Elevated peripheral leukocyte counts in acute cervical artery dissection

Elevated serum levels of anti-collagen type I antibodies in patients with spontaneous cervical artery dissection and ischemic stroke: a prospective multicenter study

Introduction

Spontaneous cervical artery dissection (sCAD) is a rare vasculopathy whose trigger is still unknown. We hypothesized that autoimmunity against components of the vascular wall might play a critical role in sCAD and examined anti-collagen type I antibodies in patients with sCAD, acute ischemic stroke, patients with thromboendarterectomy, and controls.

Methods

Fifty-seven patients with sCAD (age 45.7 ± 10.2 years, female 18 (31.6%)) were prospectively enrolled in four German stroke centers. Blood samples were collected at baseline, at day 10 ± 3, and after 6 ± 1 months. Patients with ischemic stroke not related to CAD (n=54, age 56.7 ± 13.7 years, female 15 (27.8%)), healthy probands (n=80, age 57.4 ± 12.9 years, female 56 (70%)), and patients undergoing thromboendarterectomy of the carotid artery (n=9, age 70.7 ± 9.3 years, female 2 (22.2%)) served as controls. Anti-collagen type I antibodies were determined by enzyme-linked immunosorbent assays (ELISAs).

Results

Patients with acute sCAD had higher serum levels of anti-collagen type I antibodies (33.9 ± 24.6 µg/ml) than probands (18.5 ± 11.0 µg/ml; p <0.001) but lower levels than patients with ischemic stroke not related to sCAD (47.8 ± 28.4 µg/ml; p=0.003). In patients with sCAD, serum levels of anti-collagen type I antibodies were similar in the acute, subacute, and chronic phase. Levels of anti-collagen type I antibodies significantly correlated with circulating collagen type I (rho=0.207, p=0.003).

Conclusion

Anti-collagen type I antibodies seem not to represent a trigger for acute sCAD or ischemic stroke but may rather be linked to the metabolism and turnover of collagen type I.

COVID-19 Does Not Increase the Risk of Spontaneous Cervical Artery Dissection

Background Case reports have raised the possibility of an association between coronavirus disease 2019 (COVID-19) and spontaneous cervical artery dissection (sCeAD), yet no large studies have examined this association. We hypothesized that adults with confirmed COVID-19 would have an increased risk of sCeAD over the subsequent six months compared to test-negative controls after adjusting for confounding variables. Methods We obtained data from a United States medical records network (TriNetX, Inc., Cambridge, MA) of >106 million patients, providing adequate power needed for this rare outcome. We identified two cohorts of adults meeting the criteria of (1) test-confirmed COVID-19 or (2) non-COVID-19 test-negative controls, from April 1, 2020, to December 31, 2022. Patients with previous COVID-19 or conditions predisposing to sCeAD were excluded. Propensity matching was used to control for variables associated with sCeAD and markers of healthcare utilization. Results The number of patients reduced from before matching (COVID-19: 491,592; non-COVID-19: 1,472,895) to after matching, resulting in 491,115 patients per cohort. After matching, there were 22 cases of sCeAD in the COVID-19 cohort (0.0045%) and 20 cases in the non-COVID-19 cohort (0.0041%), yielding a risk ratio of 1.10 (95% CI: 0.60-2.02; P = 0.7576). Both cohorts had a median of five healthcare visits during follow-up. Conclusions Our results suggest that COVID-19 is not a risk factor for sCeAD. This null finding alleviates the concern raised by initial case reports and may better direct future research efforts on this topic.

Ovarian hyperstimulation syndrome with carotid artery dissection and cerebral infarction: a case report

BACKGROUND AND PURPOSE

Ovarian hyperstimulation syndrome (OHSS) is one of the most serious iatrogenic complications in assisted reproductive technology, which seem rarely associated with cerebrovascular diseases. We reported a patient diagnosed with OHSS combined with carotid artery dissection and massive cerebral infarction.

CASE PRESENTATION

We reported a unique case of a 31-year-old woman who experienced abdominal pain, blurred consciousness, and speech inability after 15-day continuous injection of human gonadotropin for infertility. Imaging examination showed hyperacute cerebral infarction in the left frontotemporal island parietal lobe and left internal carotid artery dissection. After therapeutic use of low-molecular-weight heparin calcium anticoagulation and other conventional cerebrovascular treatments, she eventually achieved a good prognosis.

