5 / 100 000 for vertebral artery dissection. It can be assumed that many cases go unreported. We present the clinical features here to help physicians diagnose this disease entity as rapidly as possible. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed. RESULTS Spontaneous dissection of the internal carotid or vertebral artery is characterized by a hematoma in the vessel wall. It often arises in connection with minor injuries; underlying weakness of the arterial wall (possibly only temporary) may be a predisposing factor. Acute unilateral pain is the main presenting symptom. In internal carotid dissection, the site of the pain is temporal in 46% of cases, and frontal in 19%; in vertebral artery dissection, it is nuchal and occipital in 80%. Pain and local findings, such as Horner syndrome, are generally present from the beginning, while stroke may arise only after a latency of hours to days. If the diagnosis is made early with MRI, CT, or ultrasound, and anticoagulation or antiplatelet drugs can help prevent a stroke, yet none of these methods can detect all cases. Recurrent dissection is rare, except in patients with connective tissue diseases such as Ehlers-Danlos syndrome or fibromuscular dysplasia. Spontaneous dissection of the great vessels of the neck must be differentiated from aortic dissection spreading to the supra-aortic vessels and from traumatic dissection due to blunt or penetrating vascular trauma. CONCLUSION Dissection of the cervical brain-supplying vessels is not always revealed by the imaging methods that are used to detect it. Stroke prevention thus depends on the physician's being aware of the symptoms and signs of this disease entity, so that early diagnosis can be followed by appropriate treatment.
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Affiliation(s)
- Christian Arning
- Praxis Neurologie und Neuro-Ultraschall, Hamburg,*Facharzt für Neurologie und Psychiatrie Moorhof 2d, D-22399 Hamburg, Germany
| | | | - Bernd Eckert
- Department of Neuroradiology, Asklepios Klinik Altona, Hamburg
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Guida A, Tortora F, Tortora M, Buono G, Marseglia M, Tarantino M, Rizzuti M, Loiudice G, Manganelli F, Briganti F. Dissective tandem stroke: an endovascular approach. Radiol Case Rep 2022; 17:2170-2174. [PMID: 35479967 PMCID: PMC9035657 DOI: 10.1016/j.radcr.2022.03.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 11/20/2022] Open
Abstract
Ischemic stroke due to internal carotid artery occlusion is a potential devastating condition. More frequently the occlusions are embolic in nature, but sometimes they are caused by arterial dissection and their treatment is a challenge. We describe an illustrative case where a young patient with middle cerebral artery stroke caused by carotid artery dissection was submitted to endovascular treatment of mechanical thrombectomy and stenting, giving an excellent outcome. We believe that tandem approach is a treatment of choice in these cases.
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Affiliation(s)
- Amedeo Guida
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
- Corresponding author.
| | - Fabio Tortora
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
| | - Mario Tortora
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
| | - Giuseppe Buono
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
| | - Mariano Marseglia
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
| | - Margherita Tarantino
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
| | - Michele Rizzuti
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
| | - Giovanni Loiudice
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
| | - Fiore Manganelli
- Department of Neuroscience and Reproductive Sciences and Dentistry, University “Federico II”, Naples, Italy
| | - Francesco Briganti
- Department of Advanced Biomedical Sciences, Neuroradiology Unit, University “Federico II”, Naples, Italy
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Reading J, Bhatt R, Kilbey L, Breene R, Hall G, Kavirayani A, Joseph R, Ramdas S. Double Trouble: Stroke in a Child with Down's Syndrome. JOURNAL OF PEDIATRIC NEUROLOGY 2022. [DOI: 10.1055/s-0042-1742688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractDown's syndrome (trisomy 21) is well recognized to be associated with several autoimmune conditions such as hypothyroidism, celiac disease, and diabetes mellitus. Antiphospholipid syndrome (APS), an immune disorder, can cause a stroke due to the prothrombotic state. APS is associated with several autoimmune diseases including systemic lupus erythematosus, rheumatoid arthritis, and systemic vasculitis, as well as Down's syndrome. Down's syndrome is linked to several other risk factors for stroke including congenital heart disease, moyamoya disease, and arterial dissection. We present the case of a 3-year-old girl child patient with Down's syndrome, who presented with an acute arterial ischemic stroke secondary to carotid artery dissection and subsequently was also confirmed to have APS. We review the literature on Down's syndrome and APS, the proposed pathophysiology, and management strategies. We present a case of a 3-year-old girl with Down's syndrome and who presented with stroke, review previously published cases, and discuss the conditions and their management. Autoimmune conditions, such as antiphospholipid syndrome, are more common in individuals with Down's syndrome, and as such should be investigated when these children present with symptoms suggestive of stroke.
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Affiliation(s)
- Jacob Reading
- Department of Pediatrics, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Ree'Thee Bhatt
- Department of Pediatrics, Milton Keynes University Hospital National Health Service Foundation Trust, Milton Keynes, United Kingdom
| | - Laura Kilbey
- Department of Pediatrics, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Richard Breene
- Department of Pediatrics, Northampton General Hospital National Health Service Trust, Northampton, United Kingdom
| | - Georgina Hall
- Department of Pediatric Hematology, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Akhila Kavirayani
- Department of Pediatric Rheumatology, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Robin Joseph
- Department of Radiology, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Sithara Ramdas
- Department of Pediatric Neurology, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
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Tarsia J, Vidal G, Zweifler RM. Arterial Dissection, Fibromuscular Dysplasia, and Carotid Webs. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Venturini G, Vuolo L, Pracucci G, Picchioni A, Failli Y, Benvenuti F, Sarti C. Association between carotid artery dissection and vascular tortuosity: a case-control study. Neuroradiology 2021; 64:1127-1134. [PMID: 34766191 DOI: 10.1007/s00234-021-02848-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/26/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE We aimed to verify if vascular tortuosity (VT) may represent a risk factor for spontaneous epiaortic vessel dissection (sEVD) in young adult patients. METHODS We identified 304 patients aged under 55 years consecutively admitted for acute cerebrovascular events to our Stroke Unit. After checking the possibility to perform a 3D reconstruction of epiaortic vessels on CT-angiography images, we selected and compared fifty patients with sEVD (cases) with fifty-one patients without dissection (controls). VT of carotid and vertebral arteries was measured on reconstructions evaluating the vascular tortuosity index (VTI), calculated according to a specific algorithm, and the presence of kinking and coiling. Differences between groups were analyzed by Student-t test for numeric variables and chi-square test for categoric ones. A ROC curve analysis was used to look for a VTI threshold value beyond which the risk of dissection was significantly increased. RESULTS VTI was significantly higher in cases than in controls only considering carotid arteries (p = 0.029); cases did not have a significantly higher rate of kinking and coiling than controls (p = 0.059 and 0.077, respectively). We have found a significant VTI threshold value of 27.9% (under curve area = 61.6%, p = 0.04) only for carotid artery dissection. CONCLUSION VT appears to be associated with an increased risk of dissection for the carotid district but not for the vertebral one. The different structure, embryogenesis, and pathophysiology of dissection between the two districts could explain this finding. VTI threshold as carotid artery dissection predictor deserves confirmation in larger studies.
