Antithrombotic treatment for acute extracranial carotid artery dissections: a meta-analysis

Spontaneous Intracranial Vertebral Artery Dissection: A Rare Cause of Ischemic Stroke

The dissection of the V4 vertebral artery (VA) is the most prevalent form of intracranial dissection, which can manifest either as ischemia or as a subarachnoid hemorrhage (SAH). Patient outcomes are significantly affected by their initial presentation; ischemic symptoms often indicate that the dissection remains primarily subintimal or within the medial layer, though it can occasionally extend to the basilar artery. In contrast, patients with ruptured VA dissection (VAD) experience a considerably higher mortality rate, as the dissection can reach the adventitial layer, heightening the risk of recurrent hemorrhage. It can show fluctuating imaging findings, making an accurate diagnosis and timely treatment essential. Currently, there are no established diagnostic criteria for VAD, and its diagnosis largely depends on imaging. The presence of intramural hematoma, identified via three-dimensional, black-blood, T1-weighted imaging, has been recognized as the most reliable indicator for diagnosing VAD and is crucial for establishing a definitive diagnosis. DSA remains a fundamental diagnostic technique not only in hemorrhagic patients but also in ischemic patients. The medical treatment of ischemic patients has not yet been well defined, and evidence-based data are lacking. This review aims to summarize the main clinical, pathophysiological, and neuroradiological features of intracranial VAD presenting with ischemic stroke, providing to clinicians the available information in order to individualize the treatment.

Comparative and Prognosis Study of Peripheral Arterial Dissections

OBJECTIVE

Peripheral arterial dissections are uncommon, with cervical artery dissections being the most prevalent. Comparative data on the evolution of renal, splanchnic, and coronary dissections are scarce. This study aimed to characterise and assess the prognosis of non-aortic arterial dissections based on their anatomical territories.

METHODS

Patients with dissection of cervical, coronary, renal, or splanchnic arteries from 2017 - 2022 that were documented at Nantes University Hospital were included retrospectively.

RESULTS

A total of 185 patients were included. Compared with other arterial territories, patients with coronary or vertebral dissections were more frequently females (p = .006), patients with vertebral or renal dissections were younger (p = .009), and patients with splanchnic dissections had more heritable connective tissue disorders (HCTDs) (p = .002); these differences were statistically significant for each comparison with the other groups. Cardiovascular risk factors did not statistically significantly differ according to the territory dissected. Ischaemic complications represented 44.8%, 91.7%, 88.2%, and 20.0% for cervical, coronary, renal, and splanchnic dissections, respectively (p < .001). The median follow up was 19 months (range 1 - 177 months). For all territories, symptomatic recurrence of dissection was observed in 10.3%, and the median time to recurrence was 34 months. Symptomatic dissection recurrence rates for patients with a single dissection at diagnosis and for multiple dissections were 6.8% and 22.2%, respectively (p = .030). In the multiple territories dissection group, there were more females (83.3% vs. 34.2%; p < .001), more HCTDs were identified (11.1% vs. 1.9%; p = .024), and patients were younger (p = .049).

CONCLUSION

Patients' clinical phenotypes differed according to the territory initially dissected, with a higher frequency of HCTDs in splanchnic dissections. Dissections affecting several beds or territories at diagnosis were associated with a higher rate of recurrence. These data need to be confirmed in large prospective studies.

Association between cervicocerebral artery dissection and tortuosity - a review on quantitative and qualitative assessment

Cervicocerebral artery dissection stands out as a significant contributor to ischemic stroke in young adults. Several studies have shown that arterial tortuosity is associated with dissection. We searched Pubmed and Embase to identify studies on the association between arterial tortuosity and cervicocerebral artery dissection, and to perform a review on the epidemiology of cervicocerebral artery tortuosity and dissection, pathophysiology, measurement of vessels tortuosity, strength of association between tortuosity and dissection, clinical manifestation and management strategies. The prevalence of tortuosity in dissected cervical arteries was reported to be around 22%-65% while it is only around 8%-22% in non-dissected arteries. In tortuous cervical arteries elastin and tunica media degradation, increased wall stiffness, changes in hemodynamics as well as arterial wall inflammation might be associated with dissection. Arterial tortuosity index and vertebrobasilar artery deviation is used to measure the level of vessel tortuosity. Studies have shown an independent association between these two measurements and cervicocerebral artery dissection. Different anatomical variants of tortuosity such as loops, coils and kinks may have a different level of association with cervicocerebral artery dissection. Symptomatic patients with extracranial cervical artery dissection are often treated with anticoagulant or antiplatelet agents, while patients with intracranial arterial dissection were often treated with antiplatelets only due to concerns of developing subarachnoid hemorrhage. Patients with recurrent ischemia, compromised cerebral blood flow or contraindications for antithrombotic agents are usually treated with open surgery or endovascular technique. Those with subarachnoid hemorrhage and intracranial artery dissection are often managed with surgical intervention due to high risk of re-hemorrhage.

Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association

Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.