CONCLUSIONS

OHSS seemd rarely associated with cerebrovascular diseases, such as infarction and carotid artery dissection. Encountering abdominal symptoms combined with neurologic symptoms, a detailed history and a thorough examination are essential. It is necessary to comprehensively analyze the pathogenesis and formulate individualized therapy according to the specific conditions of patients.

Analysis of a delayed diagnosis of carotid artery aneurysm presenting as a parapharyngeal space infection

It is very rare for extracranial carotid artery dissection to present as a carotid pseudoaneurysm. A delayed diagnosis and delayed treatment will lead to rupture of carotid pseudoaneurysm and massive hemorrhage and death. In this paper, we reviewed the progress of the disease in one patient and reviewed the relevant literature reports to understand the characteristics of the disease. The patient had two consultations within the otolaryngology department. The patient later showed signs of infection in the parapharyngeal space and then died of an aneurysmal rupture and massive hemorrhage.

A review of carotid and vertebral artery dissection

Cervical artery dissection is a major cause of ischaemic stroke in young adults. The diagnosis can be challenging as some patients may present with seemingly benign symptoms such as a headache, neck pain or dizziness. However, the neurological sequelae of a transient ischaemic attack, vision loss or ischaemic stroke are potentially devastating. All hospital clinicians must be able to recognise this diagnosis and organise timely and appropriate investigations as antithrombotic treatment reduces the risk of stroke recurrence. This article reviews the literature to provide practical information for clinicians to recognise key risk factors and features of history and examination which should raise suspicion of cervical artery dissection. Diagnosis can now be made using the non-invasive, commonly available modalities of computed tomography angiography or magnetic resonance angiography. Timely treatment with antithrombotic agents is recommended to reduce the rate of an ischaemic stroke.

Influenza-Like Illness is Associated with Increased Short-Term Risk of Cervical Artery Dissection

INTRODUCTION

Non-traumatic Cervical Artery Dissection (CeAD) is a leading cause of ischemic stroke in the young. Influenza-like illnesses (ILI) trigger ischemic strokes. We hypothesized that influenza and ILI are associated with CeAD.

METHODS

In a case-crossover study within the New York State (NYS) Department of Health Statewide Planning and Research Cooperative System (2006-2014), we used ICD-9 codes to exclude major trauma and to define CeAD, influenza, and the Centers for Disease Control defined ILI. We estimated the association of ILI and influenza with CeAD by comparing their prevalence in intervals immediately prior (0-30,0-90,0-180, and 0-365 days) to CeAD (case period) to their prevalence exactly one and two years earlier (control periods). Conditional logistic regression models generated odds ratios and 95% confidence intervals (OR, 95% CI). Models were adjusted for NYS estimates of influenza prevalence rates.

RESULTS

Our sample included 3,610 cases of CeAD (mean age 52±16 years, 54.7% male, 6.2% Hispanic, 9.9% Black, 68.7% White). During case periods, 7.3% had one or more ILI. ILI was more likely within 90 days of CeAD compared to the same time interval one and two years before (0-15 days: adjusted OR 1.88, 95%CI 1.20-2.94; 0-30 days: adjusted OR 1.74, 95%CI 1.22-2.46; 0-90 days: adjusted OR 1.35, 95%CI 1.00-1.81). Influenza trended with CeAD (adjusted OR 1.86, 95%CI 0.37-9.24), but these results were not statistically significant, due to limited instances of confirmed influenza.

CONCLUSIONS

ILI may increase risk of CeAD for 15 days, and possibly up to three months.

Combined utility of blood glucose and white blood cell in predicting outcome after acute ischemic stroke: The ENCHANTED trial

BACKGROUND

As hyperglycemia and leukocytosis individually predict poor outcome in acute ischemic stroke (AIS), we aimed to determine the significance of their combination on functional outcome and symptomatic intracerebral hemorrhage (sICH) among participants of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).