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Affiliation(s)
- Gabriele Venturini
- NEUROFARBA Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Luisa Vuolo
- Neuroradiology Unit, Careggi University Hospital, Largo Piero Palagi, 1, 50139, Florence, Italy
| | - Giovanni Pracucci
- NEUROFARBA Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Antonella Picchioni
- NEUROFARBA Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Ylenia Failli
- NEUROFARBA Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Federica Benvenuti
- NEUROFARBA Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Cristina Sarti
- NEUROFARBA Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy.
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Williams L, Delaney F, Kenny G, Marnane M, Kavanagh E, Sheehan G, Murphy S. Varicella-Zoster Vasculopathy Causing Carotid Artery Dissection. Neurol Clin Pract 2021; 11:e373-e375. [PMID: 34484920 DOI: 10.1212/cpj.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/04/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Laura Williams
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Francis Delaney
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Grace Kenny
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Michael Marnane
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Eoin Kavanagh
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Gerald Sheehan
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
| | - Séan Murphy
- Department of Neurology (LW, MM), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Radiology (FD, EK), Mater Misericordiae University Hospital, Dublin, Ireland; Department of Stroke Medicine (GK, SM), Mater Misericordiae University Hospital, Dublin, Ireland; and Department of Infectious Diseases (GS), Mater Misericordiaae University Hospital, Dublin, Ireland
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14
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Progressive triple cervical artery dissection in association with upper respiratory tract infection. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Hunter MD, Moon YP, Miller EC, Kulick ER, Boehme AK, Elkind MS. Influenza-Like Illness is Associated with Increased Short-Term Risk of Cervical Artery Dissection. J Stroke Cerebrovasc Dis 2021; 30:105490. [PMID: 33253984 PMCID: PMC10086675 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION Non-traumatic Cervical Artery Dissection (CeAD) is a leading cause of ischemic stroke in the young. Influenza-like illnesses (ILI) trigger ischemic strokes. We hypothesized that influenza and ILI are associated with CeAD. METHODS In a case-crossover study within the New York State (NYS) Department of Health Statewide Planning and Research Cooperative System (2006-2014), we used ICD-9 codes to exclude major trauma and to define CeAD, influenza, and the Centers for Disease Control defined ILI. We estimated the association of ILI and influenza with CeAD by comparing their prevalence in intervals immediately prior (0-30,0-90,0-180, and 0-365 days) to CeAD (case period) to their prevalence exactly one and two years earlier (control periods). Conditional logistic regression models generated odds ratios and 95% confidence intervals (OR, 95% CI). Models were adjusted for NYS estimates of influenza prevalence rates. RESULTS Our sample included 3,610 cases of CeAD (mean age 52±16 years, 54.7% male, 6.2% Hispanic, 9.9% Black, 68.7% White). During case periods, 7.3% had one or more ILI. ILI was more likely within 90 days of CeAD compared to the same time interval one and two years before (0-15 days: adjusted OR 1.88, 95%CI 1.20-2.94; 0-30 days: adjusted OR 1.74, 95%CI 1.22-2.46; 0-90 days: adjusted OR 1.35, 95%CI 1.00-1.81). Influenza trended with CeAD (adjusted OR 1.86, 95%CI 0.37-9.24), but these results were not statistically significant, due to limited instances of confirmed influenza. CONCLUSIONS ILI may increase risk of CeAD for 15 days, and possibly up to three months.
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Affiliation(s)
- Madeleine D Hunter
- Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA; Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA.
| | - Yeseon P Moon
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA; Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA.
| | - Eliza C Miller
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA; Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA.
| | - Erin R Kulick
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA; Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA.
| | - Amelia K Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA; Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, NY, USA.
| | - Mitchell Sv Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA; Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, NY, USA.
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16
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Asan L, Deuschl C, Forsting M, Kleinschnitz C, Köhrmann M. Oropharyngeal swab for SARS-CoV-2 test causing atypical internal carotid artery dissection and stroke in a patient after mild COVID-19. Ther Adv Neurol Disord 2021; 14:17562864211033521. [PMID: 35173807 PMCID: PMC8842151 DOI: 10.1177/17562864211033521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/30/2021] [Indexed: 11/21/2022] Open
Abstract
We report a patient who had recovered from pneumonia caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) presenting with acute cerebral ischemia due to
atypical dissection of the left internal carotid artery immediately after an oropharyngeal
swab (OPS) for SARS-CoV-2 RT-PCR testing. The symptoms consisting of right-side
hemiparesis and aphasia improved after systemic thrombolysis and the patient recovered
completely in the further course. We demonstrate findings from imaging (computed
tomography, magnetic resonance imaging, neurovascular ultrasound) among other
investigations and discuss coronavirus disease 2019 (COVID-19)-related vessel wall
vulnerability as well as tissue injury posed by the swab procedure as underlying causes of
the dissection. Individuals performing OPSs during the corona pandemic should be aware of
this so far undescribed complication.
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Affiliation(s)
- Livia Asan
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, Essen, 45147, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Essen, Germany
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17
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Sun G, Yang Y, Chen Z, Yang L, Diao S, Huang S, Wang Y, Wang Y, Sun B, Yuan X, Xu X. Neutrophil to Lymphocyte Ratio Predicts Outcome of Stroke by Cervicocranial Arterial Dissection. Front Med (Lausanne) 2020; 7:598055. [PMID: 33330561 PMCID: PMC7729127 DOI: 10.3389/fmed.2020.598055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 11/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose: Neutrophil to lymphocyte ratio (NLR) is positively associated with poor prognosis in patients with cerebral infarction. The goal of this prospective study is to explore the predictive value of NLR in patients with acute ischemic stroke (AIS) caused by cervicocranial arterial dissection (CCAD). Methods: Ninety-nine patients with AIS caused by CCAD met criteria for inclusion and exclusion were selected for this study. We collected baseline data on the admission including NLR. The primary poor outcome was major disability (modified Rankin Scale score ≥ 3) or death at 3 months after AIS. Results: A total of 20 (20.2%) patients had a poor outcome at 3 months after AIS. According to the 3-month outcome, the patients were divided into two groups and univariate and multivariable analyses were conducted. Among the risk factors, elevated NLR levels were independently associated with 3-month poor outcomes. Further, we made the ROC curve to evaluate the predictive value of NLR level on prognosis. The area under the curve was 0.79 and a cut-off value of NLR was 2.97 for differentiating the poor outcome. We divided patients into groups according to the cut-off value. Patients with high NLR have a higher risk of poor outcome than those with low NLR (P < 0.05). Conclusion: As an inflammatory marker, elevated NLR levels were associated with 3-month poor outcome in AIS caused by CCAD.
