Cervical Artery Dissection: A 5-Year Prospective Study in the Belluno District

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic review of the effectiveness of carotid surgery and endovascular carotid stenting versus best medical treatment in managing symptomatic acute carotid artery dissection

Cervical artery dissection (CeAD) with an intramural haematoma can lead to stroke risk, especially in young patients. We performed comprehensive searches of the Cochrane Stroke Group Trials Register, the CENTRAL, MEDLINE and EMBASE to review the effectiveness of surgical and endovascular interventions versus best medical treatment alone for symptomatic CeAD. Furthermore, we aim to elaborate on the phenotypic individual disease manifestations of spontaneous Cervical Artery Dissection (sCAD) and how they translate into stroke and risk of dissection recurrence. Primary outcomes were ipsilateral stroke and disability. Secondary outcomes were death, any stroke, or transient ischaemic attack, residual stenosis >50%, recurrence of CeAD, expanding pseudo-aneurysm or major bleeding. Our search yielded no randomised controlled trials and/or controlled clinical trials (CCTs) comparing either carotid surgery or endovascular therapy with optimal medical management; thus there was no evidence to support the use of any specific method for management of extracranial CeAD in patients who fail antithrombotic therapy. However, despite the absence of controlled studies to compare surgery or endovascular therapy in patients who fail antithrombotic therapy, carotid surgery in young patients can be justified as a personalized precision approach given the high morbidity and mortality in this age group.

Spontaneous extracranial arterial dissections in a case of patient with osteogenesis imperfecta

Background: Osteogenesis imperfecta (OI), also known as brittle bone disease, is an inherited disease characterized by increased bone brittleness and decreased bone mass. OI patients may also be associated with exoskeleton manifestations such as hearing loss, articular ligament laxity, and heart valve lesions. Reports of internal carotid and cerebral artery dissection related to OI patients are very rare. We present the first case of acute cerebral infarction caused by the progressive stripping of the carotid artery dissection Chinese patient with Osteogenesis imperfecta.Case: A 48-year-old Chinese male who had no prior medical history or bad habits was to admitted the hospital due to leftside temporal headache, paroxysmal right limb weakness, and prolonged blurred vision experienced for a week. After a series of tests were performed to exclude superficial temporal arteritis, the patient was diagnosed with transient ischemic attack and was given aspirin, clopidogrel and atorvastatin without further headache and blurred vision. However, he was again admitted to the emergency department the following day due to right limb weakness for 7 h that was considered acute cerebral infarction caused by left carotid artery dissection.Conclusion: The findings in this case support that internal carotid and cerebral artery dissection may be one of the complications of Osteogenesis imperfecta.

Common Carotid Artery Dissection in Multiple Extracranial Injury: A Case Report

Traumatic common carotid artery dissection (CCAD) is rare. To our knowledge, only 14 case reports have described traumatic CCAD previously. Here, we report a case of CCAD in a patient with severe trauma. A 50-year-old man was lying on the road after drinking alcohol when a car drove over him. Computed tomography (CT) revealed multiple rib fractures with hemopneumothorax, lung contusion, flail chest, large amount of hematoma with bladder rupture, and fractures on the C6 spinous process, sacral ala, iliac bone, and pubic ramus. Repair of the bladder rupture, exploratory thoracotomy, and open reduction of multiple rib fractures were performed. Right side hemiparesis was observed on hospital day 4. Brain CT showed a large acute left middle cerebral artery infarction. CT angiography showed focal carotid dissection at the left common carotid artery with intimal flap. The CCAD was located at the C6 level. Clexane (enoxaparin sodium) treatment was initiated. An abdominal CT scan revealed a huge retroperitoneal hematoma and increased amount of hematoma in the prevesical and perivesical space, 10 days later. The patient died two days later. Although traumatic CCAD is rare, this case report provides useful information for trauma surgeons regarding the treatment and diagnosis of similar cases.