Intimal Injury Potentially Plays a Key Role in the Formation of Carotid Artery Dissection: A Novel Animal Model Establishing

Research on the pathophysiological mechanism of carotid artery dissection and its clinical translation is limited due to the lack of effective animal models to simulate the occurrence of this condition. Assuming that intimal injury is an important factor in the formation of carotid dissection, we established a novel method for inducing carotid dissection models by scraping the carotid intima using a fine needle. Scraping the carotid intima with fine needles can induce the rapid formation of carotid dissection. Magnetic resonance imaging and hematoxylin-eosin staining suggest the presence of false lumens and mural hematomas in the vessels. Our model-induction technique, inspired by iatrogenic catheter-induced artery dissections (carotid, coronary, aortic), significantly mimics the pathological process of clinical carotid dissection. The results suggest that mechanical injury may be a significant cause of carotid dissection and that intimal injury is a major factor in the formation of arterial dissections. This approach will provide assistance in the understanding of medically induced arterial dissection.

Antiplatelets Versus Anticoagulation in Cervical Artery Dissection: A Systematic Review and Meta-analysis of 2064 Patients

BACKGROUND AND OBJECTIVES

In young people aged < 50 years, cervical artery dissection (CeAD) is among the most common causes of stroke. Currently, there is no consensus regarding the safest and most effective antithrombotic treatment for CeAD. We aimed to synthesize concrete evidence from studies that compared the efficacy and safety of antiplatelet (AP) versus anticoagulant (AC) therapies for CeAD.

METHODS

We searched major electronic databases/search engines from inception till September 2021. Cohort studies and randomized controlled trials (RCTs) comparing anticoagulants with antiplatelets for CeAD were included. A meta-analysis was conducted using articles that were obtained and found to be relevant. Mean difference (MD) with 95% confidence interval (CI) was used for continuous data and odds ratio (OR) with 95% CI for dichotomous data.

RESULTS

Our analysis included 15 studies involving 2064 patients, 909 (44%) of whom received antiplatelets and 1155 (56%) received anticoagulants. Our analysis showed a non-significant difference in terms of the 3-month mortality (OR 0.47, 95% CI 0.03-7.58), > 3-month mortality (OR 1.63, 95% CI 0.40-6.56), recurrent stroke (OR 0.97, 95% CI 0.46-2.02), recurrent transient ischaemic attack (TIA) (OR 0.93, 95% CI 0.44-1.98), symptomatic intracranial haemorrhage (sICH) (OR 0.38, 95% CI 0.12-1.19), and complete recanalization (OR 0.70, 95% CI 0.46-1.06). Regarding primary ischaemic stroke, the results favoured AC over AP among RCTs (OR 6.97, 95% CI 1.25-38.83).

CONCLUSION

Our study did not show a considerable difference between the two groups, as all outcomes showed non-significant differences between them, except for primary ischaemic stroke (RCTs) and complete recanalization (observational studies), which showed a significant favour of AC over AP. Even though primary ischaemic stroke is an important outcome, several crucial points that could affect these results should be paid attention to. These include the incomplete adjustment for the confounding effect of AP-AC doses, frequencies, administration compliance, and others. We recommend more well-designed studies to assess if unnecessary anticoagulation can be avoided in CeAD.

Antiplatelets or anticoagulants? Secondary prevention in cervical artery dissection: an updated meta-analysis

BACKGROUND

Extracranial artery dissection involving either internal carotid artery or vertebral artery is a major cause of stroke in adults under 50 years of age. There is no conclusive evidence whether antiplatelets or anticoagulants are better suited in the treatment of extracranial artery dissection.

OBJECTIVES

To determine whether antiplatelets or anticoagulants have advantage over the other in the treatment of extracranial artery dissection for secondary prevention of recurrent ischemic events or death.

METHODS

Present meta-analysis followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement. Database search was done in Medline, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov from inception to May 2021 using pre-defined search strategy. Additional studies were identified from reference lists from included studies, reviews and previous meta-analyses. Outcome measures were ischaemic stroke, ischaemic stroke or transient ischaemic attack (TIA), and death.

RESULTS

Two RCTs and 64 observational studies were included in the meta-analysis. While the outcome measures of stroke, stroke or TIA and death were numerically higher with antiplatelet use, there were no statistically significant differences between antiplatelets and anticoagulants.

CONCLUSION

We found no significant difference between antiplatelet and anticoagulation treatment after extracranial artery dissection. The choice of treatment should be tailored to individual cases.

Antiplatelet vs. Anticoagulation in Cervical Artery Dissection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: The optimal management for cervical artery dissection (CAD) is uncertain. This study aimed to summarize the current randomized controlled trials (RCTs) to compare the efficacy and safety of antiplatelet and anticoagulation therapies for CAD. Methods: A literature search was conducted in the major databases, such as MEDLINE, Embase, and the Cochrane Library. Only the RCTs comparing the antiplatelet and anticoagulation therapies for the patients with CAD were included. Combined estimates of the relative risk (RR) of antiplatelet vs. anticoagulation were analyzed. Heterogeneity was measured using the I 2 statistical analysis. The analyses were performed in the intention-to-treat (ITT) and per-protocol (PP) population, respectively. Results: Two RCTs involving 444 patients in the ITT population and 370 patients in the PP population were included. The quality of studies was high overall. In the ITT population, compared with the patients in the anticoagulation group, the patients in the antiplatelet group showed a higher rate of ischemic stroke within 3 months (RR = 6.73 [95% CI, 1.22-37.15], I 2 = 0%, P = 0.029). No difference between these two treatment groups was found for the outcomes of transient ischemic attack (RR = 0.37 [95% CI, 0.09-1.58], I 2 = 0%, P = 0.181), intracranial hemorrhage (RR = 0.33 [95% CI, 0.01-7.98], I 2 = 0%, P = 0.494), major extracranial bleeding (RR = 0.31 [95% CI, 0.01-7.60], I 2 = 0%, P = 0.476), or the composite of these outcomes within 3 months. For the PP population, the results of the meta-analysis of outcomes between the antiplatelet and anticoagulation groups were consistent with the ITT population. Conclusions: Compared with the antiplatelet group, the anticoagulation group has a lower risk of ischemic stroke without increasing bleeding risk when treating CAD. Anticoagulation seems to be superior over the antiplatelet in treating CAD but needs to be further tested by specifying several issues, such as location, initial symptom types, and treatment protocols.