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Affiliation(s)
- Guangbi Sun
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yi Yang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhiguo Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Le Yang
- School of Public Health, Fujian Medical University, Fuzhou, China
| | - Shanshan Diao
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shicun Huang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiqing Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiting Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Baoliang Sun
- Department of Neurology, The Second Affiliated Hospital, Shandong Academy of Medical Sciences, Shandong First Medical University, Taian, China
| | - Xia Yuan
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xingshun Xu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China.,The Institute of Neuroscience, Soochow University, Suzhou, China
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18
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Tai MLS, Sia SF, Kadir KAA, Idris MI, Tan KS. Cough-Induced Extracranial Internal Carotid Artery Dissection. Case Rep Neurol 2020; 12:149-155. [PMID: 33505287 DOI: 10.1159/000501069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/16/2019] [Indexed: 11/19/2022] Open
Abstract
Background Coughing due to respiratory tract infections may lead to internal carotid artery (ICA) dissection. Aim We are presenting a patient with an unusual cough-induced ICA dissection. Case Report A 42-year-old health care worker presented with bilateral hand numbness which resolved spontaneously. This initial episode was followed 9 days later with intermittent episodes of right hand and leg weakness with speech difficulty. Two days later, he had another episode of speech difficulty. One week prior to the first presentation, he had upper respiratory tract infection with ongoing strong bouts of coughing. Magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) of the brain showed early ischaemic changes at the left frontal and left parietal regions. MR angiography (MRA) showed high signal intensity at the left proximal ICA and poor flow beyond the left carotid bulb. Cerebral angiography revealed left ICA dissection. Conclusion Proper identification of cough-induced extracranial ICA dissection is important because this is treatable.
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Affiliation(s)
- Mei-Ling Sharon Tai
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sheau Fung Sia
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khairul Azmi Abdul Kadir
- Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohamad Imran Idris
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kay Sin Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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19
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Qiu FQ, Li CC, Zhou JY. Hemorrhagic fever with renal syndrome complicated with aortic dissection: A case report. World J Clin Cases 2020; 8:5795-5801. [PMID: 33344576 PMCID: PMC7716303 DOI: 10.12998/wjcc.v8.i22.5795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/13/2020] [Accepted: 09/22/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hemorrhagic fever with renal syndrome is caused by hantaviruses presenting with high fever, hemorrhage, and acute kidney injury. Microvascular injury and hemorrhage in mucus were often observed in patients with hantavirus infection. Infection with bacterial and virus related aortic aneurysm or dissection occurs sporadically. Here, we report a previously unreported case of hemorrhagic fever with concurrent aortic dissection.
CASE SUMMARY A 56-year-old man complained of high fever and generalized body ache, with decreased platelet counts of 10 × 109/L and acute kidney injury. The enzyme-linked immunosorbent assays test for immunoglobulin M and immunoglobulin G hantavirus-specific antibodies were both positive. During the convalescent period, he complained sudden onset acute chest pain radiating to the back, and the computed tomography angiography revealed an aortic dissection of the descending aorta extending to iliac artery. He was diagnosed with hemorrhagic fever with renal syndrome and Stanford B aortic dissection. The patient recovered completely after surgery with other support treatments.
CONCLUSION Hemorrhagic fever with renal syndrome complicated with aortic dissection is rare and a difficult clinical condition. Hantavirus infection not only causes microvascular damage presenting with hemorrhage but may be risk factor for acute macrovascular detriment. A causal relationship has yet to be confirmed.
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Affiliation(s)
- Feng-Qi Qiu
- Department of Respiratory Disease, Thoracic Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Cong-Cong Li
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
| | - Jian-Ya Zhou
- Department of Respiratory Disease, Thoracic Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310000, Zhejiang Province, China
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20
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Shivakumar N, Rajagopal R, Norris JH, Martinez-Devesa P. Non-Traumatic Carotid Artery Dissection Following an Episode of Orbital Cellulitis: A Case Report. Cureus 2020; 12:e11175. [PMID: 33262912 PMCID: PMC7689807 DOI: 10.7759/cureus.11175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Carotid artery dissection (CAD) is a haemorrhage into the arterial wall disrupting the intimal layers of the vessel. We present a case of a 16-year-old male with a non-traumatic spontaneous CAD. The patient presented with Horner's syndrome following an episode of orbital cellulitis secondary to sinusitis requiring sinus drainage surgery. Subsequent magnetic resonance imaging (MRI) revealed a CAD. The patient was treated with antiplatelet medication.
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Affiliation(s)
- Natesh Shivakumar
- Otolaryngology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Rajini Rajagopal
- Otolaryngology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Jonathan H Norris
- Ophthalmology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Pablo Martinez-Devesa
- Otolaryngology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
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21
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Katsi V, Antoniou CK, Manolakou P, Toutouzas K, Tousoulis D. What's in a prick? Vaccines and the cardiovascular system. Hellenic J Cardiol 2020; 61:233-240. [PMID: 31740362 DOI: 10.1016/j.hjc.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 07/22/2019] [Accepted: 09/28/2019] [Indexed: 12/24/2022] Open
Abstract
Evidence suggests a crucial role for vaccines in cardiovascular disease, mediated not only by disease prevention but also by immunomodulatory effects. This review attempts to briefly present the effects of pathogens and vaccines on the cardiovascular system and potential mechanisms for the development of vaccines against cardiovascular diseases per se. Current epidemiological evidence regarding vaccine effectiveness in different categories of heart disease is discussed, as well as current international guidelines' recommendations. In summary, cardiologists should strive to promote vaccination against specific pathogens with proven beneficial effects on cardiovascular diseases.
