Spontaneous Cervical Artery Dissection

Ischemic stroke in young Asians caused by spontaneous cervical artery dissection may be due to slightly increased homocysteine

Background

Spontaneous cervical artery dissection (sCAD) is a non-atherosclerotic vascular disease among young and middle-aged individuals of unknown etiology that is recognized as a cause of ischemic stroke. Total plasma homocysteine (tHcy) is associated with an increased risk of sCAD, but the precise mechanism and level of tHcy remain unclear.

Methods

Fasting tHcy levels were determined in 296 patients with a first ischemic stroke due to sCAD (n = 159) and in age-/gender-matched hospital-based controls (n = 137) within 24 h after the onset of symptoms.

Results

The mean age of sCAD patients with ischemic stroke and controls was 45.6 years; 61.0% of the cases and controls were male. The prevalence rates of hypertension, diabetes mellitus, and hyperlipidemia in sCAD patients were significantly increased. Fasting tHcy levels in sCAD patients were significantly higher (12.81 ± 5.24 μmol/L, 95% CI: 11.79-13.89) than those in controls (10.21 ± 3.33 μmol/L, 95% CI: 9.92-11.89, p < 0.001). Compared with the lowest homocysteine quartile, the quartile between 12.1 and 14.54 μmol/L was significantly associated with sCAD, with an adjusted odds ratio of 4.7. The adjusted odds ratio was 5.02 (95% CI: 1.91-13.39, p = 0.001) for every 1 μmol/L increase in log homocysteine according to the logistic regression model. Although sCAD occurred more often in winter than in other seasons (p = 0.02), tHcy levels in sCAD were not significantly different in terms of seasonal variation (p > 0.05).

Conclusion

Our results suggest that mildly increased tHcy may be a predisposing risk factor for ischemic stroke in young Asians caused by sCAD and that the relationship between them is significant; however, the precise mechanism requires further study. This result also supports the screening of fasting tHcy in young Asian adults for early intervention and control of tHcy levels, which plays an important role in early clinical prediction and intervention of sCAD.

Interplay between carotid artery dissection and thrombophilia leading to ischaemic stroke after minor head trauma in an adolescent: a case report

Stroke in children is more common than is often realised; there are numerous potential causes, including carotid artery injury resulting from minor head or neck trauma, as well as genetic conditions associated with thrombophilia. A 13-year-old boy suffered an arterial ischaemic stroke (AIS) secondary to dissection of the left internal carotid artery (ICA) after he headed the ball during a game of football. He presented with generalised tonic-clonic seizure, loss of consciousness, right-sided hemiplegia and aphasia. Neuroradiological imaging showed left caudate, putaminal and posterior insular ischaemic infarct secondary to complete occlusion of the left ICA and accompanying partial left middle cerebral artery occlusion. He was treated with anticoagulant and anti-aggregant agents. Rarely, minor head trauma can result in internal carotid artery dissection, thrombus formation and arterial occlusion, leading to arterial ischaemic stroke. Prompt diagnosis and management are crucial to achieve a good neurological outcome.Abbreviations: AIS: arterial ischaemic stroke; ANA: anti-nuclear antibody; APA: anti-phospholipid antibody; APTT: activated partial thromboplastin time; CAD: carotid artery dissection; CCAD: cranio-cervical artery dissection; CRP: C-reactive protein; CT: computed tomography; CTA: computed tomography angiography; dsDNA: double-stranded DNA; ESR: erythrocyte sedimentation rate; ICA: internal carotid artery; LA: lupus anticoagulant; MCA: middle cerebral artery; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; MTHFR: methylenetetrahydrofolate reductase; PT INR: prothrombin time international normalised ratio.

Traumatic and Spontaneous Vertebral Artery Dissections: An Analysis of Tertiary-Center 310 Patient Cohort

BACKGROUND

Vertebral artery dissections (VADs) are rare yet potentially devastating events. While the etiology of these events is either traumatic or spontaneous, there is a paucity of quantitative literature comparing the two.

OBJECTIVE

To identify differences in predisposing factors, event characteristics, and clinical outcomes between traumatic VADs (tVADs) and spontaneous VADs (sVADs).

METHODS

We retrospectively identified patients with VADs presenting to our institution at VAD onset with at least a 3-mo follow-up. Demographics, event characteristics, treatment details, and neurological outcomes as modified Rankin scale (mRS) scores were collected.

RESULTS

Of the 310 patients sustaining 366 VADs total, 187 (60.3%) patients experienced a total of 221 (60.4%) sVADs and 123 (39.7%) patients experienced a total of 145 (39.6%) tVADs. sVADs were more likely to occur in the intracranial course of the artery (P = .042) and have a lower mRS at discharge, 3-month, and last clinical follow-up (P = 003, .002, and .001, respectively). tVADs were more likely associated with concomitant fractures (P < .001).

