Vertebral Artery Dissection in Sport: A Systematic Review

Recurrence of cervical artery dissection: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Cervical artery dissection (CAD) involving the carotid or vertebral arteries is an important cause of stroke in younger patients. The purpose of this systematic review is to assess the risk of recurrent CAD.

METHODS

A systematic review and meta-analysis was conducted on studies in which patients experienced radiographically confirmed dissections involving an extracranial segment of the carotid or vertebral artery and in whom CAD recurrence rates were reported.

RESULTS

Data were extracted from 29 eligible studies (n = 5898 patients). Analysis of outcomes was performed by pooling incidence rates with random effects models weighting by inverse of variance. The incidence of recurrent CAD was 4% overall (95% confidence interval (CI) = 3-7%), 2% at 1 month (95% CI = 1-5%), and 7% at 1 year in studies with sufficient follow-up (95% CI = 4-13%). The incidence of recurrence associated with ischemic events was 2% (95% CI = 1-3%).

CONCLUSIONS

We found low rates of recurrent CAD and even lower rates of recurrence associated with ischemia. Further patient-level data and clinical subgroup analyses would improve the ability to provide patient-level risk stratification.

It's in the game: A review of neurological lesions associated with sports

INTRODUCTION

The practice of sports may lead to neurological injuries. While relatively uncommon (overall incidence of approximately 2.5%), and mostly benign and transient, some conditions may be life-threatening and permanent. Thus, both clinical neurologists and sports physicians should be aware of their existence and relevance. We aimed to review all sports-related neurological injuries and illnesses reported in the literature.

METHODS

Following SANRA guidelines, we performed a narrative review and searched PubMed and Scopus databases. Relevant sports were selected based on their recognition as an Olympic sport by the International Olympic Committee. Chronic traumatic encephalopathy (CTE) and other neurodegenerative disorders were not included.

RESULTS

A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries have also been extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, e.g. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, e.g. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma.

CONCLUSION

Sports-related neurological injuries are increasingly receiving more social and medical attention and are an important cause of morbidity and mortality. This review may serve as a guide to physicians managing these challenging situations.

Top of basilar syndrome due to vertebral artery dissection: How high-resolution MRI and CD31 analysis of thrombus could help

INTRODUCTION AND IMPORTANCE

Vertebral artery dissection is a rare but serious condition that can lead to neurological deficits and even death. It is commonly associated with trauma or underlying vascular diseases. Top of basilar syndrome (TOBS) is a neurological condition that can result from vertebral artery dissection, either by direct ischemia or secondary occlusion due to distal embolization of injured inner vascular tissue. We here present a patient who was initially suffering from seizure then had TOBS due to a progressive vertebral artery dissection, with emphasis of high-resolution MRI imaging and immunohistochemistry study of the thrombus.

CASE PRESENTATION

A young male presented to the emergency department with sudden onset of seizure. A history of recent neck exercise was reported. The patient had gaze palsy, adduction disability, and dysarthria. High-resolution MRI showed a vertebral artery dissection with evidence of occlusion of the top of basilar artery. After the thrombectomy, a pathologic study revealed CD31[+] tissue in the thrombus, indicating an origin from dissected vertebral artery.

CLINICAL DISCUSSION AND CONCLUSION

It's important to recognize and treat vertebral artery dissection promptly due to its varying symptoms. Using high-resolution MRI at early stage and conducting pathologic analysis of CD31 on the thrombus can assist in the diagnosis, potentially leading to more precise treatment plans and better outcomes for patients.

Predictors of ischemic events in patients with unilateral extracranial vertebral artery dissection: A single-center exploratory study

Objective

Extracranial vertebral artery dissection (EVAD) is one of the main causes of stroke in young and middle-aged patients. However, the diagnosis is challenging. This study aimed to identify the characteristics of EVAD on color duplex ultrasonography (CDU) and high-resolution magnetic resonance imaging (hrMRI), hoping to improve the accuracy and determine the relative contribution of vessel findings and clinical factors to acute ischemic events.