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Affiliation(s)
- Vasiliki Katsi
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | | | - Panagiota Manolakou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
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22
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Rodríguez-Castro E, Mosqueira AJ, Santamaría-Cadavid M, Arias-Rivas S. [Progressive triple dissection of the cervical arteries in association with upper respiratory tract infection]. Neurologia 2020; 36:177-179. [PMID: 32565038 DOI: 10.1016/j.nrl.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/20/2019] [Accepted: 12/14/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- E Rodríguez-Castro
- Unidad de Ictus, Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España.
| | - A J Mosqueira
- Unidad de Neurorradiología, Servicio de Radiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España
| | - M Santamaría-Cadavid
- Unidad de Ictus, Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España
| | - S Arias-Rivas
- Unidad de Ictus, Servicio de Neurología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España
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23
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Morassi M, Bigni B, Cobelli M, Giudice L, Bnà C, Vogrig A. Bilateral carotid artery dissection in a SARS-CoV-2 infected patient: causality or coincidence? J Neurol 2020; 267:2812-2814. [PMID: 32533323 PMCID: PMC7292240 DOI: 10.1007/s00415-020-09984-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Mauro Morassi
- Department of Diagnostic Imaging, Unit of Neuroradiology, Fondazione Poliambulanza Istituto Ospedaliero, Via L. Bissolati 57, 25124, Brescia, Italy.
| | - Barbara Bigni
- Head and Neck Department, Unit of Neurology, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Milena Cobelli
- Department of Diagnostic Imaging, Unit of Neuroradiology, Fondazione Poliambulanza Istituto Ospedaliero, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Lodoviga Giudice
- Head and Neck Department, Unit of Neurosurgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Claudio Bnà
- Department of Diagnostic Imaging, Unit of Radiology, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Alberto Vogrig
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero, Santa Maria della Misericordia, Udine, Italy
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Abstract
PURPOSE OF REVIEW Although the clinical approach to the young adult stroke patient is similar to that of an older adult, several important differences exist. The purpose of this article is to concisely review the epidemiology, pathophysiology, risk factors, clinical manifestations, diagnostic methods and current treatment options for the young adult ischemic stroke patient. RECENT FINDINGS Evidence clearly indicates that the incidence ischemic stroke in young adults is on the rise. A variety of factors are implicated, including an increased burden of classic and emerging vascular risk factors, and improved stroke detection, among other causes. Improved awareness, prevention and successful treatment of the young adult stroke patient is of great importance, particularly given the major long-term socioeconomic impact strokes have on the patient, their family and society at large. SUMMARY In this review, we focus on the latest epidemiologic, diagnostic and treatment paradigms to improve physician awareness and optimize outcomes in young adult ischemic stroke patients. An overview of the clinical presentations of various stroke syndromes is described, emphasizing key causes physicians should consider, as well as providing recommendations regarding evaluation and treatment. Important causes including dissection and inflammatory and noninflammatory vasculopathies are emphasized. The diagnoses of cerebral venous thromboses, cardioembolic stroke and paradoxical emboli are also discussed. The effects of established and emerging risk factors on large and small vessel disease, as well as genetic contributions, are also highlighted.
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25
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Bakradze E, Kirchoff KF, Antoniello D, Springer MV, Mabie PC, Esenwa CC, Labovitz DL, Liberman AL. Varicella Zoster Virus Vasculitis and Adult Cerebrovascular Disease. Neurohospitalist 2019; 9:203-208. [PMID: 31534609 PMCID: PMC6739663 DOI: 10.1177/1941874419845732] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The role of Varicella zoster virus (VZV) in neurological illness, particularly cerebrovascular disease, has been increasingly recognized. Primary infection by VZV causes varicella (chickenpox), after which the virus remains latent in neuronal ganglia. Later, during aging or immunosuppression, the virus can reactivate causing zoster (shingles). Virus reactivation can also spread to cerebral arteries causing vasculitis and stroke. Zoster is a recognized risk factor for stroke, but stroke can occur without preceding zoster rash. The diagnosis of VZV cerebral vasculitis is established by abnormal brain imaging and confirmed by presence of viral DNA or anti-VZV antibodies in cerebrospinal fluid. Treatment with acyclovir with or without prednisone is usually recommended. VZV vasculitis is a unique and uncommon stroke mechanism that has been under recognized. Careful diagnostic investigation may be warranted in a subgroup of patients with ischemic stroke to detect VZV vasculitis and initiate appropriate therapy. In the following review, we detail the clinical presentation of VZV vasculitis, diagnostic challenges in VZV detection, and suggest the ways to enhance recognition and treatment of this uncommon disease.
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Affiliation(s)
- Ekaterina Bakradze
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kathryn F. Kirchoff
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Antoniello
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Peter C. Mabie
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Charles C. Esenwa
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel L. Labovitz
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ava L. Liberman
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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26
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Chen WT, Chang FC, Huang HC, Tsai JY, Chung CP. Total and differential leukocyte counts in ischemic stroke caused by vertebrobasilar artery dissection. J Neurol Sci 2019; 404:101-105. [PMID: 31352292 DOI: 10.1016/j.jns.2019.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/21/2019] [Accepted: 07/17/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Vertebrobasilar artery dissection(VBD) is a common etiology of posterior circulation stroke(PCS). However, the etiology of VBD itself remains unclear. The present study aimed to test whether inflammation is involved in the mechanism of VBD by evaluating its relationship with total and differential leukocyte counts. METHODS Patients with PCS caused by VBD or by large artery atherosclerosis(LAA) were recruited between January 1, 2012 and December 31, 2014 from the Taipei Veterans General Hospital. Age- and sex-matched non-stroke(NS) volunteers were also included. Univariate and multivariate analyses were performed to compare total/differential leukocyte counts among VBD, LAA, and NS groups. RESULTS One-hundred-one patients with VBD [average age: 64.8(15.1) years; 77(76.2%) males], 70 with LAA [average age: 73.9(10.6) years; 44(62.9%) males], and 202 NS [average age: 64.8(15.1) years; 77(76.2%) males] patients were included in the present study. Compared with the NS and LAA groups, respectively, the VBD group had significantly higher total leukocyte and neutrophil counts and frequency of high leukocyte (>10,000 × 106/L) and high neutrophil (>8000 × 106/L) counts. Multivariate analyses, adjusted for age, sex, and vascular risk factors, showed that the VBD group, compared with the other groups, had an odds-ratio of 5.04 (95% confidence interval:2.43-10.43) and 5.90 (2.70-12.92) with respect to the prevalence of high leukocyte and high neutrophil counts. CONCLUSION VBD was associated with high leukocyte and neutrophil counts. Our results support that inflammation and neutrophil-related pathophysiology might be involved in the mechanism of VBD; however, the causal relationship would need further investigations.
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Affiliation(s)
- Wan-Ting Chen
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Feng-Chi Chang
- Department Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hui-Chi Huang
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jui-Yao Tsai
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Ping Chung
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan.