Stroke Prevention in Cervical Artery Dissection

PURPOSE OF REVIEW

Cervical artery dissection (CAD) is rare, yet it is a common cause of stroke in young and middle-aged adults. Historically, some senior clinicians favored anticoagulation in the prevention of stroke due to CAD. Choosing the optimal antithrombotic treatment with either antiplatelet (AP) or anticoagulant (AC) medications remains a challenge. This paper will review the clinical features and imaging of CAD, and the acute treatment and prevention of stroke due to CAD.

RECENT FINDINGS

Until 2015, there were no prospective randomized trials in the optimal antithrombotic management of CAD. The Cervical Artery Dissection in Stroke Study (CADISS) trial found that treatment with AC did not lower the risk of subsequent stroke or death at 3 months when compared to AP agents. This led to a paradigm shift in national guidelines. In 2021, The Biomarkers and Antithrombotic Treatment in of Cervical Artery Dissection (TREAT-CAD) trial however did not confirm the non-inferiority of AP therapy in stroke prevention due to CAD. The optimal antithrombotic management for stroke prevention in CAD remains uncertain, while the superiority of anticoagulation has not been established, nor has the non-inferiority of AP agents. The future direction of research should consider early preventative treatment, dual treatment with AP agents, direct oral AC medications, and aggregation of data from existing randomized trials.

ESO guideline for the management of extracranial and intracranial artery dissection

The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.

Cervical and intracranial artery dissections

This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.

Establishment of Carotid Artery Dissection and MRI Findings in a Swine Model

Carotid artery dissection (CAD) is the leading cause of ischemic stroke in young patients; however, the etiology and pathophysiology of CAD remain largely unknown. In our study, two types of dissections (length × width: 1.5 cm × 1/3 circumference of intima, Group I, n = 6; or 1.5 cm × 2/3 circumference of intima, Group II, n = 6) were created between the media and intima. Ultrasound (within 2 h after dissection) showed a dissociated intima in the lumen and obstructed blood flow in the surgical area. Digital subtraction angiography (DSA, 72 h after dissection), magnetic resonance imaging (MRI, 72 h after dissection), and hematoxylin–eosin (H&E, 7 days after dissection) staining confirmed stenosis (33.67 ± 5.66%) in Group I and total occlusion in Group II. In 10 out of 12 swine, the CAD model was established using a detacher and balloon dilation, and morphological outcomes (stenosis or occlusion) after CAD were determined by the size of intimal incision.

Clival fractures in children: a challenge in the trauma room setting!

OBJECTIVE

A clival fracture is a rare but life-threatening traumatic brain injury in the adult and pediatric populations. To date, there are very few conclusive recommendations in the literature concerning the diagnosis and treatment of pediatric clival fractures.

METHODS

In 2014 and 2015, two pediatric patients with severe blunt head trauma and clival fractures were evaluated and treated at a level I trauma center. Both cases are documented and supplemented by an extensive review of the literature focusing on the diagnostic workup, classification, and clinical course of clival fractures in children.

RESULTS

The clinical course of two children (8 and 9 years old) with clival fractures in concert with other intra- and extracranial injuries was analyzed. A total of 17 papers encompassing 37 patients (age range, 1-18 years) were included for a systematic review. The literature review revealed a mortality rate of 23% in pediatric patients with a clival fracture. Over 50% of the patients presented with cranial nerve damage, and two-thirds suffered from intracranial vascular damage or intracerebral bleeding.

CONCLUSIONS

Clival fractures are a very rare but severe consequence of blunt head trauma in the pediatric population and may be challenging to diagnose, especially in cases with an unfused sphenooccipital synchondrosis. Vascular damage following clival fractures appears to be as common in pediatric patients as in adults. Therefore, contrast-enhanced CT of the cervical spine and head and/or magnetic resonance angiography is strongly recommended to rule out vascular injury of the extra- and intracranial brain-supplying vessels within the trauma room setting.

Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial

BACKGROUND

Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines-based on available evidence from mostly observational studies-suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection.

METHODS

We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0-3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460.

FINDINGS

Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI -4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group.

INTERPRETATION

Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection.

FUNDING

Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.