Methods

Patients with unilateral EVAD were recruited and divided into ischemia and non-ischemia groups. Clinical features of patients and the lesion location; a variety of signs which indicate dissection, including the presence of an intimal flap, double lumen, intramural hematoma, dissecting aneurysm, intraluminal thrombus, and irregular lumen; and other quantitative parameters of each dissected segment on CDU and hrMRI were reviewed, respectively. Multiple logistic regression was performed to explore the association between clinical, imaging characteristics, and ischemic events in patients with unilateral EVAD.

Results

Ninety-six patients with unilateral EVAD who met the inclusion criteria were enrolled during a six-year period. Overall, 41 cases (42.7%) were confirmed as ischemic stroke (n = 40) or transient ischemic attack (n = 1) during the 48 h after the onset of symptoms. Men, infections during the last week, and smoking were more common in the ischemia group. Intraluminal thrombus and occlusion on CDU were more prevalent in patients with cerebral ischemia than in those without (36.6 vs. 5.5%; p < 0.001, and 39.0 vs. 9.1%; p = 0.001, respectively). On hrMRI, intraluminal thrombus and occlusion were also more frequent in the ischemia group than in the non-ischemia group (34.1 vs. 5.5%; p < 0.001, and 34.1 vs. 9.1%; p = 0.003, respectively). In addition, lesion length on hrMRI was significantly longer for patients with ischemia (81.5 ± 41.7 vs. 64.7 ± 30.8 mm; p = 0.025). In multivariable logistic regression analysis, male gender, infections during the last week, and the presence of intraluminal thrombus on CDU and hrMRI were independently associated with acute ischemic events.

Conclusion

Male sex, infections during the last week, and the presence of intraluminal thrombus due to dissection are associated with an increased risk of ischemic events in patients with unilateral EVAD.

Cervical Artery Dissections and Ischemic Strokes Associated with Vascular Neck Compression Techniques (Sportive Chokes)

BACKGROUND

Strangulation as a fight-finishing maneuver in combat sports, termed "choking" in that context, occurs worldwide millions of times yearly. This activity can be trained safely, but devastating injuries can occur.

OBJECTIVE

Our aim was to present a case series of cervical artery dissections and ischemic strokes associated with sportive choking. Sharing these cases is meant to draw awareness, to assist emergency physicians in caring for these athletes, and to provide a platform for further research.

METHODS

Institutional Review Board approval was obtained. Participants consented for medical information transfer and anonymous academic reproduction. The minimum medical record information necessary for inclusion was a report of diagnosis-confirming advanced imaging. Participants were contacted for primary information in addition to what the medical records could provide and to confirm some information in the record (e.g., pertinent medical history, demographic characteristics, choking event description, medical care, and commentary on their current health). Medical records and additional first-hand information were reviewed and participants were included if they had a diagnosed dissection or stroke likely associated with a sportive choke.

RESULTS

Ten cases met all criteria for inclusion. There were 5 cases of carotid artery dissection, 3 cases of vertebral artery dissection, and 2 cases of ischemic stroke without dissection. Nine of 10 participants survived and 3 of 10 have returned to submission grappling training.

CONCLUSIONS

Cervical artery dissections and ischemic strokes can occur in association with sportive choking. Emergency physicians must be aware of the widespread nature of this activity and must be vigilant in approaching management of patients with symptoms consistent with these injuries.