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Pashaei-Marandi A, Kini A, Al Othman B, Lee AG, Falardeau J. The sign of the cross. Surv Ophthalmol 2019; 66:145-148. [PMID: 31129261 DOI: 10.1016/j.survophthal.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 10/26/2022]
Abstract
Acute, painful, transient, right-sided, monocular visual loss lasting 4 hours developed in a 46-year-old man. This was followed by headache and left-sided transient hemiparesis. The association of ipsilateral transient vision loss with transient contralateral hemiparesis implicates involvement of the ipsilateral internal carotid artery (i.e., a crossed symptom).
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Affiliation(s)
| | - Ashwini Kini
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Bayan Al Othman
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA; Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York, USA.
| | - Julie Falardeau
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA
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28
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Coburn JA, Golden E, Brucker J, Kennedy TA. Nontraumatic Vascular Emergencies of the Neck. Semin Ultrasound CT MR 2019; 40:157-171. [PMID: 31030739 DOI: 10.1053/j.sult.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Nontraumatic vascular emergencies of the head and neck are uncommon, but can occur in patients with central venous catheters, head and neck infections, and in patients with head and neck cancer. Recognizing the imaging findings of vascular complications in these patient populations is critically important to ensure expeditious treatment to avoid significant morbidity and mortality.
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Affiliation(s)
- John A Coburn
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Edwarda Golden
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Justin Brucker
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Tabassum A Kennedy
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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McCrea N, Fullerton HJ, Ganesan V. Genetic and Environmental Associations With Pediatric Cerebral Arteriopathy. Stroke 2019; 50:257-265. [DOI: 10.1161/strokeaha.118.020479] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Nadine McCrea
- From the Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London (N.M.)
| | | | - Vijeya Ganesan
- Clinical Neurosciences, UCL Great Ormond Street Institute of Child Health, London (V.G.)
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Mélé N, Turc G. Stroke Associated With Recent Mycoplasma Pneumoniae Infection: A Systematic Review of Clinical Features and Presumed Pathophysiological Mechanisms. Front Neurol 2018; 9:1109. [PMID: 30622505 PMCID: PMC6308181 DOI: 10.3389/fneur.2018.01109] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 12/04/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: An association between Mycoplasma pneumoniae (MP) infection and stroke has been described, especially in children. However, current knowledge on this rare potential cause of stroke is scant. The purpose of this systematic review of all published cases was to help better understand the relationships between recent MP infection and ischemic stroke on a clinical, radiological and pathophysiological perspective. Material and Methods: A PubMed and Embase search was performed in September 2018 to identify all published cases of stroke occurring within 4 weeks after MP infection. Results: Twenty-eight patients with ischemic stroke associated with MP infection were identified. Median age was 8 years (range: neonate to 57). The middle cerebral artery territory was involved in 25 (89%) patients. Fifteen (54%) patients had at least one arterial occlusion. Elevated D-dimer and/or fibrinogen was reported in 8 (29%) patients. Four patients had transient anticardiolipin IgM antibodies. Cerebrospinal fluid analysis showed pleocytosis in 7/20 (35%) patients (median: 19 leucocytes/μL, range: 10 to 63) and MP PCR was positive in 3/8 (38%) patients. The etiological work-up was considered inconclusive in 25 (89%) patients. Three (11%) patients died during follow-up, all of early respiratory deterioration. Neurological functional outcome was good in 22/27 (81%) patients. Conclusion: The association between MP infection and ischemic stroke in children and young adults is rare. Underlying pathogenesis might include hypercoagulability and vasculitis. Most patients achieve a favorable recovery. Whether MP infection could be a long-term risk factor for stroke by promoting atherosclerosis is uncertain and deserves further investigation.
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Affiliation(s)
- Nicolas Mélé
- Service de Neurologie, Centre Hospitalier Sainte-Anne, Paris, France.,Université Paris Descartes, Paris, France.,INSERM UMR 894, Paris, France.,DHU Neurovasc, Paris, France
| | - Guillaume Turc
- Service de Neurologie, Centre Hospitalier Sainte-Anne, Paris, France.,Université Paris Descartes, Paris, France.,INSERM UMR 894, Paris, France.,DHU Neurovasc, Paris, France
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Compter A, Schilling S, Vaineau CJ, Goeggel-Simonetti B, Metso TM, Southerland A, Pezzini A, Kloss M, Touzé E, Worrall BB, Thijs V, Bejot Y, Reiner P, Grond-Ginsbach C, Bersano A, Brandt T, Caso V, Lyrer PA, Traenka C, Lichy C, Martin JJ, Leys D, Sarikaya H, Baumgartner RW, Jung S, Fischer U, Engelter ST, Dallongeville J, Chabriat H, Tatlisumak T, Bousser MG, Arnold M, Debette S. Determinants and outcome of multiple and early recurrent cervical artery dissections. Neurology 2018; 91:e769-e780. [DOI: 10.1212/wnl.0000000000006037] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/21/2018] [Indexed: 01/25/2023] Open
Abstract
ObjectiveTo assess putative risk factors and outcome of multiple and early recurrent cervical artery dissection (CeAD).MethodsWe combined data from 2 multicenter cohorts and compared patients with multiple CeAD at initial diagnosis, early recurrent CeAD within 3 to 6 months, and single nonrecurrent CeAD. Putative risk factors, clinical characteristics, functional outcome, and risk of recurrent ischemic events were assessed.ResultsOf 1,958 patients with CeAD (mean ± SD age 44.3 ± 10 years, 43.9% women), 1,588 (81.1%) had single nonrecurrent CeAD, 340 (17.4%) had multiple CeAD, and 30 (1.5%) presented with single CeAD at admission and had early recurrent CeAD. Patients with multiple or early recurrent CeAD did not significantly differ with respect to putative risk factors, clinical presentation, and outcome. In multivariable analyses, patients with multiple or early recurrent CeAD more often had recent infection (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.29–2.53), vertebral artery dissection (OR 1.82, 95% CI 1.34–2.46), family history of stroke (OR 1.55, 95% CI 1.06–2.25), cervical pain (OR 1.36, 95% CI 1.01–1.84), and subarachnoid hemorrhage (OR 2.85, 95% CI 1.01–8.04) at initial presentation compared to patients with single nonrecurrent CeAD. Patients with multiple or early recurrent CeAD also had a higher incidence of cerebral ischemia (hazard ratio 2.77, 95% CI 1.49–5.14) at 3 to 6 months but no difference in functional outcome compared to patients with single nonrecurrent CeAD.ConclusionPatients with multiple and early recurrent CeAD share similar risk factors, clinical characteristics, and functional outcome. Compared to patients with single nonrecurrent CeAD, they are more likely to have recurrent cerebral ischemia at 3 to 6 months, possibly reflecting an underlying transient vasculopathy.