Rare case of bilateral traumatic internal carotid artery dissection

A 55-year-old man was working in a trench when the wall collapsed in on him, pinning him to the wall. On arrival in the emergency department the patient began reporting of right-sided headache. Neurological examination revealed left-sided reduced sensation with weakness. Whole-body CT scan showed right-sided flail chest and bilateral haemothorax as well as loss of flow and thinning of the distal right internal carotid artery (ICA) and loss of grey white matter differentiation in keeping with traumatic ICA dissection with a right middle cerebral artery (MCA) infarct. He was started on aspirin 300 mg once daily. 3 days postadmission the patient experienced worsening of vision and expressive dysphasia. CT angiogram showed bilateral ICA dissections extending from C2 to the skull base. The patient was managed conservatively in the stroke unit for infarction and was discharged home for follow-up in stroke clinic.

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.

Safety of unilateral endovascular occlusion of the cervical segment of the vertebral artery without antecedent balloon test occlusion

BACKGROUND AND PURPOSE

Antecedent balloon test occlusion is often performed prior to vertebral artery sacrifice, but there is limited data to suggest this adds a significant clinical benefit, especially in the setting of trauma. Furthermore, balloon test occlusion can be time-consuming, add to the technical complexity of the procedure, and increase the overall cost of treatment. The purpose of this study was to determine the safety of unilateral vertebral artery occlusion without antecedent balloon test occlusion as part of the treatment regimen in patients with traumatic vertebral artery dissection, cervical tumor, or intracranial aneurysm.

MATERIALS AND METHODS

The medical records and imaging studies of 59 patients in whom unilateral endovascular cervical vertebral artery occlusion was performed were retrospectively reviewed. Procedure-related stroke was defined as imaging evidence of acute infarct in the vascular territories supplied by the occluded vertebral artery or new focal neurologic deficit developing in the first 30 days after vertebral artery occlusion attributable to infarction in the posterior circulation.

RESULTS

Fifty-nine patients underwent unilateral endovascular cervical vertebral artery occlusion to prevent potential thromboembolic complications of vertebral artery injury, for treatment of intracranial aneurysms, or for presurgical embolization of a cervical vertebral tumor. Unilateral occlusion was performed when endovascular reconstruction was considered impossible or deemed more risky than deconstruction. Fifty-eight of the 59 patients underwent vertebral artery occlusion without antecedent balloon test occlusion. None of the 59 patients had clinical or imaging evidence of a postprocedural infarct.

CONCLUSIONS

In this series, endovascular occlusion of a cervical segment of 1 vertebral artery was safely performed without antecedent balloon test occlusion. As long as both vertebral arteries were patent and converged at the vertebrobasilar junction, there was anatomic potential for retrograde filling of the distal intracranial vertebral artery to the level of the posterior inferior cerebellar artery origin, and there was no major vascular supply to the spinal cord arising from the target segment of the affected vessel. Dominant and nondominant vertebral arteries were safely occluded, and no infarcts were attributed to the treatment.

Endovascular treatment of cervical artery dissection: ten case reports and review of the literature

PURPOSE

The role of endovascular treatment in cases of cervical artery dissection (CeAD) is debatable. With an increasing number of endovascular therapies such as endovascular recanalization and embolization the number of complications such as iatrogenic dissection is also rising. We report our experience with endovascular stenting in the treatment of patients presenting with CeAD.

METHODS

We included all consecutive patients with CeAD (n = 168) treated in our hospital between 2001 and 2010 for our retrospective study. Patients with CeAD were considered eligible for stenting: (1) in iatrogenic dissections and (2) in noniatrogenic dissections if they suffered from recurrent ischemic events despite antithrombotic treatment.

RESULTS

During our observation period 10 out of 168 patients presenting with CeAD were selected for stenting. Several types of stents were used. Stenting was technically successful in 8 but unsuccessful in 2 patients with complete arterial occlusion. Stent-related clinically apparent complications occurred in 3 of the 10 patients. All were transient. During a mean follow-up of 47 (±24.8) months none of the patients had new cerebrovascular ischemic events.

