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Zhou B, Hua Z, Li C, Jiao Z, Cao H, Xu P, Liu S, Li Z. Classification and management strategy of spontaneous carotid artery dissection. J Vasc Surg 2024:S0741-5214(24)01210-2. [PMID: 38777158 DOI: 10.1016/j.jvs.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/02/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Spontaneous carotid artery dissections (sCAD) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 sCAD patients and proposed a new classification for sCAD with prognostic and therapeutic significance. METHODS This is a retrospective review of prospectively collected data from June 2018 to June 2023 of sCAD patients treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types. Type Ⅰ: intramural hematoma or dissection with < 70% luminal narrowing; type Ⅱ: intramural hematoma or dissection with ≥ 70% luminal narrowing; type Ⅲ: dissecting aneurysm; type ⅣA: extracranial carotid artery occlusion; type ⅣB: tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCAD. RESULTS A total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 sCAD patients was 49.5 years, 78% were male, 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 (28.4%) type Ⅰ, 50 (25.4%) type Ⅱ, 60 (30.5%) type Ⅲ, and 31 (15.7%) type Ⅳ dissections. During a mean hospitalization length of 11.4±47.0 days, there were 9 recurrent strokes (4.6%) after medical treatment, 2 (1.0%) type Ⅲ dissections, 7 (3.6%) type Ⅳ dissections, all ipsilateral, and 1 death. Overall, there were 7 (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent stroke and 3 (1.5%, all type Ⅲ dissections) recurrent TIA in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine (51.8%) type I dissections were completely recanalized after antithrombotic therapy. A total of 19 (38 %) of type II dissections and 44 (73%) of type III dissections received endovascular treatment (EVT) for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight (33%) type IVB dissections received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all p > .05). Favorable outcome was achieved in 168 (93.9%) patients. CONCLUSIONS This study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcome should undergo further research.
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Affiliation(s)
- Baoning Zhou
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhaohui Hua
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chong Li
- The Vascular Care Group, Darien, CT, America
| | - Zhouyang Jiao
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui Cao
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Xu
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shirui Liu
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Li
- Department of Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China;.
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Pini R, Faggioli G, Lodato M, Campana F, Vacirca A, Gallitto E, Gargiulo M. Medical and interventional outcome of dissection of the cervical arteries: systematic review and meta-analysis. J Vasc Surg 2024:S0741-5214(24)00999-6. [PMID: 38636608 DOI: 10.1016/j.jvs.2024.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/29/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The management of cervical artery dissections (CADs) is poorly standardized given the scarce number of prospective studies comparing medical and interventional approach to CAD. The aim of the present study is to perform a systematic review and meta-analysis of studies on the treatments of CAD. METHODS Systematic review and meta-analysis (pre-registered on PROSPERO [CRD42022297512] are performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses [PRISMA] guidelines searching in three different databases [PubMed, Embase and Cochrane Database]) of studies on medical or interventional approach to CAD. Only prospective studies were selected to reduce the risk of bias for the primary meta-analysis. Secondarily, retrospective studies were also included. The aim was to assess the rate of stroke and of stroke/death/bleeding (major or intracranial) by Der Simonian-Laird weights of random effects model. RESULTS After screening 456 articles, 6 prospective and 22 retrospective studies were identified. Two randomized controlled trials and five retrospective studies comparing antiplatelet (APT) vs oral anticoagulant therapy (OAC) for CAD were identified, as well as four prospective and 17 retrospective single-arm studies evaluating stenting for CAD. In the meta-analysis of randomized controlled trials comparing APT vs OAC, 444 patients were considered, and a borderline significant association was identified in terms of stroke/death in the APT vs OAC groups (odds ratio [OR], 5.6; 95% confidence interval [CI], 0.94-33.38; P = .06; I2 = 0%). No differences were found for the stroke/death/bleeding outcome (OR, 1.25; 95% CI, 0.19-8.18; P = .81; I2 = 0%) between the two treatments. In the meta-analysis including also retrospective studies, overall risk of bias was considered "serious," and 4104 patients were included with no differences in APT vs OAC for stroke (OR, 1.06; 95% CI, 0.53-2.11; P = .29; I2 = 18%); no other comparisons were possible. The pooled meta-analysis of prospective studies on stenting for CAD included four series, for a total of 68 patients, in whom stenting was adopted primarily after failed medical therapy or after traumatic dissection. The pooled rate of stroke/death was 7% (95% CI, 3%-17%; I2 = 0%). The analysis of moderators identified a significant inverse association between the percentage of traumatic dissection and a reduction in postoperative stroke (Y = -1.60-2.02X; P = .03). The pooled rate of the composite endpoint of stroke/death/ or major bleeding was 8% (95% CI, 3%-18%; I2 = 0%). Secondarily, the meta-analysis also included 17 retrospective studies with overall 457 patients and showed a 2.1% pooled rate of stroke/death (95% CI, 1.0%-3.3%; I2 = 0%) and 3.2% stroke/death/bleeding (95% CI, 1.8%-4.7%; I2 = 0%). CONCLUSIONS Few prospective studies on CAD treatment are present in literature. APT and OAC seem to have similar efficacy in reducing the recurrence of stroke after CAD. No definitive conclusion can be drawn for stenting, due to the low number of studies available. More prospective studies are necessary to evaluate its potential additional value over medical therapy alone in the early phase after CAD.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy.