CONCLUSION

Despite similar patient populations, tVADs are associated with higher mRS scores at all time points. Although further study is needed, this may suggest other concomitant trauma rather than the VAD itself is contributing to worse neurological status in patients with tVADs.

Cervical Artery Dissection and Sports

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

Extracellular matrix protein signature of recurrent spontaneous cervical artery dissection

OBJECTIVE

To assess whether connective tissue disorder is evident in patients with spontaneous cervical artery dissection and therefore identify patients at risk of recurrence using a cutting-edge quantitative proteomics approach.

METHODS

In the ReSect study, all patients with spontaneous cervical artery dissection treated at the Innsbruck University Hospital since 1996 were invited to attend a standardized clinical follow-up examination. Protein abundance in skin punch biopsies (n = 50) was evaluated by a cutting-edge quantitative proteomics approach (liquid chromatography-mass spectrometry) that has hitherto not been applied to such patients.

RESULTS

Patients with 1-time single-vessel (n = 19) or multiple-vessel (n = 13) dissections did not differ between each other or compared to healthy controls (n = 12) in protein composition. Patients with recurrent spontaneous cervical artery dissection (n = 6), however, showed significantly different expression of 25 proteins compared to the other groups combined. Literature review and Gene Ontology term annotation check revealed that 13 of the differently expressed proteins play a major role in the structural integrity of connective tissue or are linked to connective tissue disorders. These proteins showed clustering to a collagen/elastin cluster and one consisting of desmosome related proteins.

CONCLUSION

This study unravels an extracellular matrix protein signature of recurrent spontaneous cervical artery dissection. In the long run and after large-scale validation, our findings may well assist in identifying patients at risk of recurrent spontaneous cervical artery dissection and thus guide therapy.

Anatomical Variations of Vertebrobasilar Artery are Closely Related to the Occurrence of Vertebral Artery Dissection-An MR Angiography Study

GOAL

Intracranial arterial dissection is a major cause of ischemic stroke and subarachnoid hemorrhage in relatively young patients. We assessed the hypothesis that the tortuosity of the vertebrobasilar artery is associated with the occurrence of vertebral artery (VA) dissection, using MR angiography (MRA).

MATERIALS AND METHODS

This study enrolled 43 patients with VA dissection, and 63 age- and sex-matched healthy subjects were used as the controls. MRA was employed to evaluate the presence of dominant VA and the lateral shift of vertebrobasilar junction in both groups. The VA diameters were considered different when the difference was greater than .3 mm. These anatomical variations were divided into 3 types: Type 1 (vertebrobasilar junction within 2 mm from the midline), Type 2 (>2 mm-lateral shift of vertebrobasilar junction to the ipsilateral side of the dominant VA), and Type 3 (>2 mm-lateral shift of vertebrobasilar junction to the contralateral side of the dominant VA).

FINDINGS

The presence of dominant VA and the lateral shift of vertebrobasilar junction were more prevalent in patients with VA dissection than in the controls (OR: 3.46, P = .013, and OR: 4.51, P = .001, respectively). The lateral shift of vertebrobasilar junction was classified into Type 1 (n = 6), Type 2 (n = 13), and Type 3 (n = 17) among patients with VA dissection, while into Type 1 (n = 20), Type 2 (n = 8), and Type 3 (n = 7) among the controls. Type 3 predominance was observed in patients with VA dissection (P = .02).

CONCLUSIONS

Anatomical variations of the vertebrobasilar artery may play an important role in the occurrence of VA dissection.

Craniocervical Arterial Dissection in Children: Pathophysiology and Management

BACKGROUND

Craniocervical arterial dissection is a commonly reported arteriopathy associated with stroke in children. It is characterized by a high stroke recurrence rate and variable outcomes. Here we review the pathophysiology, clinical presentation, and diagnostic neuroimaging approaches that are helpful in accurate diagnosis and follow-up of children with arterial dissection.

METHODS

MEDLINE searches (2000 to 2018) for articles that contained patients aged less than 18 years with craniocervical arterial dissection was performed, with the goal of analyzing their presenting features, pathophysiological mechanisms, and imaging characteristics and interventions.

RESULTS

Sixteen articles met the study criteria and reported 182 cases of craniocervical arterial dissection, 68% male, average age 8.6 years. Dissection was associated with head and neck trauma in 56% of the cases and frequently involved the posterior (61%) and extracranial locations (64%); the vertebral artery was the most commonly involved artery (60%). The most common clinical presentation was hemiparesis (80/160, 50%), followed by headache (64/164, 39%). Magnetic resonance imaging was the preferred neuroimaging method, followed by cerebral catheter angiography as a gold standard definitive neurovascular imaging modality when the initial vascular imaging revealed nondiagnostic findings.

