Extracranial and intracranial vertebral artery dissection: long-term clinical and duplex sonographic follow-up

Predicting vessel recanalization in extracranial internal carotid artery dissection: a nomogram based on ultrasonography and clinical features

Background

Extracranial internal carotid artery dissection (EICAD) is a prominent factor in ischemic stroke in young patients, and vessel recanalization is correlated with stroke recurrence. We propose to determine the possible association between carotid duplex ultrasound (CDU) features, clinical factors, and vessel recanalization in EICAD patients.

Methods

In the current retrospective study, data from 202 patients diagnosed with EICAD by CDU and confirmed by computed tomography angiography (CTA) or high-resolution magnetic resonance imaging (HRMRI) were encompassed. Patients were randomized 7:3 into training cohort (n = 142) and validation cohort (n = 60). The least absolute shrinkage and selection operator (LASSO) regression analysis and multivariate logistic regression analysis were used to build a nomogram to predict recanalization. At last, we assessed the performance of the nomogram with an area under the receiver operating characteristic curve (AUC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC).

Results

The nomogram included CDU features (intramural hematoma, Intraluminal thrombus, and stenosis degree) and age, with AUC values of 0.906 (95% CI: 0.857-0.946) and 0.903 (95% CI: 0.820-0.963) in the training cohort and the validation cohort, respectively. Using a probability cutoff of 0.5 derived from the Youden index, patients were stratified into high-risk (recanalization probability <50%) and low-risk groups (≥50%). DCA showed that the nomogram performed significantly better across various threshold probabilities, and CIC demonstrated that the nomogram offers superior net benefit across a broad range of threshold probabilities, indicating its significant predictive value.

Conclusion

A nomogram depended on CDU and clinical features could accurately predict recanalization in EICAD patients. The nomogram may facilitate early identification of high-risk patients and personalized therapeutic strategies.

High risk and low prevalence diseases: Spontaneous cervical artery dissection

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.

Point-of-Care Ultrasound in Neurology - Report of the EAN SPN/ESNCH/ERcNsono Neuro-POCUS Working Group

In the last decade, ultrasound examination in neurology has been undergoing a significant expansion of its modalities. In parallel, there is an increasing demand for rapid and high-quality diagnostics in various acute diseases in the prehospital setting, the emergency room, intensive care unit, and during surgical or interventional procedures. Due to the growing need for rapid answers to clinical questions, there is particular demand for diagnostic ultrasound imaging. The Neuro-POCUS working group, a joint project by the European Academy of Neurology Scientific Panel Neurosonology, the European Society of Neurosonology and Cerebral Hemodynamics, and the European Reference Centers in Neurosonology (EAN SPN/ESNCH/ERcNsono Neuro-POCUS working group), was given the task of creating a concept for point-of-care ultrasound in neurology called "Neuro-POCUS". We introduce here a new ultrasound examination concept called point-of-care ultrasound in neurology (Neuro-POCUS) designed to streamline conclusive imaging outside of the ultrasound center, directly at the bedside. The aim of this study is to encourage neurologists to add quick and disease-oriented Neuro-POCUS to accompany the patient in the critical phase as an adjunct not a substitution for computed tomography, magnetic resonance imaging, or standard comprehensive neurosonology examination. Another goal is to avoid unwanted complications during imaging-free periods, ultimately resulting in advantages for the patient.

Recurrent vertebrobasilar strokes and transient-ischemic attacks with challenging workup: Case report