CONCLUSION

In our patient sample stenting due to dissection is a rare procedure performed in less than 10% of CAD patients. It should be considered as a feasible rescue treatment in cases of impending stroke despite optimal antithrombotic therapy.

The quality of reports on cervical arterial dissection following cervical spinal manipulation

BACKGROUND

Cervical artery dissection (CAD) and stroke are serious harms that are sometimes associated with cervical spinal manipulation therapy (cSMT). Because of the relative rarity of these adverse events, studying them prospectively is challenging. As a result, systematic review of reports describing these events offers an important opportunity to better understand the relation between adverse events and cSMT. Of note, the quality of the case report literature in this area has not yet been assessed.

PURPOSE

1) To systematically collect and synthesize available reports of CAD that have been associated with cSMT in the literature and 2) assess the quality of these reports.

METHODS

A systematic review of the literature was conducted using several databases. All clinical study designs involving CADs associated with cSMT were eligible for inclusion. Included studies were screened by two independent reviewers for the presence/absence of 11 factors considered to be important in understanding the relation between CAD and cSMT.

RESULTS

Overall, 43 articles reported 901 cases of CAD and 707 incidents of stroke reported to be associated with cSMT. The most common type of stroke reported was ischemic stroke (92%). Time-to-onset of symptoms was reported most frequently (95%). No single case included all 11 factors.

CONCLUSIONS

This study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke. Improving the quality, completeness, and consistency of reporting adverse events may improve our understanding of this important relation.

Antithrombotic drugs for carotid artery dissection

BACKGROUND

Extracranial internal carotid artery dissection (eICAD) is a leading cause of stroke in younger patients.

OBJECTIVES

1. To determine whether, in patients with eICAD, treatment with anticoagulants, antiplatelet agents or control was associated with a better functional outcome. 2. To compare, among patients treated with either anticoagulants or antiplatelet agents, the risk of ischaemic strokes and major bleeding episodes.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 3 October 2009). In addition, we performed comprehensive searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to November 2009) and EMBASE (January 1980 to November 2009), checked all relevant papers for additional eligible studies and contacted authors and researchers in the field.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials and non-randomised studies (if they reported on outcome stratified by antithrombotic treatment and included at least four patients) of anticoagulants or antiplatelet agents for the treatment of extracranial internal carotid artery dissection. Two review authors independently extracted data.

DATA COLLECTION AND ANALYSIS

Primary outcomes were death (all causes) and death or disability. Secondary outcomes were ischaemic stroke, symptomatic intracranial haemorrhage, and major extracranial haemorrhage during the reported follow-up period. The first choice treatment was taken for analyses.

MAIN RESULTS

We did not find any completed randomised trials. Comparing antiplatelets with anticoagulants across 36 observational studies (1285 patients), there were no significant differences in the odds of death (Peto odds ratio (Peto OR) 2.02, 95% CI 0.62 to 6.60), or the occurrence of ischaemic stroke (OR 0.63, 95% CI 0.21 to 1.86) (34 studies, 1262 patients). For the outcome of death or disability, there was a non-significant trend in favour of anticoagulants (OR 1.77, 95% CI 0.98 to 3.22; P = 0.06) (26 studies, 463 patients). Symptomatic intracranial haemorrhages (5/627; 0.8%) and major extracranial haemorrhages (7/425; 1.6%) occurred only in the anticoagulation group; however, for both these outcomes, the estimates were imprecise and indicated no significant difference between the two treatment modalities.

AUTHORS' CONCLUSIONS

There were no randomised trials comparing either anticoagulants or antiplatelet drugs with control, thus there is no evidence to support their routine use for the treatment of extracranial internal carotid artery dissection. There were also no randomised trials that directly compared anticoagulants with antiplatelet drugs and the reported non-randomised studies did not show any evidence of a significant difference between the two.