CONCLUSIONS

The diagnosis of arterial dissection requires a high index of suspicion and consideration for detailed neurovascular imaging, including both the cranial and cervical regions. Neurovascular imaging challenges, especially visualization of arterial abnormalities, highlight the importance of appropriate and timely use of specific neurovascular imaging techniques. Magnetic resonance imaging appears to be the preferred neurovascular imaging modality in children with arterial dissection and may obviate the need for invasive cerebral catheter angiography.

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

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

Recurrence of cervical artery dissection

Objective

To explore the recurrence of cervical artery dissection (CeAD).

Methods

A single-center consecutive series of 282 CeAD patients was prospectively recruited during first admission from 1995 to 2012. Patients with a follow-up of at least 1 year (n = 238) were eligible for the current analysis. All patients with clinical symptoms or signs of recurrent CeAD on ultrasound were examined by MRI. Dermal connective tissue morphology was studied in 108 (45.4%) patients.

Results

Median follow-up was 52 months (range 12–204 months). In all, 221 (92.8%) patients presented with monophasic CeAD, including 188 (79.0%) patients with a single CeAD event, 11 (4.6%) with simultaneous dissections in multiple cervical arteries, and 22 (9.2%) with subsequent events within a single phase of 4 weeks. Seventeen patients (7.1%) had late (>1 month after the initial event) recurrent CeAD events, including 5 (2.1%) with multiple recurrences. Patients with late recurrences were younger (37.5 ± 6.9 years) than those without (43.8 ± 9.9; p = 0.011). Ischemic stroke occurred in 164 (68.9%) patients at first diagnosis, but only 4 of 46 (8.7%) subsequent events caused stroke (p < 0.0001), while 19 (41.3%) were asymptomatic. Connective tissue abnormalities were found in 54 (56.3%) patients with monophasic and 8 (66.7%) with late recurrent dissections (p = 0.494).

Conclusion

Twenty-two (9.2%) patients had new CeAD events within 1 month and 17 (7.1%) later recurrences. The risk for new events was significantly higher (about 60-fold) during the acute phase than during later follow-up. Connective tissue abnormalities were not more frequent in patients with late recurrent events than in those with monophasic CeAD.

Multiple cranial neuropathies as a presentation of spontaneous internal carotid artery dissection: A case report and literature review

Cervical artery dissection is an underrecognized cause of lower cranial neuropathies and diagnosis can remain elusive if not properly investigated. We present a case of an internal carotid artery dissection that was initially missed in a 48-year-old man who presented with subacute-onset of dysarthria, dysphagia, and unilateral tongue weakness. Knowledge of the most common presenting symptoms, relevant neuroanatomy, and neuroimaging techniques is essential to avoid misdiagnosis. Pseudoaneurysm formation from subadventitial carotid artery dissection may result in compressive neuropathies of cranial nerves IX, X, XI, and XII without associated cerebral ischemia. The absence of intraluminal narrowing on CT or MR angiography should not dissuade the clinician; T1-weighted axial cervical MRI with fat-saturation provides the highest sensitivity and specificity to identify these lesions.

Vascular Tortuosity May Be Associated With Cervical Artery Dissection

BACKGROUND AND PURPOSE

Dissection is an increasingly recognized cause of ischemic stroke, which occurs spontaneously or after trauma, in relatively young patients. We hypothesized that there might be a predisposing factor weakening the vascular wall and that arterial tortuosity might be higher in patients with dissection.

METHODS

We consecutively enrolled cervical artery dissection (CerAD) patients who had undergone magnetic resonance angiography. Age- and sex-matched healthy subjects who underwent magnetic resonance angiography in a routine health examination were used as controls. The tortuosity was measured semiautomatically from the carotid artery and vertebral artery (VA) arteries. Tortuosity index was defined as: [(arc/chord)-1×100] in each arteries. Independent risk factors associated with CerAD were investigated using multivariable analysis. Subgroup analysis according to the dissected artery was performed.

RESULTS

There were no differences in vascular risk factors between the 75 CerAD patients and the 75 controls. The tortuosity indexes of the contralesional VA (16.3±6.8 versus 12.1±4.5, respectively; P<0.001) and carotid artery (8.8±4.0 versus 7.3±2.9, respectively; P=0.01) were higher in patients with CerAD compared with those of control subjects. VA tortuosity (odds ratio, 1.175; P=0.001) was independently associated with the presence of CerAD. In subgroup analysis, VA tortuosity was significantly higher in 57 patients with VA dissection than in controls (P<0.001), and carotid artery tortuosity was marginally higher in 18 patients with carotid artery dissection (P=0.05).