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Demetrious JS. Spontaneous cervical artery dissection: a fluoroquinolone induced connective tissue disorder? Chiropr Man Therap 2018; 26:22. [PMID: 30002812 PMCID: PMC6036697 DOI: 10.1186/s12998-018-0193-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/01/2018] [Indexed: 11/12/2022] Open
Abstract
Background Spontaneous cervical artery dissections more often manifest in young people and have been associated with catastrophic consequences. Some indeterminate risk factors have been identified, making the diagnosis of developing dissections quite difficult. Fluoroquinolone antibiotics have been recognized for their degradative effects on connective tissue. Recent studies have implicated fluoroquinolones in the genesis of aortic artery aneurysms. It is the purpose of this paper to provide reasoning for a testable hypothesis of whether fluoroquinolones constitute a risk factor associated with cervical artery dissections. Methods A PubMed search was conducted to investigate whether cervical artery dissection has been associated with fluoroquinolone use. An assessment of risk factors was made of hereditary connective tissue disorders, infection, and seasonal predisposition related to cervical artery dissection. These factors were considered in conjunction with reports of connective tissue toxicity associated with fluoroquinolone medications. Results It appears that no reported cases of cervical artery dissection have previously been correlated with fluoroquinolone use. Heritable connective tissue disorders, infection, seasonal predisposition and condition latencies are associated with fluoroquinolone medications. Several recent articles have implicated fluoroquinolones with aortic dissections and aneurysm. Conclusion A causal relationship of fluoroquinolone antibiotics to cervical artery dissection is plausible. The suppositions developed in this paper are insufficient to suggest that fluoroquinolones currently represent an established risk factor in the development of cervical artery dissections. Fluoroquinolones may indeed be a novel and previously unrecognized cause of cervical artery dissections.
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Turner RC, Lucke-Wold BP, Boo S, Rosen CL, Sedney CL. The potential dangers of neck manipulation & risk for dissection and devastating stroke: An illustrative case & review of the literature. BIOMEDICAL RESEARCH AND REVIEWS 2018; 2:10.15761/BRR.1000110. [PMID: 29951644 PMCID: PMC6016850 DOI: 10.15761/brr.1000110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chiropractic cervical manipulation is a common practice utilized around the world. Most patients are never cleared medically for manipulation, which can be devastating for those few who are at increased risk for dissections. The high velocity thrust used in cervical manipulation can produce significant strain on carotid and vertebral vessels. Once a dissection has occurred, the risk of thrombus formation, ischemic stroke, paralysis, and even death is drastically increased. In this case report, we highlight a case of a 32-year-old woman who underwent chiropractic manipulation and had vertebral artery dissection with subsequent brainstem infarct. She quickly deteriorated and passed away shortly after arrival to the hospital. Although rare, one in 48 chiropractors have experienced such an event. We utilize this case to highlight the risk associated with cervical manipulation and urge open dialogue between chiropractors and physicians. Receiving medical clearance prior to cervical manipulation in potential at risk patients would drastically reduce morbidity and mortality.
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Affiliation(s)
- Ryan C Turner
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, West Virginia
- West Virginia Clinical & Translational Science Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Brandon P Lucke-Wold
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, West Virginia
- West Virginia Clinical & Translational Science Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Sohyun Boo
- Department of Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Charles L Rosen
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, West Virginia
- West Virginia Clinical & Translational Science Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Cara L Sedney
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia
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Millet JD, Cavallo JJ, Scoutt LM, Gunabushanam G. Sonographic Evaluation of Complications of Extracranial Carotid Artery Interventions. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:769-781. [PMID: 28877355 DOI: 10.1002/jum.14376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 06/07/2023]
Abstract
Carotid endarterectomy and carotid artery stenting are among the most common peripheral vascular procedures performed worldwide. Sonography is the initial and often only imaging modality used in the evaluation of iatrogenic carotid arterial injuries. This pictorial essay provides an overview of the clinical and sonographic findings of complications after interventions in the extracranial carotid arteries, including dissection, fluid collections, pseudoaneurysm, thrombosis, thromboembolism, restenosis, and stent deformation. Grayscale, color, and pulsed Doppler imaging findings are reviewed, and correlations with computed tomography, magnetic resonance imaging, and angiography are provided.
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Affiliation(s)
- John D Millet
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Joseph J Cavallo
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Leslie M Scoutt
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gowthaman Gunabushanam
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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University education and cervical artery dissection. J Neurol 2018; 265:1065-1070. [DOI: 10.1007/s00415-018-8798-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/08/2018] [Accepted: 02/12/2018] [Indexed: 10/18/2022]
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Narula N, Siddiqui F, Katyal N, Avula A, Chalhoub M. Internal Carotid Artery Dissection with Lidocaine Nerve Block Injection Trauma: A Rare Case Report. Cureus 2018. [PMID: 29531880 PMCID: PMC5837233 DOI: 10.7759/cureus.2027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Internal carotid artery dissection (ICAD) accounts for 25% of cerebrovascular accidents in young and middle-aged patients. Dissection occurs when the intimal wall of an artery is damaged as a result of trauma or defect. ICAD development after dental work is a relatively uncommon phenomenon. Our study highlights a rare presentation of ICAD that resulted from a direct lidocaine nerve block injection in a patient undergoing pulpotomy for a right maxillary second premolar tooth. We have described the case and reviewed the literature on this rare but potentially life-threatening phenomenon.
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Affiliation(s)
| | - Faraz Siddiqui
- Pulmonary and Critical Care, Staten Island University Hospital
| | | | - Akshay Avula
- Pulmonary and Critical Care, Staten Island University Hospital
| | - Michel Chalhoub
- Pulmonary and Critical Care, Staten Island University Hospital
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Spontaneous cervical artery dissection is accompanied by a hypercoagulable state and simultaneous inflammatory condition. J Neurol 2017; 265:308-314. [DOI: 10.1007/s00415-017-8696-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 12/26/2022]
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Abstract
OPINION STATEMENT Optimal diagnosis and management of stroke in young adults benefit from a multidisciplinary team, including a vascular neurology specialist. In addition to the "standard" vascular risk factors including smoking, hypertension, diabetes, and hyperlipidemia, one needs to consider alternative etiologies including substance abuse, carotid/vertebral artery dissections, and rare genetic conditions among others. Once a young patient is determined to have had a stroke, the next question a clinician should ask is why did this patient have a stroke? A "heart to head" diagnostic approach is recommended. A thorough history is performed, including a detailed family history with specific annotations on each family member. A thorough physical examination is necessary including a careful evaluation of the patient's general appearance, noting any joint laxity, and/or abnormalities of the skin, eyes, and heart. Findings across multiple organ systems in the patient and/or their family may indicate a genetic etiology. After an initial head CT rules out hemorrhagic stroke, additional testing should include a brain MRI, neck and cerebral vascular imaging (e.g., CTA for head and neck), transthoracic echocardiogram with a bubble study, telemetry monitoring, basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen), and, when appropriate, sickle screen and pregnancy test. There should be a low threshold to obtain blood cultures or a lumbar puncture. The acute treatment of ischemic stroke in young adult patients does not differ from treatment of older adults, using intravenous alteplase within 4.5 h, assuming no contraindications. In suspected proximal large artery occlusive disease, interventional clot extraction procedures should be employed in patients deemed eligible. Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted. The mainstay of preventative therapy is aspirin for most etiologies; however, for atrial fibrillation, anticoagulation is recommended. Statin therapy is another pharmacologic intervention recommended in most stroke patients. Other measures employed are blood pressure reduction, smoking cessation, optimal glucose control in diabetic patients, the initiation of a healthy diet and regular exercise, and lastly, substance abuse counseling in appropriate patients.