Cervicocranial arterial dissection

Cervicocranial arterial dissection (CCAD) occurs when there is a tear in the intimal layer of the carotid or vertebral arteries with subsequent extravasation of blood into the subintimal layers. The dissection may be extradural, intradural, or extend over both segments. The contents of the subintimal layers are highly thrombogenic, and thus, embolism, vessel stenosis, or occlusion may follow. Symptoms of dissection may be caused by local injury to the blood vessel or by ischemia to the retina or brain. Thus, dissection should always be considered in patients who present with Horner syndrome associated with ipsilateral headache, carotidynia, ocular pain, or amaurosis fugax. Rare neuro-ophthalmologic presentations of dissection include anterior and posterior ischemic optic neuropathy; central retinal artery occlusion; ophthalmic artery occlusion; transient ophthalmoparesis; and third, fourth, or sixth cranial nerve palsy. The most common serious complication of dissection is ischemic stroke. No randomized controlled trials have evaluated therapies for patients presenting with CCAD. Thus, treatment is essentially empiric and often varies by region. Medical management is first line in most patients. Given the propensity for thrombus formation and early embolization or occlusion, acute anticoagulation using intravenous heparin or low-molecular-weight heparinoids followed by short-term, dose-adjusted warfarin is the treatment of choice for most patients with extradural CCAD who present early after symptom onset. The risk of cerebral ischemia is greatest in the first few weeks after dissection; thus, it is reasonable to recommend antiplatelet agents for patients who present late and have not had evidence of ischemia. Intradural dissection is rare but is associated with a meaningful risk of subarachnoid hemorrhage (SAH). As a result, anticoagulants and antiplatelet agents should not be used if SAH is suspected or confirmed. Endovascular intervention may be necessary in a small minority of cases with recurrent events despite anticoagulation or SAH due to intradural dissection. Of special note, CCAD is not considered a contraindication for tissue plasminogen activator use in acute stroke patients who are otherwise eligible for treatment.

Antiplatelets Versus Anticoagulation in Cervical Artery Dissection

Background and Purpose— The widespread preference of anticoagulants over antiplatelets in patients with cervical artery dissection (CAD) is empirical rather than evidence-based.

Summary of Review— This article summarizes pathophysiological considerations, clinical experiences, and the findings of a systematic metaanalysis about antithrombotic agents in CAD patients. As a result, there are several putative arguments in favor as well as against immediate anticoagulation in CAD patients.

Conclusions— A randomized controlled trial comparing antiplatelets with anticoagulation is needed and ethically justified. However, attributable to the large sample size which is required to gather meaningful results, such a trial represents a huge venture. This comprehensive overview may be helpful for the design and the promotion of such a trial. In addition, it could be used to encourage both participation of centers and randomization of CAD patients. Alternatively, antithrombotic treatment decisions can be customized based on clinical and paraclinical characteristics of individual CAD patients. Stroke severity with National Institutes of Health Stroke Scale score ≥15, accompanying intracranial dissection, local compression syndromes without ischemic events, or concomitant diseases with increased bleeding risk are features in which antiplatelets seem preferable. In turn, in CAD patients with (pseudo)occlusion of the dissected artery, high intensity transient signals in transcranial ultrasound studies despite (dual) antiplatelets, multiple ischemic events in the same circulation, or with free-floating thrombus immediate anticoagulation is favored.

A systematic review of the risk factors for cervical artery dissection

BACKGROUND AND PURPOSE

Cervical artery dissection (CAD) is a recognized cause of ischemic stroke among young and middle-aged individuals. The pathogenesis of dissections is unknown, although numerous constitutional and environmental risk factors have been postulated. To better understand the quality and nature of the research on the pathogenesis of CAD, we performed a systematic review of its risk factors.

METHODS

PubMed [MEDLINE (1966 to February 22, 2005)] and Embase (1980 to February 22, 2005) were searched to identify studies fulfilling the inclusion criteria. Two reviewers independently assessed methodological quality of the primary studies. Relevant data were extracted, including the risk factor(s) investigated, characteristics of the study population, and strength of the association(s).