Detecting the stroke etiology in young patients can be challenging. Among others, determining causality between ischemic stroke and patent foramen ovale (PFO) remains a complicated task for stroke neurologists, given the relatively high prevalence of PFOs. Thorough diagnostic workup to identify incidental vascular risk factors and rare embolic sources is crucial to avoid premature PFO closure suggesting successful secondary stroke prevention. In this paper, we report on a 38-year-old patient with recurrent vertebrobasilar territory, especially right posterior inferior cerebellar artery (PICA) territory strokes. After the initial suspicion of a left vertebral artery (VA) dissection was not confirmed by ultrasound and magnetic resonance imaging (MRI) and other major risk factors were excluded, a PFO was detected and closed. Successful PFO closure was confirmed by transesophageal echocardiography, yet recurrent transient-ischemic attacks and vertebrobasilar strokes, especially during nighttime and in the early morning, occurred despite various antiplatelet and antithrombotic regimes and a persistent right-to-left shunt was detected by bubble transcranial Doppler. Finally, MRI after another vertebrobasilar infarction detected a transient left VA occlusion that finally led to the diagnosis of a left VA pseudoaneurysm from an incident emboligenic dissection in the atlas segment. This pseudoaneurysm together with an anatomical variant of the right PICA originating with the right anterior inferior cerebellar artery from the basilar artery finally explained the recurrent ischemic events of the patient. After successful treatment with coil occlusion, the patient suffered no further stroke and recovered completely. In summary, stroke in the young remains a diagnostic challenge. The incidental finding of a PFO should not deter from thorough stroke workup and the follow-up of these patients including PFO closure verification should be performed under the guidance of vascular neurologists.

Overview of Imaging Modalities in Stroke

PURPOSE OF THE REVIEW

This article reviews common imaging modalities used in diagnosis and management of acute stroke. Each modality is discussed individually and clinical scenarios are presented to demonstrate how to apply these modalities in decision-making.

RECENT FINDINGS

Advances in neuroimaging provide unprecedented accuracy in determining tissue viability as well as tissue fate in acute stroke. In addition, advances in machine learning have led to the creation of decision support tools to improve the interpretability of these studies.

SUMMARY

Noncontrast head computed tomography (CT) remains the most commonly used initial imaging tool to evaluate stroke. Its exquisite sensitivity for hemorrhage, rapid acquisition, and widespread availability make it the ideal first study. CT angiography (CTA), the most common follow-up study after noncontrast head CT, is used primarily to identify intracranial large vessel occlusions and cervical carotid or vertebral artery disease. CTA is highly sensitive and can improve accuracy of patient selection for endovascular therapy through delineations of ischemic core. CT perfusion is widely used in endovascular therapy trials and benefits from multiple commercially available machine-learning packages that perform automated postprocessing and interpretation. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) can provide valuable insights for outcomes prognostication as well as stroke etiology. Optical coherence tomography (OCT), positron emission tomography (PET), single-photon emission computerized tomography (SPECT) offer similar insights. In the clinical scenarios presented, we demonstrate how multimodal imaging approaches can be tailored to gain mechanistic insights for a range of cerebrovascular pathologies.

Usefulness of Carotid Ultrasonography for Risk Stratification of Cerebral and Cardiovascular Disease

Carotid ultrasonography is useful for the assessments of the risk stratification for stroke or coronary artery disease, because it is a simple, repeatable, and noninvasive procedure. The carotid intima-media thickness (IMT), which is assessed using carotid ultrasonography, is a widely used surrogate marker for the severity of atherosclerosis. Several large clinical studies showed that increased carotid IMT is associated with the future stroke or cardiovascular events. In addition, in many clinical trials, it has been adopted for surrogate markers of clinical endpoints of medical intervention. Moreover, carotid ultrasonography allows the measurement of the presence and characteristics of plaques and the severity of carotid artery stenosis. The unstable morphology of plaque, such as hypoechoic, ulcer, and mobility, is associated with future ischemic stroke events. The screening tool of asymptomatic carotid artery stenosis is also important, although whether routine carotid ultrasonography assessment is recommended in the general population remains controversial. The screening of carotid artery stenosis using ultrasonography is essential for not only daily clinical settings but also management of patients with acute ischemic stroke. The patients with atherothrombotic stroke with severe internal carotid artery stenosis should be considered to surgical intervention, and duplex ultrasound approach is important to estimate for the severity of carotid stenosis. Physicians should keep in mind the usefulness of carotid ultrasonography for risk stratification of cerebral and cardiovascular disease based on various aspects. In addition, visual assessment or dynamic changes using carotid ultrasonography could provide the various and valuable insights in clinical settings.

Detection of Stenosis Progression in Intracranial Vertebral Artery Dissection Using Carotid Ultrasonography

BACKGROUND

The purpose of this study was to assess whether carotid ultrasonography indices detect arterial stenosis progression in patients with vertebral artery (VA) dissection.