METHODS

Post-hoc analyzes of the full ENCHANTED cohort, an international, multicenter, quasi-factorial, randomized, open, blinded outcome-assessed trial of low- versus standard-dose intravenous alteplase and early intensive versus standard blood pressure (BaP) lowering treatment in 4557 thrombolysis-eligible and treated AIS patients. Patients were divided into four groups according to baseline blood glucose and white blood cells (WBC) levels: A (normal glucose + WBC), B (hyperglycemia + normal WBC), C (normal glucose + high WBC), and D (hyperglycemia + high WBC). Logistic regression models were used to determine associations of each group and poor functional outcome (modified Rankin scale scores 2-6) at 90 days and sICH within 48 h, adjusted for confounders. Quality of model fit was examined with Akaike information classification (AIC), Bayesian information classification (BIC), and likelihood ratio test.

RESULTS

Of 4181 AIS patients included in analyzes, and with group A as the reference, an increasing odds of poor functional outcome was evident across groups B (odds ratio [OR] 1.38, 95 % confidence interval [CI] 1.17-1.63), C (OR 1.26, 95 %CI 0.99-1.60), and D (OR 2.26, 95 %CI 1.79-2.85) (P trend <0.001). Group D patients also had a higher rate of sICH (P trend <0.05). The model fit with the combination of blood glucose and WBC was better than models of their individual components.

CONCLUSIONS

Using a combination of blood glucose and WBC provides strong prognostic significance than either alone in thrombolyzed AIS patients.

Serum-Based Proteomics Reveals Lipid Metabolic and Immunoregulatory Dysregulation in Cervical Artery Dissection With Stroke

Cervical artery dissection (CAD) is an important causal factor for stroke in young and middle-aged individuals and presents a great burden to the individual stroke victim. However, the pathophysiological mechanisms underlying CAD remain unknown. Here, an iTRAQ (isobaric tagging for relative and absolute quantitation)–based quantitative proteomic approach was performed, to identify differentially expressed proteins in serum samples obtained from spontaneous CAD and non-CAD ischemic stroke subjects. Differential protein expression was analyzed for Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway overrepresentation, and six differential proteins were selected for enzyme-linked immunosorbent assay validation. Through KEGG analysis, the significantly differentiated proteins were primarily involved in immunoregulation, blood coagulation, and lipid metabolism. For the first time, differential expressions of apolipoprotein B, apolipoprotein C-I, lipopolysaccharide-binding protein, vascular cell adhesion molecule 1, fibulin-1, and ficolin-2 were confirmed as being significantly upregulated in CAD as compared to non-CAD ischemic stroke subjects. In conclusion, proteomic analysis reveals that early perturbation of immunoregulation and lipid metabolism may be involved in the pathophysiology of CAD. Specifically, the panel of six proteins identified is promising as serum-based biomarkers for the detection of increased CAD risk in stroke subjects.

Internal carotid and vertebral artery dissection: morphology, pathophysiology and provoking factors

The causes of internal carotid artery (ICA) and vertebral artery (VA) dissection, as well as its provoking factors, remain understudied. The aim of this paper was to explore morphological changes in the ICA/VA walls, factors provoking dissection, clinical signs and biomarkers of connective tissue (CT) damage. A total of 271 patients were examined, of whom 54% were women. The mean age of the participants was 37.0 ± 10 years. Clinical signs and biomarkers of CT damage (matrix metalloproteinase 9, tissue inhibitor of metalloproteinase 1, hydroxyproline, sulphated glycosaminoglycans) were analyzed in 82 patients and 40 healthy volunteers. Histologic examination of dissected and seemingly intact arteries conducted in 5 cases revealed signs of arterial wall dysplasia similar to those characteristics of fibromuscular dysplasia: thinning and splitting of the internal elastic membrane, areas of fibrosis, irregular orientation of myocytes, and their necrosis in the tunica media. Clinical signs and biomarkers of CT dysplasia (CTD) were more pronounced in patients with arterial dissection than in the controls. The major provoking factors were head turns and physical activity (42%), minor head injury (10%), and acute respiratory infection in the month preceding arterial dissection (14%). We conclude that arterial wall dysplasia is a predisposing factor for ICA/VA dissection, both spontaneous and provoked. The analysis of CTD biomarkers and clinical signs suggests connective tissue pathology in patients with ICA/VA dissection.