CONCLUSIONS

CerAD is associated with tortuous cervical arteries, which may implicate weakened cervical vascular structure in these patients.

[Competence Network Stroke. A successful model for stroke research]

In 1999 the German Ministry of Education and Research initiated a funding initiative for competence networks in health research in order to improve research and health care for major diseases with high morbidity and relevance to public health. All major players in a given field were invited to cooperate. The aims were to improve horizontal as well as vertical networking in order to improve research quality and the transfer of new results into general clinical practice. Another aim was to establish sustainable structures for lasting cooperation. After a highly competitive application round, the Competence Network Stroke was among the very first to be funded. The incidence of stroke in Germany is about 250,000 new patients per year, it is the leading cause of adult impairment and its societal impact is dramatic.This article describes how the Competence Network Stroke managed to meet the above-mentioned goals and how cooperation among stroke researchers and caregivers in Germany has improved. Furthermore it provides examples of researcher achievements in the network, which have advanced research and benefited patients.

Management of pediatric craniocervical arterial dissections

PURPOSE

Craniocervical arterial dissections (CCADs) represent a preventable cause of acute ischemic stroke (AIS). Our objective was to describe clinical presentation, imaging features, treatment strategies, and report clinical and imaging outcomes of CCADs at a large pediatric tertiary referral center.

METHODS

Electronic medical records were queried using variations of the word dissection for patients under 25 years of age with neuroimaging over a 13-year period. Medical and imaging records were reviewed to identify carotid, vertebral, or intracranial dissections. Demographics, presenting symptoms, presence of AIS, mechanism of injury, dissection location, dissection treatment, and complications stemming from treatment were collected. Clinical outcome was classified according to modified Rankin Scale (mRS) score. Imaging follow-up was obtained until the dissection healed or stabilized.

RESULTS

A total 6,289 patients met initial search criteria. Of the 42 (0.7%) patients with CCADs, 23 (54.8%) had internal carotid artery (ICA) dissections, and 17 (40.5%) had vertebrobasilar (VB) dissections. More females had ICA dissections (p = 0.002), and more males had VB dissections (p = 0.01). CCADs associated with traumatic presentation occurred in 34 patients (81.0%), while 8 (19.0%) were spontaneous. Good outcomes (mRS 0-3) were noted for 36 patients, and 5 had poor outcomes (mRS 4-6). In the 17 patients with vessel occlusion, 50.0% had partial or complete recanalization at a mean follow-up of 23.9 months.

CONCLUSIONS

CCAD is commonly related to trauma and presents with AIS. The majority of patients experience good clinical outcome. Recanalization of initial vessel occlusion occurs in half of cases at 2 years.

Traumatic vertebral artery injury: proposal for classification of the severity of trauma and likelihood of fatal outcome

Vertebral artery injury (VAI) occurs after (blunt) trauma as well as spontaneously. The risk of incurring VAI from a blunt trauma probably parallels the severity of trauma, often referred to as major- and minor-trauma. However, the literature does not provide concrete definitions of these terms. This study aims to define minor- and major-trauma and to analyze the likelihood of fatal outcome in VAI. For this purpose, classification criteria of major- and minor-trauma were developed and a PubMed database search was performed for articles on VAI published prior to 2013. The definitions of minor- and major-trauma, derived mainly from radiological screening criteria in cervical spine injury and based on the mechanism leading to the injury, were used in the analysis of the literature. The search produced 241 VAI cases with sufficiently detailed data for the comparison of major-trauma (52 cases, 50 lethal), minor-trauma (8 cases, none lethal), and no-trauma (182 cases, 69 lethal). The numbers of lethal cases in the total study population and subgroups differed significantly between the groups (Fisher's exact test) and the likelihood ratios (LRs) of lethal outcome were substantially higher in the major-trauma group compared to the other groups. The highly significant p values show that the proposed criteria differentiate between trauma types with regard to fatal outcome. The presented results can assist in the evaluation of forensic cases of VAI.

Basilar extension and posterior inferior cerebellar artery involvement as risk factors for progression of the unruptured spontaneous intradural vertebral artery dissection

BACKGROUND AND PURPOSE

Spontaneous intradural vertebral artery dissection (siVAD) primarily causes stroke in young and middle-aged individuals; however, data on the relationship between vertebrobasilar morphology and the progression of siVAD are limited.

METHODS

We retrospectively reviewed the data of 77 adult patients who were diagnosed with unruptured siVAD and treated conservatively. We analysed the clinical characteristics, vertebrobasilar morphologies and progression. Progression was defined as siVAD-induced stroke or morphological worsening of the siVAD.