Stroke and Athletes: A Scoping Review

Stroke (i.e., cerebrovascular accident) affects one in 10,000 people between the ages of 14 and 45; however, very little is known about the frequency and type of stroke that occurs in athletes. The risk of injury to the neurovascular structures may depend on the type of sport involvement, although, sport-specific incidence rates are not known. Therefore, the goal of our scoping review was to provide some guidance to better inform the development of a context-fit stroke model by summarizing studies on a broad research topic related to stroke or cerebrovascular accident in sport based on a strict athlete definition. We used the guidance of Arksey and O'Malley's five-stage-process for a scoping review. Databases included MEDLINE(R) Epub Ahead of Print, In-Process & Other Non- Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), and Embase (OVID databases); CINAHL Plus with Full Text, SportDiscus with Full Text (Ebsco databases); and Scopus. Publication dates were from 1979-2020 across nine different countries resulting in 39 individual cases of stroke with an athlete age range of 14-56 years (95% male). The major inciting event(s) prior to stroke onset were headaches (38.4%), head trauma (30.7%), and neck injury and/or vertebral artery dissection (20.5%). Several sporting activities were represented with American football as the most prevalent (30.7%). In summary, we found that sports with an aspect of impact, collision, or microtrauma can lead to subsequent stroke. These sport-related traumatic events were often difficult to diagnose because of the longer interval before ischemia occurred. Therefore, health care providers should be particularly attuned to the possibility of stroke when evaluating athletes presenting with or without neurological deficit.

Assessing Cranial Nerves in Physical Therapy Practice: Findings from a Cross-Sectional Survey and Implication for Clinical Practice

BACKGROUND AND OBJECTIVE

Serious pathologies of the neck can potentially result in cranial nerve palsy. Knowledge about cranial nerve examination (CNE) seems sparse, and its use is still unknown. We aim to investigate the knowledge, skills, and utilization of CNE of Italian physiotherapists.

MATERIALS AND METHODS

An online cross-sectional survey.

RESULTS

396 completed the survey, reaching the required sample size. Although Italian physiotherapists consider CNE relevant (mean ± SD = 7.6/10 ± 2.0), over half of all responders (n = 229 (57.8%)) were not trained in the fundamentals and around a third did not use it in their daily practice (n = 138 (34.8%)). Additionally, participants were unconfident and insecure in conducting (n = 152 (38.4%) and n = 147 (37.1%)), interpreting (n = 140 (35.4%) and n = 164 (41.4%)), and managing the CNE (n = 141 (35.6%) and n = 154 (38.9%)). Possessing a musculoskeletal specialization was associated with an increased value attributed to clinical practice guidelines and reduced the lack of confidence in conducting, interpreting, and managing the CNE (respectively, n = 35 (25.5%), p = 0.0001; n = 32 (23.4%) p = 0.0002; n = 32 (23.4%) p = 0.0002). Working in a direct access setting significantly increased the considered relevance of guidelines and the concerns about arterial (p = 0.004) and other serious pathologies (p = 0.021). Pain and visual disturbances were considered the main indicators to CNE, demonstrating limited knowledge of signs and symptoms' indicating CNE. Participants considered specific training in CNE as relevant (mean ± SD = 7.6/10 = 2.1).

CONCLUSIONS

a substantial proportion of Italian physiotherapists are not schooled in the fundamentals of cranial nerve examination. Given the number of physiotherapists who work in first contact roles, this is a professional concern.

Cervical Artery Dissection and Sports

Cervical artery dissection (CeAD) occurring in the context of sports is a matter of concern for CeAD patients. They seek advice on the role of sports in CeAD and on the safety of resuming sports after CeAD. The scarcity of studies and guidelines addressing these issues poses a challenge. We aimed at summarizing the current knowledge about CeAD and sports in order to provide an informed, comprehensive opinion for counseling CeAD patients. We took into account pathophysiological considerations, observations of cases reports, series, and registries, and conclusions by analogy from aortic dissection or inherited connective tissue syndromes. In summary, practicing active sports as the cause of CeAD seems uncommon. It seems recommendable to refrain from any kind of sports activities for at least 1 month, which can be extended in case of an unfavorable clinical or neurovascular course. We recommend starting with sport activities at low intensity—preferably with types of endurance sports—and to gradually increase the pace in an individually tailored manner, taking into circumstances of the occurrences of the CeAD in the individual patient (particularly in relation to sports), the meaning of sports activities for the individual well-being, the presence or absence of comorbidities and of neurological sequela, neurovascular findings, and whether there are signs of an underlying connective tissue alteration. Major limitations and several forms of bias are acknowledged. Still, in the absence of any better data, the summarized observations and considerations might help clinicians in advising and counseling patients with CeAD in clinical practice.