| | - Marcello Lodato
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Federica Campana
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Andrea Vacirca
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
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Alfandy F, Dugue R, Pulli B, George PM. Intravenous Tenecteplase and Carotid Artery Stenting in a Young Adult With Fibromuscular Dysplasia and Carotid Dissection. Stroke 2024; 55:e56-e60. [PMID: 38152960 DOI: 10.1161/strokeaha.123.045026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
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Long B, Pelletier J, Koyfman A, Bridwell RE. High risk and low prevalence diseases: Spontaneous cervical artery dissection. Am J Emerg Med 2024; 76:55-62. [PMID: 37995524 DOI: 10.1016/j.ajem.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Spontaneous cervical artery dissection (sCAD) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of sCAD, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION sCAD is a condition affecting the carotid or vertebral arteries and occurs as a result of injury and compromise to the arterial wall layers. The dissection most commonly affects the extracranial vessels but may extend intracranially, resulting in subarachnoid hemorrhage. Patients typically present with symptoms due to compression of local structures, and the presentation depends on the vessel affected. The most common symptom is headache and/or neck pain. Signs and symptoms of ischemia may occur, including transient ischemic attack and stroke. There are a variety of risk factors for sCAD, including underlying connective tissue or vascular disorders, and there may be an inciting event involving minimal trauma to the head or neck. Diagnosis includes imaging, most commonly computed tomography angiography of the head and neck. Ultrasound can diagnose sCAD but should not be used to exclude the condition. Treatment includes specialist consultation (neurology and vascular specialist), consideration of thrombolysis in appropriate patients, symptomatic management, and administration of antithrombotic medications. CONCLUSIONS An understanding of sCAD can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA
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Salehi Omran S. Cervical Artery Dissection. Continuum (Minneap Minn) 2023; 29:540-565. [PMID: 37039409 DOI: 10.1212/con.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Cervical artery dissection is a common cause of stroke in young adults. This article reviews the pathophysiology, etiology and risk factors, evaluation, management, and outcomes of spontaneous cervical artery dissection. LATEST DEVELOPMENTS Cervical artery dissection is believed to be a multifactorial disease, with environmental factors serving as possible triggers in patients who have a genetic predisposition to dissection formation. Cervical artery dissection can cause local symptoms or ischemic events, such as ischemic stroke or transient ischemic attack. Neuroimaging is used to confirm the diagnosis; classic findings include a long tapered arterial stenosis or occlusion, dissecting aneurysm, intimal flap, double lumen, or intramural hematoma. Patients with cervical artery dissection who present with an acute ischemic stroke should be evaluated for IV thrombolysis, endovascular therapy eligibility, or both. Antithrombotic therapy with either anticoagulation or antiplatelet treatment is used to prevent stroke from cervical artery dissection. The risk of recurrent ischemia appears low and is mostly limited to the first two weeks after symptom onset. ESSENTIAL POINTS Cervical artery dissection is a known cause of ischemic strokes. Current data show no difference between the benefits and risks of anticoagulation versus antiplatelet therapy in the acute phase of symptomatic extracranial cervical artery dissection, thereby supporting the recommendation that clinicians can prescribe either treatment. Further research is warranted to better understand the pathophysiology and long-term outcomes of cervical artery dissection.