RESULTS

Twenty patients experienced progression. Recurrent ischaemic events that occurred in the vertebrobasilar territory were seen in three patients (3.9%). Two of these three patients and other 17 patients showed morphological worsening. None of the patients presented with subarachnoid haemorrhage. The log-rank test showed male sex, migraine, basilar extension and the posterior inferior cerebellar artery involvement were associated with the progression. Multivariate analysis using the Cox proportional hazards model showed that only basilar extension and the posterior inferior cerebellar artery involvement were significantly related to the progression (p=0.012 and 0.019). In addition, patients with these two vertebrobasilar morphologies had a significantly shorter period of progression of siVAD than those without these morphologies (both, median 242 days; one of two, median 1292 days; none, median 2445 days).

CONCLUSIONS

Thus, some vertebrobasilar morphologies might be markers of the progression of unruptured siVAD. Although all unruptured siVAD patients should be closely monitored, those with basilar extension and posterior inferior cerebellar artery involvement should perhaps be more carefully followed than those without such morphologies.

Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association

PURPOSE

Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.

RESULTS

Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.

CONCLUSIONS

CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

Vertebral artery dissection associated with viral meningitis

Background

Vertebral artery dissection (VAD) is often associated with trauma or occurs spontaneously, inevitably causing some neurological deficits. Even though acute infection can be related to the development of spontaneous VAD (sVAD), VAD associated with viral meningitis has never been reported in the literature.

Case presentation

A 42-year-old man with fever, sore throat, and runny nose developed sudden onset of occipital headache, vertigo, transient confusion, diplopia, and ataxia. Brain stem encephalitis was diagnosed initially because the cerebrospinal fluid (CSF) study showed inflammatory changes. However, subsequent diffusion-weighted (DWI) magnetic resonance imaging of his brain demonstrated left lateral medullary infarction, and the digital subtraction angiography (DSA) confirmed VAD involving left V4 segment of the artery. Consequently, the patient was diagnosed as VAD accompanied by viral meningitis.

Conclusion

This case suggests that viral meningitis might lead to inflammatory injury of the vertebral arterial wall, even sVAD with multiple neurological symptoms.

The etiology of cervical artery dissection

The etiology of cervical artery dissection (CAD) is unclear, although a number of risk factors have been reported to be associated with the condition. On rare occasions, patients experience CAD after cervical spine manipulation, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition of interest to chiropractors. This commentary reports on the relevant anatomy of the cervical arteries, developmental features of CAD, epidemiology of the condition, and mechanisms of dissection. The analysis of CAD risk factors is confusing, however, because many people are exposed to mechanical events and known pathophysiological associations without ever experiencing dissection. No cause-and-effect relationship has been established between cervical spine manipulation and CAD, but it seems that cervical manipulation may be capable of triggering dissection in a susceptible patient or contributing to the evolution of an already existing CAD. Despite the many risk factors that have been proposed as possible causes of CAD, it is still unknown which of them actually predispose patients to CAD after cervical spine manipulation.

Hereditary connective tissue diseases in young adult stroke: a comprehensive synthesis

Though the genetic background of ischaemic and haemorrhagic stroke is often polygenetic or multifactorial, it can in some cases result from a monogenic disease, particularly in young adults. Besides arteriopathies and metabolic disorders, several connective tissue diseases can present with stroke. While some of these diseases have been recognized for decades as causes of stroke, such as the vascular Ehlers-Danlos syndrome, others only recently came to attention as being involved in stroke pathogenesis, such as those related to Type IV collagen. This paper discusses each of these connective tissue disorders and their relation with stroke briefly, emphasizing the main clinical features which can lead to their diagnosis.

Spontaneous arterial dissection: phenotype and molecular pathogenesis

Arterial dissection (AD) is defined as the longitudinal splitting up of the arterial wall caused by intramural bleeding. It can occur as a spontaneous event in all large and medium sized arteries. The histological hallmark of AD is medial degeneration. Histological investigations, gene expression profiling and proteome studies of affected arteries reveal disturbances in many different biological processes including inflammation, proteolytic activity, cell proliferation, apoptosis and smooth muscle cell (SMC) contractile function. Medial degeneration can be caused by various rare dominant Mendelian disorders. Genetic linkage analysis lead to the identification of mutations in different disease-causing genes involved in the biosynthesis of the extracellular matrix (FBN1, COL3A1), in transforming growth factor (TGF) beta signaling (FBN1, TGFBR1, TGFBR2) and in the SMC contractile system (ACTA2, MYH11). Genome wide association studies suggest that the CDKN2A/CDKN2B locus plays a role in the etiology AD and other arterial diseases.