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Affiliation(s)
- Christopher A Stack
- Department of Neurology, University of Maryland Medical Center, 16 South Eutaw Street Suite 300, Baltimore, MD, 21201, USA
| | - John W Cole
- Department of Neurology, Baltimore VA Medical Center, University of Maryland School of Medicine, 12th Floor, Bressler Building, Room 12-006, 655 West Baltimore Street, Baltimore, MD, 21201-1559, USA.
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CHEN YAN, FANG YIBIN, YANG PENGFEI, HUANG QINGHAI, LIU JIANMIN. WHICH MORPHOLOGIC AND HEMODYNAMIC CHARACTERISTICS PREDICT INTRACRANIAL FUSIFORM ANEURYSMS RUPTURE? A PATIENT-SPECIFIC COMPUTATIONAL FLUID DYNAMICS STUDY. J MECH MED BIOL 2017. [DOI: 10.1142/s0219519417500701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To identify hemodynamic and morphological parameters leading to increased risk of intracranial fusiform aneurysms (IFA) rupture using computational fluid dynamics (CFDs). A total of 24 patient-specific fusiform aneurysms models on vertebral artery were reconstructed from 3D angiography images. 11 ruptured cases and 13 unruptured cases were included. Morphologic parameters were measured and CFD parameters were calculated using CFD simulation. The length of the aneurysm is significantly shorter in ruptured group than in unruptured group. The ratio of the width to the length of an aneurysm (WLR) and the ratio of the cross-section area to the length of an aneurysm (ALR) to the averaged cross sectional areas of the inlet and outlet of the parent artery (ALaR) were significantly higher in ruptured group compared with unruptured group. Wall shear stress (WSS) of the aneurysm was normalized to the WSS of the parent artery. Hemodynamically, only low WSS was associated with higher risk of rupture. Ruptured IFAs are shorter, have bigger WLR, ALaR, and lower WSS, compared with unruptured IFAs.
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Affiliation(s)
- YAN CHEN
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P. R. China
| | - YI-BIN FANG
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P. R. China
| | - PENG-FEI YANG
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P. R. China
| | - QING-HAI HUANG
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P. R. China
| | - JIAN-MIN LIU
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, P. R. China
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Noguchi K, Aoki T, Sakamoto R, Orito K, Takeuchi Y, Hirohata M, Morioka M. Bilateral Internal Carotid Artery Aneurysms at the Subpetrosal Portion with Unilateral Lower Cranial Nerve Palsies: Review and Consideration of Surgical Strategy. J Stroke Cerebrovasc Dis 2017; 26:e55-e59. [PMID: 28162904 DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 11/30/2016] [Accepted: 12/28/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Symptomatic bilateral extracranial internal carotid artery (ICA) aneurysms at the subpetrosal portion are extremely rare, and their treatment strategy remains unknown. CLINICAL PRESENTATION A 42-year-old man presented to our hospital with a 2-month history of sudden onset of hoarseness, dysarthria, and dysphagia. Magnetic resonance imaging, magnetic resonance angiography, and computed tomography angiography revealed extracranial bilateral ICA aneurysms at the subpetrosal portion. The left-sided aneurysm compressed the left-sided lower cranial nerves (IX, X, XI, and XII), whereas the right-sided aneurysm was asymptomatic. We prioritized the treatment of the right-sided aneurysm to prevent bilateral lower cranial nerve deficits. This strategy was used because aneurysm treatment is not guaranteed to cure the left-sided cranial nerve palsies that lasted for 2 months. The right-sided ICA aneurysm was treated with ICA ligation and high-flow extracranial-intracranial bypass using the radial artery as bypass graft. Stent-assisted coil embolization was performed to the left-sided ICA aneurysm after 17 days. The patient showed no right-sided symptoms, and his left-sided symptoms remarkably improved 1 year after surgery. CONCLUSION Our unique surgical strategy of prioritizing the aneurysm on the "asymptomatic" side may be one of the best treatment approaches in an extremely rare bilateral aneurysm case.
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Affiliation(s)
- Kei Noguchi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan.
| | - Takachika Aoki
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Rokudai Sakamoto
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Kimihiko Orito
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Yasuharu Takeuchi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Masaru Hirohata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
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Thomas LC, Makaroff AP, Oldmeadow C, Attia JR, Levi CR. Seasonal variation in cervical artery dissection in the Hunter New England region, New South Wales, Australia: A retrospective cohort study. Musculoskelet Sci Pract 2017; 27:106-111. [PMID: 27852529 DOI: 10.1016/j.math.2016.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/17/2016] [Accepted: 10/19/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cervical artery dissection (CAD) is a leading cause of ischemic stroke among middle aged adults, yet the aetiology remains poorly understood. There are reports from colder northern hemisphere sites of a seasonal pattern in the incidence of CAD. Seasonality may suggest some transient putative pro-inflammatory mechanism but it is unknown whether this also exists in temperate climates. AIMS To investigate the seasonal variation in incidence of CAD in the xx Region, Australia, and to compare seasonal incidence and selected clinical features between cases of carotid and vertebral artery dissection. METHODS This retrospective observational study investigated seasonal variation in CAD from a regional stroke register between 2006 and 2014. Clinical features and site of dissection were dichotomized into autumn-winter and spring-summer groups and compared with Chi2 analysis. RESULTS 61 CAD events were identified. A strong trend was identified for CAD to occur more frequently in autumn-winter compared to spring-summer (38, 62.30% vs. 23, 37.70%; p = 0.054). Males were significantly more likely to present with vertebral artery dissection (VAD) than females (27, 73.0% vs 10, 41.7%; p = 0.014). A history of mild trauma was more common in VAD than internal carotid artery dissection (ICAD) (14, 41.2% vs 3, 13.0%; p = 0.023). Cases of VAD were more likely to have had an elevated white cell count than ICAD (16, 47.1% vs 5, 20.8%; p = 0.041). CONCLUSIONS The findings suggest seasonal variation in the CAD incidence in a temperate region of Australia. Clinicians should be vigilant for CAD or risk of CAD during the colder months.