Total and differential leukocyte counts in ischemic stroke caused by vertebrobasilar artery dissection

INTRODUCTION

Vertebrobasilar artery dissection(VBD) is a common etiology of posterior circulation stroke(PCS). However, the etiology of VBD itself remains unclear. The present study aimed to test whether inflammation is involved in the mechanism of VBD by evaluating its relationship with total and differential leukocyte counts.

METHODS

Patients with PCS caused by VBD or by large artery atherosclerosis(LAA) were recruited between January 1, 2012 and December 31, 2014 from the Taipei Veterans General Hospital. Age- and sex-matched non-stroke(NS) volunteers were also included. Univariate and multivariate analyses were performed to compare total/differential leukocyte counts among VBD, LAA, and NS groups.

RESULTS

One-hundred-one patients with VBD [average age: 64.8(15.1) years; 77(76.2%) males], 70 with LAA [average age: 73.9(10.6) years; 44(62.9%) males], and 202 NS [average age: 64.8(15.1) years; 77(76.2%) males] patients were included in the present study. Compared with the NS and LAA groups, respectively, the VBD group had significantly higher total leukocyte and neutrophil counts and frequency of high leukocyte (>10,000 × 10⁶/L) and high neutrophil (>8000 × 10⁶/L) counts. Multivariate analyses, adjusted for age, sex, and vascular risk factors, showed that the VBD group, compared with the other groups, had an odds-ratio of 5.04 (95% confidence interval:2.43-10.43) and 5.90 (2.70-12.92) with respect to the prevalence of high leukocyte and high neutrophil counts.

CONCLUSION

VBD was associated with high leukocyte and neutrophil counts. Our results support that inflammation and neutrophil-related pathophysiology might be involved in the mechanism of VBD; however, the causal relationship would need further investigations.

Combined utility of white blood cell count and blood glucose for predicting in-hospital outcomes in acute ischemic stroke

Background

High white blood cell (WBC) count and high blood glucose level are risk factors for mortality and pneumonia after acute ischemic stroke (AIS). We investigated the combined effect of high WBC count and high blood glucose level on hospital admission and in-hospital mortality and pneumonia in acute AIS patients.

Methods

A total of 3124 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included in the present study. We divided patients into four groups according to their level of WBC count and blood glucose: NWNG (normal WBC count and normal glucose), NWHG (normal WBC count and higher glucose), HWNG (higher WBC count and normal glucose), and HWHG (higher WBC count and higher glucose). Cox proportional hazard model and logistic regression model were used to estimate the combined effect of WBC count and blood glucose on all-cause in-hospital mortality and pneumonia in AIS patients.

Results

HWHG was associated with a 2.22-fold increase in the risk of in-hospital mortality in comparison to NWNG (adjusted hazard ratio [HR] 2.22; 95% confidence interval [CI], 1.21–4.07; P trend = 0.003). The risk of pneumonia was significantly higher in patients with HWHG compared to those with NWNG (adjusted odds ratio [OR] 2.61; 95% CI, 1.66–4.10; P trend < 0.001). The C-statistic for the combined WBC count and blood glucose was higher than WBC count or blood glucose alone for prediction of in-hospital mortality and pneumonia (all p < 0.01).

Conclusions

High WBC count combined with high blood glucose level at admission was independently associated with in-hospital mortality and pneumonia in AIS patients. Moreover, the combination of WBC count and blood glucose level appeared to be a better predictor than WBC count or blood glucose alone.

Electronic supplementary material

The online version of this article (10.1186/s12974-019-1422-7) contains supplementary material, which is available to authorized users.

A case-control study of the determinants for cervicocerebral artery dissection

BACKGROUND

Cervicocerebral artery dissection (CAD) is a major cause of ischemic stroke in young adults. There are many existing studies on determinants for CAD; however, they are still not totally defined. We conduct the study to further investigate the determinants for CAD based on ischemic stroke patients.

METHODS

81 ischemic stroke patients with CAD were enrolled in the CAD stroke group and 84 ischemic stroke patients without CAD were enrolled in the non-CAD stroke group. Their clinical data, such as age, gender, vascular risk factors, headache and neck pain and clinical laboratory data, were collected to analyze the differences between the two groups.