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Latacz P, Lasocha B, Pawel B, Tadeusz P, Marian S. Results of Angioplasty With Double-Layer Mesh Stent and Protection Systems of the Extra- and Intracranial Dissection of Cephalic Arteries. J Endovasc Ther 2023; 30:66-74. [PMID: 35000472 DOI: 10.1177/15266028211068767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE Although a majority of cervical artery dissections can be managed conservatively, patients presenting with cerebral embolization or significant stenosis require a more aggressive approach. However, complications associated with endovascular repair are quite frequent and optimal interventional technique still remains to be established. MATERIALS AND METHODS The aim of this post hoc survey was to analyze results of endovascular treatments for symptomatic dissections of the internal carotid and vertebral arteries, which were performed under protection and with the use of double-layer mesh stents. During endovascular procedure catheters, stents and protection systems were tailored according to the angioarchitecture of dissection, particularly to its location, length and coexisting stenotic or aneurysmatic lesions. We evaluated retrospectively midterm and late results of endovascular treatment of 25 patients presenting with symptomatic dissection of cervical arteries, including 11 patients with dissections of intracranial segments of the internal carotid artery. Follow-ups were scheduled 1, 3 and 6 after the procedure, and then every 6 months. Control computed tomography (CT) or digital subtraction angiography (DSA) arteriographies were performed 1-6 months and 12 months after endovascular repair. RESULTS There were no periprocedural major adverse events. All patients completed the 12-month follow-up. There were neither fatalities nor new neurologic adverse events at the 30-day follow-up, and no such adverse events during long-term follow-up. At 12-month follow-up, in all patients, angiographies revealed patent stents, full coverage of lesions by stents and complete thrombotic closure of the pseudoaneurysms. CONCLUSIONS A tailored endovascular management of symptomatic dissection of cervical arteries is safe and efficient, also in a long run.
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Affiliation(s)
- Pawel Latacz
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Bartlomiej Lasocha
- Chair of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Brzegowy Pawel
- Chair of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Popiela Tadeusz
- Chair of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Simka Marian
- Department of Anatomy, University of Opole, Opole, Poland
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Lauzier D, Chatterjee A, Kansagra A. Neurointerventional management of cerebrovascular trauma. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2022-2(40)-41-54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.
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Primary stent implantation for bilateral spontaneous cervical ICA dissections with hypoperfusion after 72 h from onset: a case report. CVIR Endovasc 2022; 5:40. [PMID: 35962854 PMCID: PMC9375808 DOI: 10.1186/s42155-022-00318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Spontaneous cervical internal carotid artery dissection (cICAD) is a common cause of stroke in young adults. Endovascular therapy is an indispensable treatment for cICAD in some cases, but it faces great challenges. Case presentation A bilateral spontaneous cICADs with hypoperfusion-related AIS after 72 h from the onset was presented herein. The patient responded well to primary Solitaire stent detachment at the critical flow-limiting site. Conclusions Primary stent implantation at the critical flow-limiting site rather than covering the entire dissection may be a therapeutic option in spontaneous cICAD complicated with cerebral hypoperfusion. The Solitaire stent may be a good choice at the acute and subacute stages of cICAD.
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9
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Bontinis V, Antonopoulos CN, Bontinis A, Koutsoumpelis A, Zymvragoudakis V, Rafailidis V, Giannopoulos A, Stoiloudis P, Ktenidis K. A systematic review and meta-analysis of carotid artery stenting for the treatment of cervical carotid artery dissection. Eur J Vasc Endovasc Surg 2022; 64:299-308. [PMID: 35961627 DOI: 10.1016/j.ejvs.2022.07.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of carotid artery stenting for the treatment of extracranial carotid artery dissection (CAD). DATA SOURCES Systematic review using Medline, Scopus, EMBASE and Cochrane Library. REVIEW METHODS A systematic search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. Data from the eligible studies were extracted and meta-analyzed. Primary endpoints included postoperative mortality, cerebrovascular events (CE) and modified Rankin Score for neurologic disability (mRS) at 90 days. We performed subgroup analyses between stenting of spontaneous and traumatic CAD, primary stenting versus stenting after failed medical therapy (FMT) and stenting of CAD in the presence of tandem occlusions versus stenting of isolated extracranial CAD. RESULTS Twenty-four studies with 1,224 patients were included. Pooled post-operative mortality, CE and mRS 0-2 rates were 1.71% (95%CI:0.83-2.80), 6.45% (95%CI:2.80-11.10) and 76.13% (95%CI:64.15-86.50), respectively. The pooled stroke rate was 2.16% (95%CI:0.0-6.64). Spontaneous versus traumatic CAD mortality rates were 3.20% (95%CI:1.80-4.88) and 0.00% (95%CI:0.00-1.59) while CE rates were 14.26% (95%CI:6.28-24.36) and 1.64% (95%CI:0.0-6.08). Primary stenting and stenting after FMT mortality rates were 0.63% (95%CI:0.0-5.63) and 0.0% (95%CI:0.0-2.24), while CE rates were 5.02% (95%CI:0.38-12.63) and 3.33% (95%CI:0.12-9.03). Mortality rates for tandem occlusions and isolated extracranial CAD were 5.62% (95%CI:1.76-10.83) and 0.23% (95%CI:0.0-1.88) respectively, while CE rates were 15.28% (95%CI:6.23-26.64) and 1.88% (95%CI:0.23-4.51). The methodological index for non-randomized studies (MINORS) score was 8.66 (low). CONCLUSION Both primary stenting and stenting of spontaneous CAD yielded unfavorable results regarding stent thrombosis and stroke rates. Conversely, stenting following FMT displayed acceptable mortality and complication rates corroborating the use of stenting in the setting of CAD as a second line treatment. Due to the low quality of the included studies, definite conclusions cannot be drawn necessitating further research.