Internal Carotid Artery Dissection - A Case for Antithrombotic Therapy in the Era of (Minimally) Invasive Procedures

Objectives: Carotid artery dissection represents a common cause of stroke among people aged 30-45. We present two clinical cases and a review of the literature concerning the management of internal carotid artery dissections (ICADs). Materials and methods: The two patients are a 54-year-old male and a 40-year-old female. The first patient presented to our Neurology Department for one-week-old intense occipital headache. His clinical examination revealed left-sided miosis and upper eyelid ptosis. He underwent cerebral-cervical computed tomography (CT) and computed tomography angiography (CTA) scans and the latter revealed hemodynamically significant narrowing of both ICAs (right C1-C5 and left C1-C2 segments). Transcranial Doppler ultrasonography and Doppler ultrasonography (DUS) of the cervical-cerebral arteries showed right ICA occlusion at its origin (dissection fold and intraluminal thrombosis). Cervical magnetic resonance imaging (MRI) and time-of-flight magnetic resonance angiography (MRA) revealed a semilunar-shaped T2-weighted hypersignal present in the walls of the C1-C5 segments of the right ICA and of the C1-C2 segments of the left ICA, with bilaterally reduced intraluminal flow (right more than left). These findings indicated the presence of bilateral ICA intramural hematomas caused by subacute bilateral ICAD. The second patient presented to our Neurology Department for recurrent episodes of headache and lateral cervical pain on both sides. She underwent transcranial DUS and DUS of the cervicalcerebral arteries. They revealed right ICAD fold in its upper cervical segments. The CTA scan of the supra-aortic trunks showed hemodynamically significant narrowing with subsequent diminished blood flow in the upper cervical segments of right ICA. The patient was diagnosed with right ICAD. Results:Both patients were treated using antiplatelet therapy for primary prevention of ischaemic events. Follow-up at seven months and at six months, respectively, by means of CTA of the supra-aortic trunks or MRA of the cervical region, revealed the restoration of arterial patency with subsequent normal blood flow in both cases. Conclusions: The long-term outcomes of ICADs should be kept in mind when assigning medical or endovascular management on a case-by-case basis. Antiplatelet or anticoagulant therapy is a safe and effective first-line strategy in such patients, especially in cases that do not warrant particular management.

Ischemic Stroke in the Young

The purpose of this article is to address several challenging questions in the management of young patients (those age 60 and under) who present with ischemic stroke. Do genetic thrombophilic states, strongly associated with venous thrombosis, independently cause arterial events in adults? Should cases of patent foramen ovale be closed with mechanical devices in patients with cryptogenic stroke? What are the optimal treatments for cerebral vein thrombosis, carotid artery dissection, and antiphospholipid syndrome and are DOACs acceptable treatment for these indications? What is the mechanism underlying large vessel stroke in patients with COVID-19? This is a narrative review. We searched PubMed and Embase and American College of physicians Journal club database for English language articles since 2000 looking mainly at randomized clinical trials, Meta analyses, Cochran reviews as well as some research articles viewed to be cutting edge regarding anticoagulation and cerebrovascular disease. Searches were done entering cerebral vein thrombosis, carotid dissection, anticoagulation therapy and stroke, antiphospholipid antibody and stroke, stroke in young adults, cryptogenic stroke and anticoagulation, patent foramen ovale and cryptogenic stroke, COVID-19 and stroke.

Evolving Approaches to Antithrombotics in Stroke Prevention and Treatment

The optimization of antithrombotic therapy for acute stroke treatment and secondary prevention is an evolving process based on an increasing array of studies that provide an evidence-based approach. Options have increased dramatically with the release of the non-vitamin K oral anticoagulants and with the results of recent randomized clinical trials designed to assess potential benefits versus risks for patients in an individualized fashion. Recent studies have provided important information to guide choice and dosing of antiplatelet agents as well as the length of treatment. Anticoagulant use is particularly pertinent for stroke prevention in patients at higher risk of atrial fibrillation and may have a place in certain other stroke mechanisms. One important focus of study is the potential benefit of combined antiplatelet and anticoagulant therapy. Options for our patients, when the initial choice of therapy does not demonstrate benefit or is not well tolerated, clearly, are valuable. For example, short-term dual antiplatelet therapy for minor stroke and transient ischemic attack is being adopted, but with the recognition that longer-term combined therapy is not worth the increased risk of bleeding. Alternative antiplatelet choices, such as cilostazol and possibly ticagrelor, may be of benefit for refractory patients and this could affect the decision-making process. This review represents an effort to incorporate the information from more recent stroke prevention and treatment studies with information gleaned from prior studies.

Surgical clip occlusion of the V3 segment to prevent recurrent cerebral infarction associated with extracranial vertebral artery dissection: A case report

Background:

Recurrent cerebral infarction caused by traumatic extracranial vertebral artery dissection (EVAD) is treated medically and surgically. We report a case of EVAD that was treated using surgical clip occlusion of the V3 segment to prevent recurrent cerebral infarction.

Case Description:

A 48-year-old man was admitted for a cerebral infarction caused by EVAD and was treated using 200 mg/day cilostazol. Afterward, the cerebral infarction recurred. Digital subtraction angiography revealed that initial severe stenosis of the VA ostium resulted in the final occlusion and that collateral vessels to the VA remained. We continued antiplatelet therapy, but the cerebral infarction recurred due to thromboembolism of the collateral vessels. Parent artery occlusion was planned. We exposed the V3 segment of the VA and clipped it to prevent the recurrence of cerebral infarction.

Conclusion:

Surgical clip occlusion of the V3 segment was effective for treating recurrent cerebral infarction caused by traumatic EVAD that had remained an issue despite continuing medical therapy.