MTHFR C677T, FII G20210A, FV Leiden G1691A, NOS3 Intron 4 Vntr, and APOE ε4 Gene Polymorphisms are Not Associated with Spontaneous Cervical Artery Dissection

Aims

The pathogenesis of spontaneous cervical artery dissection remains unknown. We examined the association between different polymorphisms frequently found in young patients with cryptogenic stroke [methylenetetrahydrofolate reductase ( MTHFR) C677T, factor II (prothrombin) G20210A, factor V G1691A (Leiden), nitric oxide synthase 3 ( NOS3) intron 4 VNTR, and apolipoprotein E ( APOE) ε4 gene] in patients with a cerebral infarct caused by spontaneous cervical artery dissection.

Methods

Forty-eight patients (27 males) and 96 matching control subjects were recruited. Clinical history, including cardiovascular risk factors, was assessed in all subjects. Genotypes were determined by a polymerase chain reaction with and without a restriction fragment length polymorphism. The genotypes and allele frequencies of the five genetic variants studied were compared between spontaneous cervical artery dissection cases and controls. We also incorporated our data into a meta-analysis of the MTHFR/C677T variant.

Results

Of 48 patients with spontaneous cervical artery dissection (28 vertebral and 20 carotid), the mean age of the patients was 36·6 ± SD 9·9 years. There were no significant associations between the alleles of the five genetic polymorphisms studied and spontaneous cervical artery dissection. In the meta-analysis of the MTHFR/C677T variant, a total of 564 individuals (231 cases and 333 controls) were analysed; no significant association was observed. Conclusions The results from this exploratory case-control study show the lack of an association between MTHFR, factor II G20210A, factor V G1691A, NOS3, intron 4 VNTR, and APOE ε4 gene polymorphisms and the development of spontaneous cervical artery dissection. Our findings contribute towards a better understanding of the genetic risk factors associated with spontaneous cervical artery dissection.

Cervical-artery dissections: predisposing factors, diagnosis, and outcome

Cervical-artery dissection (CAD) is a major cause of cerebral ischaemia in young adults and can lead to various clinical symptoms, some of which are benign (eg, headache, neck pain, Horner's syndrome, and cranial-nerve palsy), but most patients have a stroke or transient ischaemic attack. In addition to trauma to the neck, other risk factors have been suggested, such as infection, migraine, hyperhomocysteinaemia, and the 677TT genotype of the 5,10-methylenetetrahydrofolate reductase gene (MTHFR 677TT), although evidence is sparse. An underlying arteriopathy, which could in part be genetically determined, is believed to have a role in the development of CAD. Importantly, both research on and optimum management of CAD strongly rely on diagnostic accuracy. Although the functional outcome of CAD is good in most patients, socioprofessional effects can be important. Incidence of the disorder in the general population is underestimated. Mortality and short-term recurrence rates are low but possibly also underestimated. Further research is warranted to improve our understanding of the underlying pathophysiology, to assess the long-term outcome, and ultimately to provide treatment and prevention strategies.

Adult cervicocerebral artery dissection: a single-center study of 301 Finnish patients

BACKGROUND AND PURPOSE

There are only few small studies assessing potential risk factors, comorbidity, and prognostic factors in adult spontaneous cervicocerebral artery dissection (CAD).

METHODS

We conducted a retrospective, hospital-based analysis on the prognostic factors and association of CAD with vascular risk factors in 301 consecutive Finnish patients, diagnosed from 1994 to 2007.

RESULTS

Two thirds of the patients were men (68%). Women were younger than men. Migraine (36% of all patients), especially with visual aura (63% of all migraineurs), and smoking were more common in patients with CAD compared with the general Finnish population. At 3 months, 247 (83%) patients reached a favorable outcome. Occlusion of the dissected artery, internal carotid artery dissection (ICAD), and recent infection in infarction patients were associated with a poorer outcome. ICAD patients had less often brain infarction, but the strokes they had were more severe. Seven (2.3%) patients died during the follow-up (mean 4.0 years, 1186 patient years). Six (2%) patients had verified CAD recurrence.

CONCLUSIONS

This study provides evidence for the association of CAD with male sex, and possible association with smoking and migraine. Occlusion of the dissected artery, ICAD, and infection appear to be associated with poorer outcome.

Extracranial and intracranial vertebral artery dissection: long-term clinical and duplex sonographic follow-up

PURPOSE

To determine the value of color Doppler sonography (CDUS) in the diagnosis and follow-up of patients with extracranial and intracranial vertebral artery (VA) dissection.