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Affiliation(s)
- Vangelis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Alkis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Vassilios Zymvragoudakis
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vasileios Rafailidis
- Department of Radiology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Argirios Giannopoulos
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Stoiloudis
- 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
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Wilfling S, Kilic M, Tsoneva B, Freyer M, Olmes D, Wendl C, Linker R, Schlachetzki F. Recurrent vertebrobasilar strokes and transient-ischemic attacks with challenging workup: Case report. Brain Circ 2022; 8:50-56. [PMID: 35372722 PMCID: PMC8973451 DOI: 10.4103/bc.bc_61_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/06/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
Detecting the stroke etiology in young patients can be challenging. Among others, determining causality between ischemic stroke and patent foramen ovale (PFO) remains a complicated task for stroke neurologists, given the relatively high prevalence of PFOs. Thorough diagnostic workup to identify incidental vascular risk factors and rare embolic sources is crucial to avoid premature PFO closure suggesting successful secondary stroke prevention. In this paper, we report on a 38-year-old patient with recurrent vertebrobasilar territory, especially right posterior inferior cerebellar artery (PICA) territory strokes. After the initial suspicion of a left vertebral artery (VA) dissection was not confirmed by ultrasound and magnetic resonance imaging (MRI) and other major risk factors were excluded, a PFO was detected and closed. Successful PFO closure was confirmed by transesophageal echocardiography, yet recurrent transient-ischemic attacks and vertebrobasilar strokes, especially during nighttime and in the early morning, occurred despite various antiplatelet and antithrombotic regimes and a persistent right-to-left shunt was detected by bubble transcranial Doppler. Finally, MRI after another vertebrobasilar infarction detected a transient left VA occlusion that finally led to the diagnosis of a left VA pseudoaneurysm from an incident emboligenic dissection in the atlas segment. This pseudoaneurysm together with an anatomical variant of the right PICA originating with the right anterior inferior cerebellar artery from the basilar artery finally explained the recurrent ischemic events of the patient. After successful treatment with coil occlusion, the patient suffered no further stroke and recovered completely. In summary, stroke in the young remains a diagnostic challenge. The incidental finding of a PFO should not deter from thorough stroke workup and the follow-up of these patients including PFO closure verification should be performed under the guidance of vascular neurologists.
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Chen Y, Mofatteh M, Nguyen TN, Wellington J, Wei W, Liang W, Chen G, Hu Z, Ouyang K, Yang S. Carotid Artery Dissection and Ischemic Stroke Following Cervical Chiropractic Manipulation: Two Case Reports. Vasc Endovascular Surg 2021; 56:303-307. [PMID: 34971321 DOI: 10.1177/15385744211072660] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Patients can be at risk of carotid artery dissection and ischemic stroke after cervical chiropractic manipulation. However, such risks are rarely reported and raising awareness can increase the safety of chiropractic manipulations. CASE REPORT We present two middle-aged patients with carotid artery dissection leading to ischemic stroke after receiving chiropractic manipulation in Foshan, Guangdong Province, China. Both patients had new-onset pain in their necks after receiving chiropractic manipulations. Excess physical force during chiropractic manipulation may present a risk to patients. Patient was administered with recombinant tissue plasminogen activator after radiological diagnoses. They were prescribed 100 mg and clopidogrel 75 mg daily for 3 months as dual antiplatelet therapy. There were no complications over the follow-up period. CONCLUSION These cases suggest that dissection of the carotid artery can occur as the result of chiropractic manipulations. Patients should be diagnosed and treated early to achieve positive outcomes. The safety of chiropractic manipulations should be increased by raising awareness about the potential risks.