METHODS

This was a retrospective, single-center, observational study that enrolled patients with intracranial VA dissection who were admitted from January 2011 to June 2017. Magnetic resonance angiography (MRA) was done on admission and followed up at a median 20 days after onset (interquartile range [IQR] 9-58 days), and ultrasonography was performed at a median of 22 (interquartile range 7-56) days. Peak systolic velocity (PSV), end-diastolic velocity (EDV), mean velocity (MV), and pulsatility index (PI) were measured by ultrasonography, and the ratio of each follow-up value to the baseline (follow-up/baseline) value was calculated. Two stroke neurologists categorized into 3 groups by morphological changes of the dissected vessel: patients with stenosis progression (progression group: P-group); those with no remarkable change or dilatation improved (stable group: S-group); and those with stenosis regression or dilatation enlargement (enlargement group: E-group). Ultrasonography indices were compared among the groups.

RESULTS

Of the 42 patients who were enrolled to this study, 39 patients underwent ultrasonography and MRA on both admission and follow-up. The PI ratio was significantly higher in the P-group than in the S-group (1.96 ± .80 versus .98 ± .44, P = .02) and in the E-group (versus .65 ± .35, P < .01). There were no significant differences in the PSV ratio, EDV ratio, and MV ratio.

CONCLUSIONS

In patients with VA dissection, the PI ratio on ultrasonography is a promising index to detect stenosis progression.

Improvement and Aggravation of Spontaneous Unruptured Vertebral Artery Dissection

BACKGROUND

Intracranial vertebral artery dissection (VAD) is a well-recognized cause of stroke in young and middle-aged individuals, especially in Asian populations. However, a long-term natural course remains unclear. We investigated the long-term time course of VAD using imaging findings to examine the rate and predisposing factors for improvement.

METHODS

We registered 56 consecutive patients (40 males; mean age, 51.8 ± 10.7 years) with acute spontaneous VAD and retrospectively investigated neuroimaging and clinical course within 1 month and at 3 months ± 2 weeks, 6 months ± 2 weeks, and 12 months ± 2 weeks after onset to ascertain predisposing factors and time course for improvement.

RESULTS

The most common presenting symptoms were headache and/or posterior neck pain, seen in 41 patients (73%). Magnetic resonance imaging showed brainstem and/or cerebellum infarction in only 32 patients (57%). Of the 56 VADs, 16 (28%) presented with pearl and string sign, 5 (9%) with pearl sign, 15 (27%) with string sign, and 20 (36%) with occlusion sign. VAD occurred on the dominant side in 20 patients and on the nondominant side in the other 36 patients. The pearl and string sign was more frequently noted on the dominant side than on the nondominant side (50 vs. 17%, p = 0.008). On the other hand, occlusion occurred more often on the nondominant side than on the dominant side (47 vs. 15%, p = 0.016). Furthermore, the pearl and string sign was more frequently seen in the improvement group (41 vs. 15%, p = 0.028), whereas the occlusion sign was evident more frequently in the nonimprovement group (21 vs. 52%, p = 0.015). Follow-up neuroimaging evaluation was performed at 1 and 3 months in 91% each, and at 6 and 12 months in 82% each. VAD aggravation was identified within 1 month after onset in 14%, while VAD improvement was seen in 14, 38, 50, and 52% at each period, mainly within 6 months after onset. Older patients and current smoking were negatively associated with VAD improvement.

CONCLUSIONS

VAD improvement primarily occurs within 6 months after onset, and VAD aggravation within 1 month. It seems that older patients and current smoking are negative predictors of VAD improvement as risk factors, and as image findings, the pearl and string sign is a positive predictor and occlusion a negative predictor.

Prognosis of carotid dissecting aneurysms: Results from CADISS and a systematic review

OBJECTIVE

To determine the natural history of dissecting aneurysm (DA) and whether DA is associated with an increased recurrent stroke risk and whether type of antithrombotic drugs (antiplatelets vs anticoagulants) modifies the persistence or development of DA.

METHODS

We included 264 patients with extracranial cervical artery dissection (CAD) from the Cervical Artery Dissection in Stroke Study (CADISS), a multicenter prospective study that compared antiplatelet with anticoagulation therapy. Logistic regression was used to estimate age- and sex-adjusted odds ratios. We conducted a systematic review of published studies assessing the natural history of DA and stroke risk in patients with non-surgically-treated extracranial CAD with DA.