Hemichorea-hemiballismus as the initial manifestation of symptomatic middle cerebral artery dissection: A case report

INTRODUCTION

Hemichorea-hemiballismus, which spans a spectrum of involuntary, continuous, nonpatterned movement involving one side of the body, can emerge as the initial manifestation of acute ischemic stroke. However, because of its rarity in the community, the diagnosis and treatment are often delayed.

PATIENT CONCERNS

We report a unique case of a 47-year-old female who presented with acute onset hemichorea-hemiballismus. No obvious focal sign apart from involuntary, continuous, nonpatterned movement of her left arm and leg was presented.

DIAGNOSIS

Initial diffusion-weighted magnetic resonance imaging (MRI) was negative but significant increase of blood flow velocity in the right middle cerebral artery (MCA) stem was revealed by transcranial doppler sonography. Repeated MRI showed acute infarction in the contralateral globus pallidus. Isolated dissection of the right MCA typified by intimal flap with double lumen was identified by digital subtraction angiography and high-resolution magnetic resonance imaging (HR-MRI).

INTERVENTIONS

The patient was initially treated with dual antiplatelet agents but the uncontrollable movement deteriorated during hospitalization. Antithrombotic therapy was then intensified with combination of tirofiban and low-molecular-weight heparin. Other symptomatic treatment included volume expansion with colloidal fluid to improve cerebral perfusion. Her involuntary movement gradually diminished and the patient was discharged with rivaroxaban 15 mg/daily.

OUTCOMES

The patient had recovered with significant reduction in her hemichorea-hemiballismus. Three-month follow-up HR-MRI showed complete resolution of the MCA dissection lesions.

CONCLUSION

Prompt recognition of acute onset hemichorea-hemiballismus as the manifestation of acute ischemic stroke in appropriate clinical setting may reduce diagnostic delay. Multiple imaging techniques including cerebral digital subtraction angiography and HR-MRI can be applied to diagnosis and further clarify the mechanism of stroke, which facilitate in selection of secondary prevention therapies.

Post-Traumatic Carotid Artery Dissection Begins at the Skull Base: A Case Report

Cervical artery dissection is a rare complication of head and neck trauma. Though it is an infrequent cause of ischaemic stroke, it is more common among the young with cerebral ischaemia. The usual location of carotid dissection is just beyond the carotid bulb. We report a case of post-traumatic internal carotid dissection that began at the base of the skull after blunt head trauma from a road traffic accident. The patient is a 25-year-old right-handed lady who, 2 days after the accident, developed dysphasia and right-sided limb weakness. She had no significant past medical history. Magnetic resonance imaging (MRI) showed acute ischaemic stroke in the internal watershed regions of the left cerebral hemisphere. MR angiogram revealed focal near-occlusion of the left internal carotid artery at the base of the skull just prior to its entry into the petrous temporal bone. There were no skull fractures. She progressed despite anticoagulation. The location of the site of dissection at the base of the skull is likely due to stresses on the carotid intima at this point during flexion-extension-rotation that occurs during head injury, as this is where the internal carotid artery is tethered to the skull. Rapid recognition of symptoms of cerebral ischaemia among patients with blunt head trauma is needed to allow prompt investigation and institution of relevant therapies.

Cervical Artery Dissections with and without stroke, risk factors and prognosis: a Chilean prospective cohort

We aimed to characterize spontaneous cervical artery dissection (CeAD) patients with and without stroke and describe risk factors for cerebrovascular complications in a Chilean prospective cohort.

METHODS

Consecutive CeAD patients admitted to a Chilean center confirmed by neuroimaging. Logistic regression was used.

RESULTS

168 patients were included, median follow-up time was 157 days. Stroke occurred in 49 (29.2%) cases, 4 (2%) patients died, all of whom had a stroke, and 10 (6%) presented CeAD recurrence. In univariate analyses, men (odds ratio [OR] 3.97, 95% confidence interval [CI] 1.97-8.00, P < 0.001), internal carotid artery CeAD (OR 2.82, 95% CI 1.38-5.78, P = 0.005) and vessel occlusion (OR 4.45, 95% CI 1.38-14.38, P = 0.035) increased stroke risk. Conversely, vertebral artery dissection (OR 0.35, 95% CI 0.16-0.74, P = 0.006) and longer symptom onset to admission (O-A) time (OR 0.79, 95% CI 0.70-0.90, P < 0.001) were associated to decreased stroke risk. After multivariate analysis, men (OR 2.88, 95% CI 1.32-6.27, P = 0.008) and O-A time (OR 0.80, 95% CI 0.69-0.92, P = 0.002) remained independently associated with stroke.

CONCLUSION

CeAD presented commonly as a non-stroke entity, with favorable prognosis. Albeit to a higher frequency of CeAD in women, stroke occurred predominantly in men, who were admitted earlier.

Biomarkers and antithrombotic treatment in cervical artery dissection - Design of the TREAT-CAD randomised trial

Introduction

The type of antithrombotic treatment in cervical artery dissection patients is still a matter of debate. Most physicians prefer anticoagulants over antiplatelet agents for stroke prevention. However, this approach is not evidence-based and antiplatelets might be as safe and as effective. The 'Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection' ('TREAT-CAD') trial (clinicaltrials.gov: NCT02046460) compares Aspirin to oral anticoagulants (vitamin K antagonists) with regard to efficacy and safety by using both clinical and imaging surrogate outcome measures. TREAT-CAD tests the hypothesis, that aspirin is as safe and effective as vitamin K antagonists.