RESULTS

A total of 165 ischemic stroke patients were included. The mean age of CAD stroke group was (51.6 ± 12.4) years, and (55.5 ± 8.1) years in non-CAD stroke group, with a statistically significant difference (P = 0.017). The average level of triglycerides in CAD stroke group was (1.3 ± 0.7) mmol/L, and (1.7 ± 1.1) mmol/L in non-CAD stroke group, with a statistically significant difference (P = 0.012). There were 42.0% (34/81) of headache and neck pain in CAD stroke group and 22.6% (19/84) in non-CAD stroke group, with a statistically significant difference (P = 0.008). The key findings with significant difference were stratified and multivariate logistic regression analysis showed that age < 50 years old (OR 2.98, 95% CI 1.43-6.21, P = 0.004), triglycerides < 1.6 mmol/L (OR 3.51, 95% CI 1.69-7.27, P = 0.001) and headache and neck pain (OR 2.94, 95% CI 1.39-6.20, P = 0.005) showed a positive correlation with CAD.

CONCLUSION

In the process of diagnosis and treatment of ischemic stroke, for patients with age < 50 years old, headache and neck pain and triglycerides < 1.6 mmol/L, the cervicocerebral artery dissection should be considered, and vascular imaging examination needs to be performed in time.

Cellular profile of primary molars with pulp necrosis after treatment with antibiotic paste

The interradicular region of primary molars is permeated by many foramina, channels and accessories that connect the pulp cavity with the periapical tissues anatomically. Thus, pulp decomposition products or drugs used in endodontic treatment can trigger inflammatory reactions. The aim of this study was to evaluate the blood cell profile of the alveolar region after extraction of primary molars treated with CTZ paste. Forty-eight primary molars were selected with clinical and radiographic signs of extraction. The sample was divided into three groups with 16 teeth each: Group 1-healthy teeth; Group 2-untreated decayed teeth; and Group 3-teeth treated with CTZ paste. Immediately after the extraction, blood from the interface of the tooth socket was collected and smears were performed for further evaluation. The slides were stained by the Fast Panoptic® method and analysed by two previously trained examiners who counted the leucocytes in sets of 100 cells/slide, differentiating them into neutrophils, lymphocytes, monocytes, eosinophils and basophils. The data were analysed statistically by the MANOVA test. The blood samples from Group 2 differed significantly from Group 1 samples for all classes of leucocytes, except basophils, with higher average for lymphocytes (62.56), monocytes (7.81) and eosinophils (2.31). For Group 3, there was a relative difference (P < 0.05) to Group 2, of monocytes and eosinophils values. The blood cellularity interface in the tooth socket of primary teeth treated with CTZ paste is similar to those of healthy, exfoliated teeth and physiologically different from untreated decayed teeth.

Determinants and outcome of multiple and early recurrent cervical artery dissections

Objective

To assess putative risk factors and outcome of multiple and early recurrent cervical artery dissection (CeAD).

Methods

We combined data from 2 multicenter cohorts and compared patients with multiple CeAD at initial diagnosis, early recurrent CeAD within 3 to 6 months, and single nonrecurrent CeAD. Putative risk factors, clinical characteristics, functional outcome, and risk of recurrent ischemic events were assessed.

Results

Of 1,958 patients with CeAD (mean ± SD age 44.3 ± 10 years, 43.9% women), 1,588 (81.1%) had single nonrecurrent CeAD, 340 (17.4%) had multiple CeAD, and 30 (1.5%) presented with single CeAD at admission and had early recurrent CeAD. Patients with multiple or early recurrent CeAD did not significantly differ with respect to putative risk factors, clinical presentation, and outcome. In multivariable analyses, patients with multiple or early recurrent CeAD more often had recent infection (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.29–2.53), vertebral artery dissection (OR 1.82, 95% CI 1.34–2.46), family history of stroke (OR 1.55, 95% CI 1.06–2.25), cervical pain (OR 1.36, 95% CI 1.01–1.84), and subarachnoid hemorrhage (OR 2.85, 95% CI 1.01–8.04) at initial presentation compared to patients with single nonrecurrent CeAD. Patients with multiple or early recurrent CeAD also had a higher incidence of cerebral ischemia (hazard ratio 2.77, 95% CI 1.49–5.14) at 3 to 6 months but no difference in functional outcome compared to patients with single nonrecurrent CeAD.