RESULTS

In CADISS, DA was present in 24 of 264 patients at baseline. In 36 of 248 patients with follow-up neuroimaging at 3 months, 12 of the 24 baseline DAs persisted, and 24 new DA had developed. There was no association between treatment allocation (antiplatelets vs anticoagulants) and whether DA at baseline persisted at follow-up or whether new DA developed. During 12 months of follow-up, stroke occurred in 1 of 48 patients with DA and in 7 of 216 patients without DA (age- and sex-adjusted odds ratio 0.84; 95% confidence interval 0.10-7.31; p = 0.88). Published studies, mainly retrospective, showed a similarly low risk of stroke and no evidence of an increased stroke rate in patients with DA.

CONCLUSIONS

The results of CADISS provide evidence suggesting that DAs may have benign prognosis and therefore medical treatment should be considered.

Non-traumatic vertebral artery dissection presenting with unilateral cervical pain, hemilateral vision problems and headache

Spontaneous vertebral artery dissection is a rare condition, mainly affecting young adults with non-specific symptoms, which are often considered not severe. We report a case of a non-traumatic vertebral artery dissection in a 30-year-old woman. Our patient presented with unilateral right-sided neck pain and frontal headache during 3 weeks and recently developed right-sided vision problems. History and clinical findings were non-specific. Neurovascular imaging showed a right-sided vertebral artery dissection from C2 to C6 with an intima flap at C5-C6. The patient was observed in the stroke unit for 1 week and antithrombotics were given during 3 months. There was a complete revascularization of the vertebral artery after 3 months. A review of literature is given concerning predisposing factors, clinical symptoms, neurovascular imaging and treatment options.

Intracranial vessel wall MRI

There are many different methods of imaging the intracranial arteries; however, the vast majority of currently used techniques are based on luminal imaging. Although this is useful, it does have limitations as many different pathological processes can produce the same appearance. Therefore, directly imaging the site of the pathology - the vessel wall itself - offers the hope of discriminating between different disease processes. In this review, we will discuss the current status of vessel wall magnetic resonance imaging alongside its potential usefulness in differentiating between various disease entities.

Transcranial Doppler investigation of hemodynamic alterations associated with blunt cervical vascular injuries in trauma patients

OBJECTIVES

Blunt cervical vascular injuries, often missed with current screening methods, have substantial morbidity and mortality, and there is a need for improved screening. Elucidation of cerebral hemodynamic alterations may facilitate serial bedside monitoring and improved management. Thus, the objective of this study was to define cerebral flow alterations associated with single blunt cervical vascular injuries using transcranial Doppler sonography and subsequent Doppler waveform analyses in a trauma population.

METHODS

In this prospective pilot study, patients with suspected blunt cervical vascular injuries had diagnoses by computed tomographic angiography and were examined using transcranial Doppler sonography to define cerebral hemodynamics. Multiple vessel injuries were excluded for this analysis, as the focus was to identify hemodynamic alterations from isolated injuries. The inverse damping factor characterized altered extracranial flow patterns; middle cerebral artery flow velocities, the pulsatility index, and their asymmetries characterized altered intracranial flow patterns.

RESULTS

Twenty-three trauma patients were evaluated: 4 with single internal carotid artery injuries, 5 with single vertebral artery injuries, and 14 without blunt cervical vascular injuries. All internal carotid artery injuries showed a reduced inverse damping factor in the internal carotid artery and dampened ipsilateral mean flow and peak systolic velocities in the middle cerebral artery. Vertebral artery injuries produced asymmetry of a similar magnitude in the middle cerebral artery mean flow velocity with end-diastolic velocity alterations.

CONCLUSIONS

These data indicate that extracranial and intracranial hemodynamic alterations occur with internal carotid artery and vertebral artery blunt cervical vascular injuries and can be quantified in the acute injury phase by transcranial Doppler indices. Further study is required to elucidate cerebral flow changes resulting from a single blunt cervical vascular injury, which may guide future management to preserve cerebral perfusion after trauma.