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Affiliation(s)
- Lucy C Thomas
- Faculty of Health and Medicine, The University of Newcastle, Australia; Faculty of Health and Rehabilitation Sciences, The University of Queensland, Australia.
| | - Andrew P Makaroff
- Faculty of Health and Medicine, The University of Newcastle, Australia
| | | | - John R Attia
- Faculty of Health and Medicine, The University of Newcastle, Australia; Hunter Medical Research Institute, Newcastle, Australia
| | - Christopher R Levi
- Faculty of Health and Medicine, The University of Newcastle, Australia; Hunter Medical Research Institute, Newcastle, Australia
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Thomas LC, Hall LA, Attia JR, Holliday EG, Markus HS, Levi CR. Seasonal Variation in Spontaneous Cervical Artery Dissection: Comparing between UK and Australian Sites. J Stroke Cerebrovasc Dis 2017; 26:177-185. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/03/2016] [Indexed: 11/24/2022] Open
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Affiliation(s)
- Thomas B Stoker
- Core Medical Trainee, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge
| | - Nicholas R Evans
- Clinical Research Fellow, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ
| | - Elizabeth A Warburton
- Consultant Stroke Physician, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge
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Vaughan B, Moran R, Tehan P, Fryer G, Holmes M, Vogel S, Taylor A. Manual therapy and cervical artery dysfunction: Identification of potential risk factors in clinical encounters. INT J OSTEOPATH MED 2016. [DOI: 10.1016/j.ijosm.2016.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cervical arterial dissection: An overview and implications for manipulative therapy practice. ACTA ACUST UNITED AC 2016; 21:2-9. [DOI: 10.1016/j.math.2015.07.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 06/24/2015] [Accepted: 07/19/2015] [Indexed: 11/23/2022]
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Abstract
Cervical artery dissection (CAD) may affect the internal carotid and/or the vertebral arteries. CAD is the leading cause of ischemic stroke in patients younger than 45 years. Specific treatment (aspirin or anticoagulants) can be implemented once the diagnosis of CAD has been confirmed. This diagnosis is based on detection of a mural haematoma on ultrasound or on MRI. The diagnosis can be suspected on contrast-enhanced MRA (magnetic resonance angiography) or CT angiography, in case of long stenosis, sparing the internal carotid bulb, or suspended, at the junction of V2 and V3 segments of the vertebral artery, in patients with no signs of atheroma of the cervical arteries. MRI is recommended as the first line imaging screening tool, including a fat suppressed T1 weighted sequence, acquired in the axial or oblique plane at 1.5T, or 3D at 3T. Complete resolution of the lumen abnormality occurred in 80% of cases, and CAD recurrence is rare, encountered in less than 5% of cases. Interventional neuroradiology (angioplasty and/or stenting of the dissected vessel) may be envisaged in rare cases of haemodynamic effects with recurring clinical infarctions in the short-term.
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Blum CA, Yaghi S. Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. ARCHIVES OF NEUROSCIENCE 2015; 2. [PMID: 26478890 DOI: 10.5812/archneurosci.26670] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Cervical artery dissection (CAD) is a common cause of stroke in young adults. There is controversy over whether anticoagulation is superior to antiplatelet therapy in preventing stroke in patients with CAD, although meta-analyses to date have not shown any difference between the two treatments. EVIDENCE ACQUISITION We performed a PubMed search using each of the keywords: "Cervical artery dissection", "Dissection", "Carotid dissection", and "Vertebral dissection" between January 1st, 1990 and July 1st 2015. We identified evidence-based peer-reviewed articles, including randomized trials, case series and reports, and retrospective reviews that encompass the epidemiology, clinical manifestations, pathophysiology, treatment, and outcome of cervical artery dissection. RESULTS This paper highlights the mechanisms of cervical artery dissection and stroke in patients with dissection as well as the natural history and treatment. CONCLUSION Given the relatively rare incidence of this disease, multicenter studies with collaborative effort among stroke centers worldwide should be considered to enroll patients with cervical artery dissection in a randomized trial comparing the two treatments.
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Affiliation(s)
- Christina A Blum
- University of Pennsylvania Health System, Department of Neurology, Stroke division
| | - Shadi Yaghi
- Columbia University Medical Center, Department of Neurology, Stroke division
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Risk Factors and Clinical Presentation of Cervical Arterial Dissection: Preliminary Results of a Prospective Case-Control Study. J Orthop Sports Phys Ther 2015; 45:503-11. [PMID: 25996363 DOI: 10.2519/jospt.2015.5877] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Cross-sectional case-control study. OBJECTIVES To identify risk factors and clinical presentation of individuals with cervical arterial dissection. BACKGROUND Cervical arterial dissection is a common cause of stroke in young people and has in rare cases been associated with cervical manipulative therapy. The mechanism is considered to involve pre-existing arterial susceptibility and a precipitating event, such as minor trauma. Identification of individuals at risk or early recognition of a dissection in progress could help expedite medical intervention and avoid inappropriate treatment. METHODS Participants were individuals 55 years of age or younger from the Hunter region of New South Wales, Australia with radiologically confirmed vertebral or internal carotid artery dissection and an age- and sex-matched comparison group. Participants were interviewed about risk factors, preceding events, and clinical features of their stroke. Physical examination of joint mobility and soft tissue compliance was undertaken. RESULTS Twenty-four participants with cervical arterial dissection and 21 matched comparisons with ischemic stroke but not dissection were included in the study. Seventeen (71%) of the 24 participants with dissection reported a recent history of minor mechanical neck trauma or strain, with 4 of these 17 reporting recent neck manipulative therapy treatment. Cardiovascular risk factors were uncommon, with the exception of diagnosed migraine. Among the participants with dissection, 67% reported transient ischemic features in the month prior to their admission for dissection. CONCLUSION Recent minor mechanical trauma or strain to the head or neck appears to be associated with cervical arterial dissection. General cardiovascular risk factors, with the exception of migraine, were not important risk factors for dissection in this cohort. Preceding transient neurological symptoms appear to occur commonly and may assist in the identification of this serious pathology. LEVEL OF EVIDENCE Prognosis, level 4.
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