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Affiliation(s)
- Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Thanh N Nguyen
- Department of Neurology, Radiology, 12259Boston University School of Medicine, Boston, MA, USA
| | | | - Wenlong Wei
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Wenjun Liang
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Gan Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Zhaohui Hu
- Medical Department and Neurosurgery Department, Foshan Sanshui District People's Hospital, Foshan, China
| | - Kexun Ouyang
- Department of Radiology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Shuiquan Yang
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
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12
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Lauzier DC, Chatterjee AR, Kansagra AP. Neurointerventional management of cerebrovascular trauma. J Neurointerv Surg 2021; 14:718-722. [PMID: 34949708 DOI: 10.1136/neurintsurg-2021-017923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/04/2021] [Indexed: 11/03/2022]
Abstract
Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA .,Department of Neurological Surgery, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
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13
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Affiliation(s)
- Enrique C Leira
- Department of Neurology, Department of Neurosurgery, Carver College of Medicine and Department of Epidemiology, College of Public Health, University of Iowa, Iowa City
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Al-Bayati AR, Nogueira RG, Haussen DC. Carotid Artery Stenting: Applications and Technical Considerations. Neurology 2021; 97:S137-S144. [PMID: 34785612 DOI: 10.1212/wnl.0000000000012802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 03/03/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW To examine current understanding of diverse etiologies of extracranial carotid disease, including clinical and imaging manifestations as well as treatment approaches. RECENT FINDINGS Increasing availability of advanced cerebrovascular imaging modalities continues to elucidate atherosclerotic and nonatherosclerotic carotid steno-occlusive disease as a common culprit of cerebral ischemia. Individualized treatment strategies targeting each etiologic subset would optimize preventive measures and minimize recurrence of cerebral ischemia. SUMMARY Ischemic stroke is a prominent cause of mortality and long-term disability worldwide. The magnified effect of carotid disease warrants constant and close inspection.
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Affiliation(s)
- Alhamza R Al-Bayati
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
| | - Raul G Nogueira
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Diogo C Haussen
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
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15
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Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J 2021; 6:XXXIX-LXXXVIII. [PMID: 34746432 PMCID: PMC8564160 DOI: 10.1177/23969873211046475] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/26/2021] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Stephanie Debette
- Bordeaux Population Health research
center, INSERM U1219, University of Bordeaux, Bordeaux, France
- Department of Neurology and
Institute for Neurodegenerative Diseases, Bordeaux University
Hospital, France
| | - Mikael Mazighi
- Department of Neurology, Hopital Lariboisière, Paris, France
- Interventional Neuroradiology
Department, Hôpital Fondation Ophtalmologique
Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- FHU NeuroVasc, Paris, France
- Laboratory of Vascular Translational
Science, INSERM U1148, Paris, France
| | - Philippe Bijlenga
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and
Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Masatoshi Koga
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - Anna Bersano
- Fondazione IRCCS Istituto Neurologico
'Carlo Besta', Milano
| | - Janika Kõrv
- Department of Neurology and
Neurosurgery, University of Tartu, Tartu, Estonia
- Department of Neurology, Tartu University
Hospital, Tartu, Estonia
| | - Julien Haemmerli
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | | | - Piotr Tekiela
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Kaori Miwa
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - David J Seiffge
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Sabrina Schilling
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Marcel Arnold
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Hugh S Markus
- Department of Clinical
Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan T Engelter
- Department of Neurology and
Stroke Center, University Hospital and University of
Basel, Basel, Switzerland
- Neurology and
Neurorehabilitation, University Department of Geriatric
Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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Internal Carotid Dissection as the Cause of Stroke in Childhood. Case Rep Pediatr 2021; 2021:5568827. [PMID: 34258095 PMCID: PMC8261171 DOI: 10.1155/2021/5568827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022] Open
Abstract
Internal carotid artery (ICA) dissection is a cause of stroke, but it is often underdiagnosed in children. ICAs' risk factors and pathogenic mechanisms are poorly understood, and the treatment is still empirical. We report the case of a previously healthy 9-year-old girl who presented with involuntary hypertonic closure of the right hand associated with transient difficulty for both fine movements of the right arm and speech. She had a history of minor cervical trauma occurring 20 days prior to our observation without other associated risk factors. Magnetic resonance imaging and magnetic resonance angiography showed ischemic lesions due to the left ICA dissection. Treatment with both acetylsalicylic acid and levetiracetam allowed recanalization of the ICA associated with the resolution of clinical signs. Our clinical case suggests that the ICA dissection must be suspected early whenever a child manifests mild neurologic deficits after a cervical trauma, especially if they are associated with headache and/or cervical pain. Moreover, the management of ICA dissection must be improved.
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17
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1021] [Impact Index Per Article: 340.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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18
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Sanada T, Wada H, Sato H, Shirai W, Kinoshita M, Tokumitsu N. Carotid artery stenting assisted with intravascular ultrasonography for isolated spontaneous common carotid artery dissection. J Surg Case Rep 2021; 2021:rjab232. [PMID: 34188795 PMCID: PMC8224205 DOI: 10.1093/jscr/rjab232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 11/14/2022] Open
Abstract
Isolated spontaneous common carotid artery (CCA) dissection is extremely rare. Moreover, only a few case reports for isolated spontaneous CCA dissection treated with carotid artery stenting (CAS) can be found so far. Here, the authors report a case where intravascular ultrasonography (IVUS) provided valuable information about lesion evaluation, stent selection and stent placement during CAS for isolated CCA dissection. A 69-year-old male was diagnosed with an isolated spontaneous left CCA dissection. CAS assisted with IVUS was performed to prevent further dissection and cerebral infarction recurrence. To the best of our knowledge, this is the first case report of an isolated spontaneous CCA dissection treated with CAS assisted by IVUS. CAS assisted by IVUS may be an effective treatment option to prevent intraoperative complications and further stroke recurrence for isolated spontaneous CCA dissection.