METHOD

Thirty-three patients aged 42 +/- 12 years with 40 VADS confirmed via digital subtraction angiography (DSA) (n = 37) and magnetic resonance angiography (MRA) (n = 3) were included in the study. All patients were investigated with extracranial CDUS and transcranial CDUS (TCCDUS) over a mean +/- SD follow-up period of 42 +/- 24 months and occurrence of new ischemic symptoms was assessed. Sonographic results were compared with initial and follow-up angiographic results.

RESULTS

At presentation, 24/33 (73%) patients had suffered an ischemic stroke, 5/33 (15%) had a transient ischemic attack (TIA), and 4/33 (12%) were asymptomatic. Two patients had a recurrent vertebrobasilar TIA; there was no recurrent stroke. The initial DSA findings consisted of 14 stenoses, 20 tapered occlusions, and 6 pseudoaneurysms. During follow-up, 63% of the vessels recanalized. Sonographic findings were consistent with angiographic findings in 80% at the initial examination and in 86% during follow-up. The main reason for discordant results was the failure of CDUS to detect pseudoaneurysms. No recurrence occurred in the vertebral arteries (VA), but 1 patient had an asymptomatic carotid artery dissection during follow-up.

CONCLUSION

Recurrent TIA or stroke after VAD appears to be extremely rare, independent of recanalization or persistent occlusion of the affected artery. CDUS and TCCDUS provide reliable follow-up of VAD in all patients presenting with stenosis or occlusion, but do not allow for detection of pseudoaneurysms of the VA.

[Clinical treatment and therapy for dissected cervicocerebral artery]

Dissection of a cervicocerebral artery (CAD) is the second leading cause of stroke at younger ages. The pathogenesis of spontaneous CAD is not fully clarified. Defective connective tissue components may cause an arteriopathy predisposing to CAD in combination with certain trigger and risk factors. The clinical spectrum includes local pain in the neck, headaches, Horner's syndrome, isolated cranial nerve deficits, and hemispheric or brainstem infarction. Noninvasively, CAD is confirmed by Duplex sonography, MRI, and MRA. There is no controlled study for best treatment or management. Rational initial empiric treatment in acute CAD to prevent secondary embolism is partial thromboplastin time-guided anticoagulation by intravenous heparin followed by anticoagulation with warfarin. Carotid surgery for treating CAD is not recommended. The duration of anticoagulation is best guided by Doppler sonography follow-up and should extend until normalization of blood flow or at least 6 months after the vessel was occluded. Caution should be recommended for exercises that involve excessive head movements. The recurrence rate for CAD is low at <1%/year except for patients with known hereditary connective tissue disorders or in cases with familial dissections.

Mild Hyperhomocysteinemia and Low Folate Concentrations as Risk Factors for Cervical Arterial Dissection

BACKGROUND AND PURPOSE

Elevated homocysteine (Hcy) plasma levels are associated with an increased risk of spontaneous cervical artery dissection (sCAD). We examined the potential association between Hcy, folate, vitamin B(12) levels and 5,10-methylenetetrahydrofolate reductase (MTHFR) polymorphisms in patients with cerebral infarct caused by sCAD.

PATIENTS AND METHODS

39 patients who survived a cerebral infarct caused by sCAD [20 (51%) women; 24 (61.5%) vertebral and 15 (38.5%) internal carotid arteries], and 76 healthy control subjects were included. Hcy plasma levels (fasting and after methionine load), folate and vitamin B(12) levels were measured. We also performed polymorphisms of MTHFR. Hcy, vitamin B(12), folates and polymorphisms of MTHFR were assessed and any associations were analyzed using multivariate statistics.

RESULTS

Mean plasma fasting Hcy level was 9.81 mumol/l for cases and 6.38 for controls (p = 0.001). The occurrence of sCAD was associated with elevated fasting Hcy levels (>95th percentile over the control group) with an adjusted odds ratio of 7.9 (95% CI 1.66-35). The association between low plasma folate values (<5th percentile) and the presence of CAD was 7.9 (95% CI 1.6-31) after adjusting for confounding variables. The distribution of the MTHFR genotype showed a higher TT mutant frequency among CAD patients (p = 0.034).

CONCLUSIONS

High plasma concentrations of Hcy and low plasma levels of folate were associated with an increased risk of sCAD in the sample studied. We conclude that deficiencies in nutritional status may contribute to the relatively high incidence of CAD in Mexico.