Injury deaths in Australian sport and recreation: Identifying and assessing priorities for prevention

Introduction

Sport and recreation is beneficial for health and wellbeing but comes with a probability of loss, including occasional fatal injuries. Following high-profile injury deaths in Australia, concerns are raised regarding the safety of sport participation. To understand the scale and scope of injury deaths, and identify potential prevention opportunities, the aim of this investigation was to describe the number and nature of fatal injuries in Australian sport and recreation.

Methods

This is a retrospective cohort study of injury deaths reported between 1 July 2000 to 31 December 2019 using data from the National Coronial Information System, Australia. Unintentional deaths with an external cause, where the activity was recorded as sport and exercise during leisure time were included. Drowning deaths were excluded. Presented are the number and % of cases by age, sex, sport, broad cause and annual crude death rate (population).

Results

There were 1192 deaths, averaging 63 per year. Deaths were mostly in males (84.4%), with the largest proportion in people aged 15–24 years (23.1%). Wheeled motor (26.9%) and non-motor (16.2%) sports accounted for the highest proportion of cases. The primary mechanism of death was most commonly blunt force (85.4%), followed by piercing/penetrating force (5.0%). The years 2001 and 2005 recorded the highest crude injury death rate (2001, n = 92, 0.47 per 100,000 population; 2005, n = 95, 0.47 per 100,000 population).

Conclusions

On average, there is more than one injury death per week in a sport or recreation setting in Australia. Cases occurred in many sports and recreation activities, including those generally considered to be safe (e.g. individual athletic activities, team ball sports.) Detailed investigation of the coronial recommendations that are present within each case is now needed to understand and identify potential prevention opportunities.

Recommended Musculoskeletal and Sports Medicine Curriculum for Internal Medicine Residency Training

ABSTRACT

Patients present to primary care physicians with musculoskeletal complaints more often than they do for upper respiratory infections, hypertension, or diabetes. Despite this, instruction in musculoskeletal medicine for internal medicine residents represents less than 1% of their total didactic and clinical education time. We recognize the immense breadth of knowledge and skill required to train residents in the practice of internal medicine. This curriculum guideline defines a recommended training strategy, and supplies relevant resources, to improve musculoskeletal education among internal medicine residents to optimize patient care. This curriculum guideline was created by internists who are sports medicine specialists. Sports medicine physicians promote overall health and well-being while providing expertise in acute and chronic musculoskeletal conditions, as well as how disease affects exercise and using exercise as medicine for people with chronic disease.

Recurrence of cervical artery dissection: protocol for a systematic review

INTRODUCTION

Cervical artery dissection, including carotid and vertebral artery dissection, is an important cause of stroke in the young. Risk of developing cervical artery dissection has been associated with physical activity in various forms and has been presumed to be related to minor trauma and mechanical stretching of the cervical arteries. This systematic review will aim to synthesise data on the risk of recurrent cervical artery dissection after an initial dissection. This information may be applied to further understand the natural history of this disease, and potentially to help direct evidence-based discussions on safe return to activity after dissection.

METHODS AND ANALYSIS

A broad search of multiple electronic databases (Medline, Embase, Cochrane Central Register of Controlled Trials and Web of Science) will be conducted to identify studies published as of 13 November 2019, examining all-comers with cervical artery dissection observed over time. Studies will be screened by two independent reviewers in a two-level process to determine eligibility for inclusion. Data will be pooled from eligible articles and the main outcome of recurrent cervical artery dissection at 5 years will be determined using quantitative analysis.

ETHICS AND DISSEMINATION

Ethics approval is not necessary as no primary data are being collected. The information will be disseminated in the form of a systematic review article which will be submitted to a peer-reviewed medical journal.

PROSPERO REGISTRATION NUMBER

CRD42020166105.