Patients and methods

TREAD-CAD is a Prospective, Randomised controlled, Open-labelled, multicentre, non-inferiority trial with Blinded assessment of outcome Events (PROBE-design). Key eligibility criteria are (i) clinical symptoms attributable to cervical artery dissection and (ii) verification of the cervical artery dissection diagnosis by established magnetic resonance imaging criteria. Patients are randomised to receive either Aspirin 300 mg daily or vitamin K antagonists for 90 days.

Results

Primary outcomes are assessed at 14 ± 10 days (magnetic resonance imaging and clinical examination) and at 90 ± 30 days (clinical examinations). The primary endpoint is a composite outcome measure - labelled Cerebrovascular Ischemia, major Hemorrhagic events or Death (CIHD) - and includes (i) occurrence of any stroke (including retinal infarction), (ii) new ischaemic lesions on diffusion-weighted magnetic resonance imaging, (iii) any major extracranial haemorrhage, (iv) any symptomatic intracranial haemorrhage, (v) any new haemorrhagic lesion visible on paramagnetic-susceptible sequences and (vi) death.

Discussion

After database closure, (i) central verification of cervical artery dissection diagnosis will be done by two experienced raters, (ii) adjudication of outcome events will be performed by independent adjudication committees, separately for clinical and imaging outcomes. The primary analysis will be done on the per protocol data set. The targeted sample size consists of 169 evaluable patients in the per protocol data set.

Conclusion

TREAT-CAD is testing the non-inferiority of Aspirin versus vitamin K antagonists treatment in patients with symptomatic cervical artery dissection by combined clinical and magnetic resonance imaging outcomes.

Imaging features of vertebral artery fenestration

PURPOSE

Vertebral artery fenestration (VAF) is a rare congenital vascular anomaly which has been associated with intracranial aneurysm. VAF can share some similar imaging features with vertebral artery dissection (VAD), which may confound diagnosis of the latter on CT and MR angiography. The purpose of this investigation is to assess the prevalence of VAF, evaluate its association with other vascular anomalies, and identify imaging features to help in distinguishing VAF and VAD.

METHODS

Using keyword search on CTA and MRA head and neck imaging reports from 2010 to 2017, cases of VAF and VAD were retrospectively identified and imaging was reviewed. Imaging features including laterality; vertebral segment; length of affected segment; presence, number, and caliber of lumen(s); and presence of other vascular abnormalities were recorded for all cases and subsequently compared using Pearson's chi-squared test to assess for significant differences between the groups. Patient age, gender, and clinical presentations were also recorded.

RESULTS

Of 64,888 CT and MR angiographic examinations performed, VAF was identified in 67 (0.1%) and VAD in 54 (0.1%) patients. Compared with VADs, VAFs were shorter in length (p < 0.001), wider in luminal diameter (p < 0.001), more likely to occur at the V4 segment (p < 0.01), more likely to have two distinct lumens rather than one (p < 0.01), and less likely to present post-trauma (p < 0.01). Coexisting intracranial aneurysms were identified in 9% of patients with VAF.

CONCLUSION

VAFs, although rare, can be readily distinguished from VADs on angiographic imaging. Diagnosis of VAF should prompt review for intracranial aneurysm.

Antithrombotic Management of Ischemic Stroke

PURPOSE OF REVIEW

Ischemic stroke describes a condition in which inadequate blood flow leads to lack of oxygenation to the brain tissue and ensuing neuronal death. There are multiple causes of ischemic stroke, each of which may indicate different antithrombotic management strategies. The goal of this review is to provide information about antithrombotic therapies for secondary stroke prevention based on etiology of stroke.

RECENT FINDINGS

New studies of existing antiplatelet and antithrombotic therapies have demonstrated varied efficacies of treatments based on the underlying risk factor of ischemic stroke. Understanding the optimal therapies for secondary stroke prevention can enhance care of stroke patients and lower the incidence of recurrent cerebrovascular ischemia.

Spontaneous bilateral internal carotid and vertebral artery dissections with dominant-hemisphere circulation maintained by external carotid artery–ophthalmic artery anastomoses

Spontaneous cervical artery dissection (sCAD) is a major cause of stroke in young adults. Multiple sCAD is a rarer, more poorly understood presentation of sCAD that has been increasingly attributed to cervical trauma such as spinal manipulation or genetic polymorphisms in extracellular matrix components. The authors present the case of a 49-year-old, otherwise healthy woman, who over the course of 2 weeks developed progressive, hemodynamically significant, bilateral internal carotid artery and vertebral artery dissections. Collateral response involved extensive external carotid artery–internal carotid artery anastomoses via the ophthalmic artery, which were instrumental in maintaining perfusion because circle of Willis and leptomeningeal anastomotic responses were hampered by the dissection burden in the corresponding collateral vessels. Endovascular intervention by placement of Pipeline embolization devices and Atlas stents in bilateral internal carotid arteries was successfully performed. No syndromic or systemic etiology was discovered during a thorough workup.