RESULTS

Thirty-one case-control studies were included for analysis. Selection bias, lack of control for confounding, and inadequate method of data analysis were the most common identified methodological shortcomings. Strong associations were reported from individual studies for the following risk factors: aortic root diameter >34 mm (odds ratio [OR=14.2; 95% confidence interval [CI], 3.2 to 63.6), migraine (ORadj, 3.6; 95% CI, 1.5 to 8.6), relative diameter change (>11.8%) during the cardiac cycle of the common carotid artery (ORadj, 10.0; 95% CI, 1.8 to 54.2), and trivial trauma (in the form of manipulative therapy of the neck) (ORadj, 3.8; 95% CI, 1.3 to 11). A weak association was found for homocysteine (2 studies: ORcrude, unknown; 95% CI, 1.05 to 1.52; ORcrude, 1.3; 95% CI, 1.0 to 1.7), and recent infection (ORadj, 1.60; 95% CI, 0.67 to 3.80). Two studies had conflicting findings for low levels of alpha1-antitrypsin, with the methodologically stronger study suggesting no association with CAD.

CONCLUSIONS

CAD is a multi-factorial disease. Many of the reviewed studies contained 2 or more major sources of bias commonly found in case-control studies. Only one study (of homocysteine) used healthy controls, a robust sample size, and had a low risk of biased results. The relationship between atherosclerosis and CAD has been insufficiently examined.

Antithrombotic drugs for carotid artery dissection

BACKGROUND

Extracranial internal carotid artery dissection can lead to occlusion of the artery and hence cause an ischaemic stroke. It is the underlying stroke mechanism in approximately 2.5% of all strokes. It is the second leading cause of stroke in patients younger than 45 years of age. Anticoagulants or antiplatelets may prevent arterial thrombosis in extracranial internal carotid artery dissection, but these benefits may be offset by increased bleeding.

OBJECTIVES

To determine whether antithrombotic drugs (antiplatelet drugs, anticoagulation) are effective and safe in the treatment of patients with extracranial internal carotid artery dissection, and which is the better treatment.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 3 October 2002). In addition we performed comprehensive searches of the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 2, 2002), MEDLINE (January 1966 to May 2002) and EMBASE (January 1980 to June 2002), and checked all relevant papers for additional eligible studies.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials assessing the efficacy of anticoagulants or antiplatelets for the treatment of extracranial internal carotid artery dissection, and non-randomised trials, e.g. case series (studies), that reported on any antithrombotic treatment with at least 4 patients, were eligible for inclusion. Data from all eligible studies were extracted independently by two reviewers. Disagreements were resolved by discussion.

DATA COLLECTION AND ANALYSIS

Data on the primary outcome measures were extracted systematically. These were: death (all causes) and death or disability. Secondary outcomes were: first stroke occurrence, stroke recurrence, any stroke during reported follow-up, extracranial haemorrhage, and intracranial haemorrhage. The first choice treatment was taken for analyses.

MAIN RESULTS

No randomised trials were identified. No reliable comparisons of antiplatelet drugs or anticoagulants with control were available. Twenty-six eligible studies including 327 patients (who either received antiplatelet drugs or anticoagulants) were to be included in the comparative analysis. There was no significant difference in odds of death comparing antiplatelet drugs with anticoagulants (Peto odds ratio (Peto OR) 1.59, 95% CI 0.22-11.59). There was also no significant difference in the odds of being dead or disabled (Peto OR 1.94, 95% CI 0.76-4.91). Few intracranial haemorrhages (0.5%) were reported for patients on anticoagulants, none for patients on antiplatelets.

REVIEWER'S CONCLUSIONS

There were no randomised trials comparing either anticoagulants or antiplatelet drugs with control. There is, therefore, no evidence to support their routine use for the treatment of extracranial internal carotid artery dissection. There were also no randomised trials that directly compared anticoagulants with antiplatelet drugs, and the reported non-randomised studies did not show any evidence of a significant difference between the two. We suggest that a randomised trial including at least 1400 patients in each treatment arm with this condition is clearly needed.