Color Doppler of the extracranial and intracranial arteries in the acute phase of cerebral ischemia

Vascular imaging greatly improves the possibility of locating the site of vascular occlusion in patients with acute cerebrovascular disease. Different occlusive patterns may underlie the same clinical presentation, with different prognosis and different treatment: for this reason, a diagnostic tool able to identify quickly the status of the extra- and intracranial vessels is needed. Color Doppler ultrasound of the extracranial arteries is a reliable and accurate method able to localize and quantify the carotid artery stenosis. The ultrasound quantification of the degree of stenosis is based on both morphological and velocimetric criteria: B-mode, color or power Doppler and spectral analysis are used for this purpose. Also the analysis of the plaque is an integral part of the ultrasound examination: the B mode plaque characterization (structure and surface) plays an important role in the evaluation of risk of stroke. So color Doppler ultrasound is able to select patients who may require medical therapy, carotid endarterectomy or angioplasty and stenting. Transcranial color Doppler is an inexpensive, reliable, fast, non-invasive, bedside tool: in the acute phase of stroke, it is able to evaluate quickly the intracranial arteries and monitor the possible recanalization of occluded vessel ensuring the follow-up of dynamic lesions, such as the intracranial stenosis and occlusions.

Imaging characteristics of symptomatic vertebral artery dissection: a systematic review

BACKGROUND

Vertebral artery dissection (VAD) is an important cause of stroke in the young. VAD can present with a range of imaging findings. We sought to summarize the diagnostic value of various imaging findings in patients with symptomatic VAD.

METHODS

We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality and imaging data were abstracted. Pooled proportions were calculated.

RESULTS

Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. Most studies utilized conventional angiography or magnetic resonance angiography (MRA) to diagnose VAD; computed tomographic angiography (CTA) and Doppler ultrasonography were described less frequently. Imaging findings reported were vertebral artery stenosis (51%), string and pearls (48%), arterial dilation (37%), arterial occlusion (36%), and pseudoaneurysm, double lumen, and intimal flap (22% each). In cases where conventional angiography was the reference standard, CTA was more sensitive (100%) than either MRA (77%) or Doppler ultrasonography (71%) (P=0.001).

CONCLUSIONS

Imaging findings vary widely in patients with VAD, with no single radiographic sign present in the majority of VAD patients. Nonspecific radiographic signs predominate. CTA probably has greater sensitivity for dissection than MRA or ultrasound relative to conventional angiography. Higher quality studies on imaging techniques and radiographic criteria in subjects with VAD are needed. Future studies should compare imaging techniques in well-defined, undifferentiated populations of clinical VAD suspects.

Clinical characteristics of symptomatic vertebral artery dissection: a systematic review

BACKGROUND

Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed with adverse consequences. We assessed the frequency of head/neck pain, other neurological symptoms, and cerebrovascular events in symptomatic VAD.

METHODS

We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality, and clinical data were abstracted. Pooled proportions were calculated.

RESULTS

Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. The most common symptoms were dizziness/vertigo (58%), headache (51%), and neck pain (46%). Stroke was common (63%), especially with extracranial dissections (66% vs. 32%, P<0.0001), whereas transient ischemic attack (14%) and subarachnoid hemorrhage (10%) were uncommon. Subarachnoid hemorrhage was seen only with intracranial dissections (57% vs. 0%, P=0.003). Fewer than half of the patients had obvious trauma, and only 7.9% had a known connective tissue disease. Outcome was good (modified Rankin scale 0 to 1) in 67% and poor (modified Rankin scale 5 to 6) in 10% of patients.

CONCLUSIONS

VAD is associated with nonspecific symptoms such as dizziness, vertigo, headache, or neck pain. Ischemic stroke is the most common reported cerebrovascular complication. VAD should be considered in the diagnostic assessment of patients presenting with dizziness or craniocervical pain, even in the absence of other risk factors. Future studies should compare clinical findings as predictors in well-defined, undifferentiated populations of clinical VAD suspects.