[Dissection of the internal carotid artery in a patient with connective tissue dysplasia having risk variants of several candidate genes]

Spontaneous dissection of the vessels of the neck is one of the main causes of ischemic stroke in young patients under 45 years of age. According to morphological studies, dissection of the vessels of the neck can be based on dysplastic changes in the arterial wall in arteriopathies, Marfan syndrome, Ehlers-Danlos syndrome, undifferentiated connective tissue dysplasia. The article presents a case of spontaneous dissection of the internal carotid artery in a 30-year-old patient with clinical manifestations of undifferentiated connective tissue dysplasia and carriage of homozygous variants of candidate genes: 4G/4G of the PAI-1 (-675, 4G/5G), T/T of the MTHFR C677T, 5A/5A of the MMP-3 (-1171 5A/6A) and A/A of the MMP-9 (8202A/G).

Eagle's syndrome: a piercing matter

We present an unusual case of Eagle's syndrome with bilateral internal carotid artery dissection in a 45-year-old man. Initial symptomatology included ipsilateral headaches and facial sensory symptoms. A right horner's syndrome was present on clinical examination. Radiological imaging revealed an old infarct, with bilateral carotid dissections and bilateral elongated styloid processes consistent with Eagle's syndrome. Despite initiation of secondary prevention with antiplatelet therapy, he had two further ischaemic events. The case highlights the symptomatology and complications of Eagle's syndrome, with its management discussed through a review of similar case reports.

Hit by the wave: a case of painful Horner's and intramural haematoma of the carotid

Carotid artery dissection from rupture of the vasa vasorum is under-recognised. We report the case of a 60-year-old woman presenting to our hospital with a 2-week history of right-sided headache, neck pain, unequal pupils and ptosis after being hit by a wave on the beach. She was diagnosed with painful Horner's syndrome. MR angiogram revealed dissection of the right internal carotid artery with an intramural haematoma without an intimal flap. A diagnosis of carotid artery dissection from rupture of the vasa vasorum was made. Initial antithrombotic (aspirin and clexane) were stopped as she was deemed a low stroke risk with no signs of ischaemia on MR brain. Her clinical course was uneventful with resolution of the intramural haematoma seen on repeat MR angiogram.

Imaging and Management of Blunt Cerebrovascular Injury

Blunt cerebrovascular injury (BCVI) is a relatively rare but potentially devastating finding in patients with high-energy blunt force trauma or direct cervical and/or craniofacial injury. The radiologist plays an essential role in identifying and grading the various types of vascular injury, including minimal intimal injury, dissection with raised intimal flap or intraluminal thrombus, intramural hematoma, pseudoaneurysm, occlusion, transection, and arteriovenous fistula. Early identification of BCVI is important, as treatment with antithrombotic therapy has been shown to reduce the incidence of postinjury ischemic stroke. Patients with specific mechanisms of injury, particular imaging findings, or certain clinical signs and symptoms have been identified as appropriate and cost-effective for BCVI screening. Although digital subtraction angiography was previously considered the standard examination for screening, technologic improvements have led to its replacement with computed tomographic angiography. Of note, although not appropriate for screening, improvements in magnetic resonance angiography with vessel wall imaging hold promise as supplemental imaging studies that may improve diagnostic specificity for vessel wall injuries. Understanding the screening criteria, imaging modalities of choice, imaging appearances, and grading of BCVI is essential for the radiologist to ensure fast and appropriate diagnosis and treatment. This article details the imaging evaluation of BCVI and discusses the clinical and follow-up imaging implications of specific injury findings. ^©RSNA, 2018.

Neurogenic pulmonary oedema secondary to vertebral artery dissection while playing tennis

We present a case of a patient who developed vertebral artery dissection (VAD) while playing tennis and presented with neurogenic pulmonary oedema. The case highlights two important points: acute pulmonary oedema as an unusual presenting feature of VAD and VAD, an important cause of stroke in young people, as being associated with playing low-impact sports such as tennis. These associations, independent of each other, are under-recognised and can lead to a delay in diagnosis.

Cervical Artery Dissection and Choosing Appropriate Therapy

Cervical artery dissection is a common cause of stroke in young adults. This may result from head and neck trauma; it can also occur spontaneously or secondary to genetic connective tissue or vascular disorders. Neurologic symptoms arise as a result of thromboembolism and hypoperfusion causing cerebral ischemia. We present a case of a previously healthy male who was found to have a cervical internal carotid artery dissection and the decision to use antiplatelet therapy instead of anticoagulation to prevent stroke. Data is lacking regarding the efficacy of one therapy over the other.

Headache, TIA and subarachnoid haemorrhage: dissecting an unusual cause for stroke-like symptoms

We present a case of supraclinoid internal carotid artery dissection. Eleven months prior, the patient developed isolated periorbital pain and was diagnosed with giant-cell arteritis with iritis. The patient experienced recurrent spells concerning for transient ischaemic attacks and was transferred to our institution for endovascular intervention after head CT revealed an embolic infarct with a 'dense middle cerebral artery sign.' Digital subtraction angiography was negative for occlusion, instead demonstrating luminal stenosis and poststenotic dilatation. He subsequently experienced acute neurological decline secondary to massive subarachnoid haemorrhage. Non-invasive vascular imaging revealed an intimal flap and a pseudoaneurysm at the site of luminal stenosis, confirming our suspicion for intracranial carotid artery dissection. Given the moribund clinical state, the family opted to withdraw care, and he quickly expired.