Conclusion

Patients with multiple and early recurrent CeAD share similar risk factors, clinical characteristics, and functional outcome. Compared to patients with single nonrecurrent CeAD, they are more likely to have recurrent cerebral ischemia at 3 to 6 months, possibly reflecting an underlying transient vasculopathy.

The value of plasma fibrillin-1 level in patients with spontaneous cerebral artery dissection

OBJECTIVE

To explore the value of plasma fibrillin-1 levels in patients with spontaneous cerebral artery dissection (sCeAD).

METHODS

A single-center prospective cohort of 99 consecutive patients with sCeAD between February 2013 and December 2015 were age and sex matched with 115 patients with non-sCeAD ischemic stroke and 20 healthy participants undergoing routine physical examination. The plasma fibrillin-1 level was measured with ELISA and compared among the 3 groups. The associations of fibrillin-1 with site, acuity, and severity of dissection, as well as clinical and radiographic prognosis of patients, were analyzed.

RESULTS

One hundred nine plasma samples from 99 patients with sCeAD, 115 from disease control patients, and 20 from healthy participants were collected. The plasma fibrillin-1 level of the dissection group (mean 85.56 ng/mL [95% confidence interval 81.53-89.59]) was higher than that of non-sCeAD ischemic stroke group (77.13 ng/mL [73.64-80.63], p = 0.015) or healthy controls (73.04 ng/mL [65.94-80.13], p = 0.029). Such differences were most prominent in the acute stage (97.64 ng/mL [91.64-103.64], 74.39 ng/mL [68.95-79.84], and 73.04 ng/mL [65.95-80.13], respectively). A cutoff value of 88.455 ng/mL was determined to differentiate acute dissection from nondissection stroke with a sensitivity of 0.778 and a specificity of 0.800. Higher fibrillin-1 level was detected in patients with more severe dissection radiographically (p < 0.001), while patients with lower fibrillin-1 concentration at baseline achieved better morphologic recovery on follow-up imaging tests (p = 0.003).

CONCLUSION

Plasma fibrillin-1 is a promising biomarker for aiding the diagnosis of acute sCeAD and may have potential value in lesion severity grading and radiographic prognosis prediction.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that patients with sCeAD have significantly higher levels of plasma fibrillin-1 than patients with ischemic stroke attributable to a cause other than sCeAD.

Epidemiology and cerebrovascular events related to cervical and intracranial arteries dissection: the experience of the city of Pisa

Spontaneous dissection of cervical arteries (sCAD) is a major cause of ischemic stroke in young patients, with an incidence varying from 1.7 to 3/100,000/year for extracranial internal carotid artery (ICAD) and 1 to 1.9/100,000/year for extracranial vertebral artery (VAD). Reliable epidemiological data on stroke incidence related to sCAD are scarce in Italy. This study aims to evaluate the incidence, clinical features, and outcome of cerebrovascular events related to sCAD and spontaneous intracranial arteries dissections (sIAD) in the city of Pisa (Italy). We retrospectively analyzed consecutive patients admitted between December 1997 and June 2015 with a diagnosis of stroke, TIA, or Bernard-Horner syndrome due to acute cervical or intracranial artery dissection. Considering that our hospital collects presumptively all patients hospitalized with sCAD coming from the referral geographical area, data may provide a good approximation to real incidence of sCAD in our population. Clinical and radiological features, acute treatment and outcome were collected. Seventy-seven cases were included (mean age 48.1±10.4 years, range 23-77,72.7% males), 66 residents in the district of Pisa. Crude incidence rate of cerebrovascular events due to intra or extracranial dissection was 1.88/100,000/year. The incidence of ICAD was 0.80/100,000/year and 0.43/100,000/year for VAD. Stroke occurred in 76.6% of patients. VAD was more prone to cause ischemic stroke and present with cervical pain or focal signs (p < 0.01) than ICAD group, which had older age at onset. sIAD were more frequent in the posterior circle (p = 0.01) and more associated with ischemic lesions. A good outcome (mRS 0-2) was observed in 79% of patients. This is the first epidemiological attempt to investigate impact of sCAD and sIAD in Italy.