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Affiliation(s)
- Takahiro Sanada
- The Department of Neurosurgery, Nayoro City General Hospital, Nayoro, Japan
| | - Hajime Wada
- The Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hirotaka Sato
- The Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Japan
| | - Wakako Shirai
- The Department of Neurosurgery, Nayoro City General Hospital, Nayoro, Japan
| | - Manabu Kinoshita
- The Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Japan
| | - Naoki Tokumitsu
- The Department of Neurosurgery, Nayoro City General Hospital, Nayoro, Japan
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Pérez-Sánchez S, Domínguez-Mayoral A, De Torres-Chacón R, Gamero-García MA, Barragán-Prieto A, Escudero-Martínez I, Ocete RF, Herrero-Lara J, Algaba P, Moniche F, González A, Cueto L, Montaner J. Cervical dissection diagnoses increase following endovascular treatments. J Int Med Res 2021; 48:300060520906740. [PMID: 32223660 PMCID: PMC7133397 DOI: 10.1177/0300060520906740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objectives The detection of cervical arterial dissection (CAD) has been rising in recent years owing to advanced imaging techniques. The aim of this study was to explore whether wide implementation of endovascular treatment for ischemic stroke has an impact on the diagnosis of CAD. Methods We included all patients with CAD diagnosed at two university hospitals in Seville, Spain from January 2015 to December 2017. We collected clinical variables and information on imaging techniques used for the diagnosis. Implementation of 24 hour/365 day mechanical thrombectomy began in Seville on 15 August 2016. We compared diagnosis rates of CAD performed before and after this date. Results We identified 41 patients with CAD. We found 13 patients diagnosed before (1.1% of all ischemic strokes) and 28 (2.2%) after implementation of neurointerventional therapy. In 17 patients, diagnosis was made in the acute phase. Dissection was not suspected according to computed tomography angiography in 11 patients owing to small dissections (n = 2) or total occlusion (n = 9). Conclusions CAD diagnoses have been rising in recent years, essentially owing to continuous improvement in imaging techniques. Rapid access to arteriography for thrombectomy is increasing the diagnoses of CAD, even in patients with a low suspicion of dissection.
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Affiliation(s)
- Soledad Pérez-Sánchez
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain.,Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain
| | - Ana Domínguez-Mayoral
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain.,Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain
| | - Reyes De Torres-Chacón
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain.,Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain
| | - Miguel A Gamero-García
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain.,Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain
| | - Ana Barragán-Prieto
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain.,Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain
| | - Irene Escudero-Martínez
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain.,Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Rafael F Ocete
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain.,Department of Radiology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Juan Herrero-Lara
- Department of Radiology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Pilar Algaba
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain
| | - Francisco Moniche
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain.,Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alejandro González
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain.,Department of Radiology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Luis Cueto
- Department of Radiology, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Joan Montaner
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain.,Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Seville, Spain
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20
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Predisposing factors and radiological features in patients with internal carotid artery dissection or vertebral artery dissection. BMC Neurol 2020; 20:445. [PMID: 33302898 PMCID: PMC7731460 DOI: 10.1186/s12883-020-02020-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023] Open
Abstract
Background Cervicocerebral artery dissection is an important cause of ischemic stroke in young and middle-aged individuals. However, very few studies have compared the differential features between internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD), including both cervical and intracranial artery dissections. We conducted a study to investigate the predisposing factors and radiological features in patients with ICAD or VAD. Methods All cases diagnosed with cervicocerebral artery dissection, ICAD, or VAD were identified through a medical records database, between January 2010 and January 2020. Baseline characteristics, predisposing factors, and radiological features of ICAD versus VAD were compared. Results A total of 140 patients with cervicocerebral artery dissection were included in the study, including 84 patients in the ICAD group and 56 in the VAD group. The mean age of patients in the ICAD and VAD groups was 43.37 ± 14.01 and 41.00 ± 12.98 years old, respectively. Patients with ICAD were more likely to be men compared with VAD (85.71% vs. 67.86%, p = 0.012). The frequency of hypertension, diabetes, smoking, drinking, and cervical trauma did not differ between ICAD and VAD. Dissections of ICAD were more frequently at the extracranial portions of the artery compared with those of VAD (70.24% vs. 44.64%, p = 0.003). In contrast, dissections of VAD were more common in the intracranial artery (55.36% vs. 29.76%, p = 0.003). Radiologically, double lumen (36.90% vs. 19.64%, p = 0.029) and intimal flap (11.90% vs. 1.79%, p = 0.029) were more frequently observed in ICAD than in VAD, and dissecting aneurysms were less frequent (13.10% vs. 26.79%, p = 0.041). Conclusions The distributions of cervical and intracranial artery dissections were different between ICAD and VAD. The frequencies of radiological features detected in patients with ICAD and VAD also differed.