Neurologic Injuries in Noncontact Sports

Noncontact sports are associated with a variety of neurologic injuries. Concussion, vascular injury (arterial dissection), and spinal cord trauma may be less common in noncontact sports, but require special attention from the sports neurologist. Complex regional pain disorders, muscle injury from repetitive use, dystonia, heat exposure, and vascular disorders (patent foramen ovale), occur with similar frequency in noncontact and contact sports. Management of athletes with these conditions requires an understanding of the neurologic consequences of these disorders, the risk of injury with return to play, and consideration for the benefits of exercise in health restoration and disease prevention.

The 100 most-cited articles on aortic dissection

Background

To identify and characterize the most frequently cited articles that have been published on aortic dissection.

Methods

A list of the 100 most frequently cited publications (T100) about aortic dissection was generated by performing a searching of the Science Citation Index--Expanded using “aortic dissection” as the search term. Basic information about the articles was recorded, including number of citations, journal title, journal impact factor, time since publication, first author’s country, topic/subspecialty of the research, and publication type.

Results

We finally included 180 articles on aortic dissection, from which we identified the 100 most frequently cited articles (T100). The most frequently cited article received 1079 citations, while the least frequently cited article received 68 (mean140.5 citations per article). The T100 originated from 19 countries, with more than half of them originating from the USA (n = 97). The T100 articles were published from 1955 to 2013, with 79% published during the period 1990–2009. In addition, there were 40 different journals with Circulation having the most citations (n = 38). Regarding the article type, there were 21 basic and 140 clinical research articles, one meta-analysis, and 18 review articles. Reviews had the highest mean number of citations (mean 235.5 citations per article).

Conclusions

Our study provides a historical perspective on the progress of dissection research, and helps to identify the quality of the work, the discoveries made, and the trends steering the studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0426-9) contains supplementary material, which is available to authorized users.

Clinical presentation, management, follow-up, and outcomes of isolated celiac and superior mesenteric artery dissections

OBJECTIVE

Isolated visceral artery dissections are rare entities with no current consensus guidelines for treatment and follow-up. This study aims to evaluate the presentation, management, outcomes, and follow-up practices for patients with isolated visceral artery dissections and to compare those with and without symptoms.

METHODS

In this retrospective analysis, we identified all patients with isolated celiac artery and/or isolated superior mesenteric artery dissections at a single institution between September 2006 and December 2014. Patients with concomitant aortic dissections were excluded. Cases were stratified by symptom status. Presentation, anatomic findings, treatment, outcomes, and follow-up imaging were then compared between symptomatic and asymptomatic patients.

RESULTS

We identified 25 patients including 15 with symptoms and 10 without. There were no differences in patient comorbidities; however, symptomatic patients more frequently presented with thrombus (n = 10; 67% vs n = 1; 10%; P = .01) and inflammation (n = 8; 53% vs n = 1; 10%; P = .04), and trended toward increased stenosis (n = 12; 80% vs n = 4; 40%; P = .09) compared with asymptomatic patients. All asymptomatic patients were treated with observation alone with vessel diameter enlargement noted in 33% (n = 2) of patients on follow-up imaging. Among symptomatic patients, standard treatment included a short course of anticoagulation (mean, 4.5 months) with lifelong antiplatelet therapy. Three patients underwent operative intervention for persistent or worsening symptoms, two during the index admission and one 10 months after presentation for chronic abdominal pain. Approximately 70% (n = 17) of patients in each group had follow-up imaging (computed tomography angiography: n = 14; 56%; magnetic resonance angiography: n = 4; 16%; ultrasound: n = 13; 52%). Among patients treated nonoperatively, no patients complained of symptoms at follow-up, and 50% of those with inflammation on initial imaging had resolution. Twenty-five percent (n = 4) of patients had an increase in vessel size; however, all vessels remained less than 2 cm in maximal diameter. There were no ruptures or related deaths in either group.

CONCLUSIONS

Among patients with visceral artery dissection, no ruptures occurred but diameter enlargement was documented. This disease progression suggests that routine surveillance may be appropriate; however, transitioning early to ultrasound imaging should be considered to decrease radiation, contrast, and associated costs.

Cerebrovascular disease

With 16.9 million people who suffered a first-ever stroke in 2010 worldwide, stroke is a very common vascular disease. Epidemiologic studies have played an essential role in assessing this burden and in detecting the risk factors for stroke. Primary prevention of these risk factors, primarily hypertension, smoking, diabetes, and atrial fibrillation, has reduced the incidence in high-income countries. However, stroke remains a major cause of death and disability, and therefore research should be continued. Subarachnoid hemorrhages are less prevalent than strokes but have an even higher risk of death. Similar to stroke, epidemiologic studies identified smoking and hypertension as its most important risk factors, together with excessive alcohol intake. Although rare, arterial dissections, CADASIL, arteriovenous malformations, venous sinus thrombosis, moyamoya disease, and vasculitis can lead to serious symptoms. The burden and risk factors of those rare diseases are more challenging to assess. Whenever possible, they should be recognized in a timely manner for their increased risk of stroke, but most often they are diagnosed only at the time of stroke. Some cerebrovascular abnormalities do not result in immediate symptoms. This subclinical cerebrovascular disease includes silent infarcts, white-matter lesions, and microbleeds, and is incidentally found by neuroimaging. These lesions are not innocent, as several epidemiologic studies have associated subclinical cerebrovascular disease with an increased risk of stroke, cognitive decline, dementia, and death.