Neuroinflammation in Ischemic Pediatric Stroke

Over the last decades, the importance of inflammatory processes in pediatric stroke have become increasingly evident. Ischemia launches a cascade of events: activation and inhibition of inflammation by a large network of cytokines, adhesion and small molecules, protease, and chemokines. There are major differences in the neonatal brain compared to adult brain, but developmental trajectories of the process during childhood are not yet well known. In neonatal stroke ischemia is the leading pathophysiology, but infectious and inflammatory processes have a significant input into the course and degree of tissue damage. In childhood, beside inflammation lanced by ischemia itself, the event of ischemia might be provoked by an underlying inflammatory pathophysiology: transient focal arteriopathy, dissection, sickle cell anemia, Moyamoya and more generalized in meningitides, generalized vasculitis or genetic arteriopathies (as in ADA2). Focal inflammatory reactions tend to be located in the distal part of the carotid artery or the proximal medial arteries, but generalized processes rather tend to affect the small arteries.

Risk Factors and Clinical Presentation of Cervical Arterial Dissection: Preliminary Results of a Prospective Case-Control Study

STUDY DESIGN

Cross-sectional case-control study.

OBJECTIVES

To identify risk factors and clinical presentation of individuals with cervical arterial dissection.

BACKGROUND

Cervical arterial dissection is a common cause of stroke in young people and has in rare cases been associated with cervical manipulative therapy. The mechanism is considered to involve pre-existing arterial susceptibility and a precipitating event, such as minor trauma. Identification of individuals at risk or early recognition of a dissection in progress could help expedite medical intervention and avoid inappropriate treatment.

METHODS

Participants were individuals 55 years of age or younger from the Hunter region of New South Wales, Australia with radiologically confirmed vertebral or internal carotid artery dissection and an age- and sex-matched comparison group. Participants were interviewed about risk factors, preceding events, and clinical features of their stroke. Physical examination of joint mobility and soft tissue compliance was undertaken.

RESULTS

Twenty-four participants with cervical arterial dissection and 21 matched comparisons with ischemic stroke but not dissection were included in the study. Seventeen (71%) of the 24 participants with dissection reported a recent history of minor mechanical neck trauma or strain, with 4 of these 17 reporting recent neck manipulative therapy treatment. Cardiovascular risk factors were uncommon, with the exception of diagnosed migraine. Among the participants with dissection, 67% reported transient ischemic features in the month prior to their admission for dissection.

CONCLUSION

Recent minor mechanical trauma or strain to the head or neck appears to be associated with cervical arterial dissection. General cardiovascular risk factors, with the exception of migraine, were not important risk factors for dissection in this cohort. Preceding transient neurological symptoms appear to occur commonly and may assist in the identification of this serious pathology.

LEVEL OF EVIDENCE

Prognosis, level 4.

Pathophysiology and risk factors of cervical artery dissection: what have we learnt from large hospital-based cohorts?

PURPOSE OF REVIEW

Cervical artery dissection (CeAD) is a major cause of ischemic stroke in young and middle-aged adults, although relatively uncommon in the community. Recent large collaborative projects have provided new insights into mechanisms and risk factors of CeAD.

RECENT FINDINGS

Pathologic changes observed at the media-adventitia border in temporal arteries of CeAD patients suggest a predisposing arterial wall weakness. In large multicenter series of CeAD patients, compared to age-matched healthy controls and patients with an ischemic stroke of another cause, hypertension and migraine, especially without aura, were confirmed as risk factors for CeAD, in addition to cervical trauma and recent infection. Hypercholesterolemia and being overweight were shown to be inversely associated with CeAD. Differences in risk factor profile and structural features between carotid and vertebral dissection suggest that their pathophysiology may partly differ. An association of CeAD with fibromuscular dysplasia and reversible cerebral vasoconstriction syndrome was described. Genetic risk factors of CeAD are still poorly understood.

SUMMARY

Large cohorts of CeAD patients have refined our understanding of the pathophysiology and risk factors of CeAD, but the molecular mechanisms are still poorly understood. Ongoing high-throughput genetic projects will hopefully provide novel insight into the biological substrate of CeAD.