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21
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22
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Endovascular management of carotid and vertebral artery dissections with new generation double-mesh stent and protection systems - single-center early and midterm results. Adv Cardiol 2019; 15:321-327. [PMID: 31592256 PMCID: PMC6777181 DOI: 10.5114/aic.2019.84409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/21/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Symptomatic dissections (SD) of cervical arteries are still a therapeutic problem. Although endovascular management (EM) is currently a preferred method of treatment of SD, complications associated with this method of treatment in published reports are quite frequent (3-16%). AIM In this retrospective study we analyzed the results of EM with novel, double-mesh stent and protection systems (PS) for SD of the internal carotid (IC) or vertebral arteries (VA) that coexisted with hemodynamically significant stenosis or aneurysmatic dilatation of the dissected artery. MATERIAL AND METHODS We evaluated the results of EM in 19 patients (men 15, median age: 55, range: 25-83), presenting with SD of the IC or VA with coexisting stenosis and/or aneurysmatic dilatation of the artery in segments C1-C5 of IC or V0-V4 of VA. Twelve patients had a stroke, 6 TIA, and 3 patients a headache and/or a neck pain with Horner syndrome. Stents and PS were tailored according to the location, length of dissection and coexisting stenotic or aneurysmatic lesions. RESULTS There were no new strokes, in-hospital deaths or other serious morbidities during the procedure and postprocedural hospital stay. There were no fatalities during 6-40 months of follow-up. In control angiographies performed after interventions all patients demonstrated a patent target artery, complete coverage of the dissection and aneurysm by stents and no new lesions in the area of the previous dissection. CONCLUSIONS The results of this study indicate that EM of SD of IC and VA with the new stents and PS is safe and effective with good early and midterm results.
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Effects of laser needle-knife therapy on vertebroarterial morphology and protein expression of PI-3K, AKT and VEGF in the carotid artery in a rabbit model of cervical spondylotic arteriopathy. Saudi J Biol Sci 2018; 26:390-394. [PMID: 31485183 PMCID: PMC6717135 DOI: 10.1016/j.sjbs.2018.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 11/16/2018] [Accepted: 11/18/2018] [Indexed: 12/03/2022] Open
Abstract
Purpose To explore how the use of a laser needle-knife affects vertebroarterial morphology and protein expression of PI-3K, AKT and VEGF in the carotid artery of a rabbit model of cervical spondylotic arteriopathy (CSA), and to determine its primary treatment mechanism. Methods The CSA rabbit model consisted of 30 rabbits with CSA that were randomly divided into a model group (n = 10), an acupuncture group (n = 10) and a laser needle-knife group (n = 10) plus a further 10 wild type rabbits placed into a normal group. Rabbits in the acupuncture group were treated by needling the Fengchi (GB 20) and Jiaji (EX-B2) acupoints, while those in the laser needle-knife group were treated with a laser needle-knife on the Jiaji (EX-B2) near the spinous process of the fifth cervical vertebra, the rabbit in both groups immobilized during treatment. Rabbits in the other two groups received no treatment, but were immobilized for a similar duration. The morphology of the right vertebral artery and the distribution of pore size before and after treatment were compared using BET and SEM, and the protein expression of PI-3K, AKT and VEGF in the carotid artery of the four groups measured using Western blot analysis. Results The pore diameter and specific surface area of the right vertebral artery increased after treatment, as did the number of micropores. Compared with the normal group, the protein expression of PI-3K, AKT and VEGF in the carotid artery of the model group was significantly lower (P < 0.05), while that of the laser needle-knife group was significantly higher (P < 0.05 and P < 0.01). In addition, rabbits from the acupuncture and laser needle-knife groups demonstrated significantly higher levels of protein expression of PI-3K and VEGF in the carotid artery compared with the model group (P < 0.05 and P < 0.01). Conclusions By promoting micrangium hyperplasia within the vertebral artery of rabbits with CSA, treatment with a laser needle-knife modified the protein expression of PI-3K, AKT and VEGF, suggesting that laser needle-knife therapy possibly treats CSA though these signaling pathways.