Pathomechanisms and treatment of pediatric aneurysms

Pediatric aneurysms are rare diseases distinct from classical adult aneurysms and therefore require different treatment strategies. Apart from saccular aneurysms that are more commonly found in older children, three major pathomechanisms may be encountered: trauma, infection, and dissection. The posterior circulation and more distal locations are more commonly encountered in children compared to adults, and there is an overall male predominance. Clinical findings are not only confined to subarachnoid hemorrhage but may also comprise mass effects, headaches or neurological deficits. In traumatic aneurysms, the skull base and distal anterior communicating artery are commonly affected, and the hemorrhage occurs often delayed (2-4 weeks following the initial trauma). Infectious aneurysms are mostly bacterial in origin, and hemorrhage occurs early after a septic embolic shower. Dissecting aneurysms are the most often encountered aneurysm type in children and can lead to mass effect, hemorrhage, or ischemia depending on the fate of the intramural hematoma. Treatment strategies in pediatric aneurysms include endosaccular coil treatment only for the "classical berry-type" aneurysms; in the other instances, parent vessel occlusion, flow reversal, surgical options, or a combined treatment with bypass and parent vessel occlusion have to be contemplated.

The many faces of intracranial arterial dissections

Intracranial arterial dissecting diseases are rare and challenging diseases with a high associated morbidity and mortality. Their common pathomechanic origin is related to blood entering the vessel wall via an endothelial and intimal tear. Depending on the fate of the thus established intramural hematoma, different symptoms may ensue including mass effect, subarachnoid hemorrhage or ischemia. If the mural hematoma ruptures all vascular layers of the intradural artery, a subarachnoid hemorrhagic will occur. If the intramural hematoma reopens distally into the parent vessel on the other hand, ischemic embolic events may happen following intramural clot formation. If the mural hematoma does neither open itself into the parent vessel nor into the subarachnoid space, the vessel wall may dilate leading to occlusion of perforator branches and local ischemia. Organization of the mural hematoma may result in a chronic dissecting process which may eventually lead to formation of a "giant partially thrombosed" aneurysm with thrombus of varying ages within the vessel wall, ingrowth of vasa vasorum and recurrent dissections with subsequent growth of the aneurysm from the periphery. Treatment strategies of these diseases should take the underlying pathomechanism into consideration and include, depending on the presentation medical treatment, parent vessel occlusion, flow reversal or diversion, surgical options or a combined treatment protocol.

Recanalization of vertebral artery dissection

BACKGROUND AND PURPOSE

We investigated the predictors and time course for recanalization after vertebral artery dissection.

METHODS

We prospectively studied 61 consecutive patients with confirmed diagnoses of vertebral artery dissection without intracerebral hemorrhage. Neuroimaging and clinical follow-up were performed at presentation and at 3, 6, and 12 months.

RESULTS

We included 61 patients with confirmed vertebral artery dissection; 19 were evaluated and followed up with conventional angiography, 24 with MR angiography, and 18 with CT angiography. Fifty-one patients had a stenotic dissection, 7 had an occlusive dissection, one had a double-lumen image, and 2 had a pseudoaneurysm. The estimated rate of complete recanalization after vertebral artery dissection was 45.9% at 3 months, 62.3% at 6 months, and 63.9% at 12 months. We found no association between outcome and complete or partial recanalization nor did we find any factors associated with recanalization.

CONCLUSIONS

These results suggest that recanalization of vertebral artery dissection occurs mainly within the first 6 months after the onset of symptoms regardless of the location or pattern of the dissection.

Cervical-artery dissections: predisposing factors, diagnosis, and outcome

Cervical-artery dissection (CAD) is a major cause of cerebral ischaemia in young adults and can lead to various clinical symptoms, some of which are benign (eg, headache, neck pain, Horner's syndrome, and cranial-nerve palsy), but most patients have a stroke or transient ischaemic attack. In addition to trauma to the neck, other risk factors have been suggested, such as infection, migraine, hyperhomocysteinaemia, and the 677TT genotype of the 5,10-methylenetetrahydrofolate reductase gene (MTHFR 677TT), although evidence is sparse. An underlying arteriopathy, which could in part be genetically determined, is believed to have a role in the development of CAD. Importantly, both research on and optimum management of CAD strongly rely on diagnostic accuracy. Although the functional outcome of CAD is good in most patients, socioprofessional effects can be important. Incidence of the disorder in the general population is underestimated. Mortality and short-term recurrence rates are low but possibly also underestimated. Further research is warranted to improve our understanding of the underlying pathophysiology, to assess the long-term outcome, and ultimately to provide treatment and prevention strategies.