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Stone DK, Viswanathan VT, Wilson CA. Management of Blunt Cerebrovascular Injury. Curr Neurol Neurosci Rep 2018; 18:98. [DOI: 10.1007/s11910-018-0906-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Berti AF, Zafar A, Ikram A, Calder CS, Sorte DE. Recurrent posterior circulation infarcts secondary to vertebral artery external compression treated with endovascular deconstruction. Interv Neuroradiol 2017; 24:178-182. [PMID: 29239686 DOI: 10.1177/1591019917747879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
When multiple, recurrent infarcts occur in spite of maximal medical management, the level of suspicion for atypical vascular injury should be heightened. We present a case of a patient who presented with recurrent posterior circulation infarcts despite optimized medical management. On imaging, he was found to have external anatomical vertebral artery muscular and/or osseous compression leading to repetitive vascular injury and strokes. Recurrent intimal injury and vertebral artery to intracranial emboli despite anticoagulation and subsequent dual antiplatelet therapy necessitated definitive operative management. Surgical bypass, external surgical decompression, reconstructive endovascular, and deconstructive endovascular techniques were carefully considered. A deconstructive endovascular approach was chosen as the least morbid option. The use of endovascular plugs such as a microvascular plug provides a quick and effective means of achieving a therapeutic parent artery occlusion in lieu of traditional coil occlusion. Although reserved as a last resort, parent artery occlusion can be a viable option to treat recurrent strokes, particularly in a nondominant vertebral artery.
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Affiliation(s)
| | - Atif Zafar
- 1 Department of Neurology, 1104 University of New Mexico , Albuquerque, USA
| | - Asad Ikram
- 1 Department of Neurology, 1104 University of New Mexico , Albuquerque, USA
| | | | - Danielle Eckart Sorte
- 2 Departments of Radiology and Neurosurgery, 1104 University of New Mexico , Albuquerque, USA
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26
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Migliaccio D, Lindquist B. A Posterior Circulation Stroke Presenting with Isolated Truncal Ataxia. Cureus 2017; 9:e1709. [PMID: 29188153 PMCID: PMC5703583 DOI: 10.7759/cureus.1709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Vertebral artery dissection is an infrequent and often misdiagnosed cause of stroke. In this case report, we describe a patient with a posterior circulation stroke caused by a vertebral artery dissection, who presented to the emergency department with isolated truncal ataxia. This case emphasizes the importance of obtaining a thorough history and physical exam for all neurologic complaints, including a careful ambulation assessment.
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Affiliation(s)
- Daniel Migliaccio
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
| | - Benjamin Lindquist
- Department of Emergency Medicine, Stanford University School of Medicine
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27
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Guan Q, Chen L, Long Y, Xiang Z. Iatrogenic Vertebral Artery Injury During Anterior Cervical Spine Surgery: A Systematic Review. World Neurosurg 2017; 106:715-722. [PMID: 28712898 DOI: 10.1016/j.wneu.2017.07.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Iatrogenic vertebral artery injury (VAI) during anterior cervical surgery is rare but potentially catastrophic. METHODS Causes, presentation, diagnosis, management, prognosis, and prevention of VAI were reviewed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. English language studies and case reports published from 1980 to 2017 were retrieved. Data on diagnosis, surgical procedures and approach, site and cause of VAI, management, outcomes, and vertebral artery (VA) status were extracted. RESULTS In 25 articles including 54 patients, VAI was diagnosed during or after surgery commonly indicated for cervical degenerative diseases (64%), tumors (14%), and trauma (9%). The incidence of VAI for each side was similar regardless of approach. Common presentations were unexpected copious surgical bleeding, delayed hemorrhage of pseudoaneurysm with neck swelling, dyspnea, hypotension, and cervical bruits caused by arteriovenous fistula. Causes included drilling (61%), instrumentation (16%), and soft tissue retraction (8%). Direct exposure or angiography confirmed VAI. Ten patients had VA anomalies; collateral status was verified in 9 before definitive treatment. Tamponade was adopted for urgent hemostasis in most cases but with a high incidence of pseudoaneurysm (48%). Unknown VA status increased occlusion risk and neurologic sequelae (41%). VA repair and stent placement had excellent outcomes. CONCLUSIONS Extensive lateral decompression, loss of landmarks, and anatomic variations or pathologic status of VA increased VAI risk. Evaluation of collateral vessels before definitive treatment helped determine appropriate management and avoid neurologic sequelae. Tamponade was not recommended as definitive treatment. Meticulous preoperative evaluation, cautious intraoperative manipulation, and real-time radiographic guidance reduced VAI risk.
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Affiliation(s)
- Qing Guan
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Long Chen
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ye Long
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhou Xiang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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