A four-generation Ehlers-Danlos syndrome with vascular dissections. Skin ultrastructure and biomechanical properties

Ehlers-Danlos syndrome (EDS) is heterogenous with regard to genetic traits, clinical manifestation, the biomechanical and microscopic properties of connective tissues, and basic molecular defects. We report on nine relatives of four generations who suffered from large vessel dissections and cutaneous microscopic changes consistent with EDS. Measurements of the mechanical properties of skin were performed using a computerized suction device (Cutometer). Morphological and biomechanical alterations suggestive of EDS were present in all examined subjects. A loose network of collagen bundles was admixed with clumsy elastic fibres. Factor XIIIa-positive dermal dendrocytes looked almost normal but were slim and rarefied in four subjects. The severity in ultrastructural alterations of the collagen network differed among the subjects. The group with the most prominent changes showed the most striking biomechanical alterations characterized by increased biologic elasticity without any excess in skin extensibility. A positive correlation was found between skin extensibility and elasticity. In conclusion, distinct alterations in the collagen scaffolding were found to be correlated to variable severity in biomechanical alterations of the skin. The predictive value of these changes for large vessel dissections in some families at risk remains to be settled.

Hemorrhagic transformation of stroke secondary to spontaneous internal carotid artery dissection

The clinical course of patients with hemorrhagic transformation in stroke secondary to spontaneous cervical internal carotid artery dissection (ICAD) has not been elucidated. We report a 36-year-old man with presentation of headache and subsequent left hemiparesis. Magnetic resonance imaging disclosed right ICAD with nearly complete occlusion of the right distal internal carotid artery and infarction over the right basal ganglion with hemorrhagic transformation in its central area. Hemorrhagic transformation can develop early in ICAD patients without preceding treatment with antithrombotic agents. Clinicians are urged to use antithrombotic agents with caution in patients with spontaneous ICAD with ischemic stroke because early hemorrhagic transformation may also be present. Possible pathomechanisms and treatment strategies are also discussed.

Trauma-induced extracranial internal carotid artery dissection leading to multiple infarcts in a young girl

Carotid artery dissections (CADs) represent an uncommon clinical condition that should be considered in the differential diagnosis of young individuals presenting with symptoms of stroke. The basic pathological changes in CAD include a disruption in the media or intima of arterial wall, through which the affected vasculature is predisposed to aneurysm or stenosis, and subsequent stroke. Carotid artery dissection may occur spontaneously or result from trauma, an underlying arteriopathic condition, or predisposing risk factors. The heterogeneous clinical presentations of CAD represent significant diagnostic difficulties, which often lead to delays in diagnosis and treatment. Further complicating the clinical picture is the lack of consensus regarding effective treatment modalities. Because of the often-subtle findings present in CAD, the treating physician must have a high index of suspicion to accurately diagnose and manage the condition. We report extracranial internal CAD in a 17-year-old girl leading to multiple infarcts that was successfully managed with initial antiplatelet therapy and subsequent anticoagulation.

Dissection of Cervical Arteries: Long-Term Follow-Up Study of 130 Consecutive Cases

BACKGROUND AND PURPOSE

We describe the natural history, functional prognosis and long-term recurrences of patients with dissection of cervical arteries (DCA) in a sequential observational study.

METHODS

We describe 130 patients with angiographically-proven DCA admitted to the Neurology Institute in Mexico City (Mexico), and analyzed clinical and neuroimaging data, treatment and outcome. Treatment with either anticoagulation or aspirin was decided by the primary physician. Primary outcome measures were recurrence (stroke and death) and clinical outcome at 6 months. Follow-up studies were performed to determine recanalization.

RESULTS

Mean age was 35.4 years; 4 patients died (3%) and 126 were followed for 3,906 person/years; 17 patients (13%) had a heralding ischemic cerebral event (6 strokes, 11 TIAS) about 8 days before the diagnosis of DCA. After diagnosis, recurrent ischemic stroke occurred in 6 patients (4.8%) within the 2 first weeks (1.5 persons/1,000 follow-up years). No significant differences were found between aspirin and anticoagulation. Recanalization was more frequent in vertebral dissections. Complete recanalization of vertebral dissections was associated with a favorable prognosis [OR 3.2 (95% CI 1.1-8.8; p = 0.02)].

CONCLUSIONS

In Mexico, DCA affects young adults and may present with a heralding stroke or TIA. We found rare, early ischemic recurrences. Vertebral territory dissections had better prognosis than carotid ones, particularly in patients with demonstrated complete recanalization.

Dissection of cervicocephalic arteries: early diagnosis and follow-up with magnetic resonance imaging

Evaluate Magnetic Resonance (MR) and Magnetic Resonance Angiography (MRA) sensibility in the diagnosis and follow-up of dissection of Internal Carotid and Vertebral Artery (ICA/VA). We revalued MR examination of 36 patients, 24 men, 12 women, aged 18-69 years. All patients underwent brain TC and MR (GE 1 Tesla); in 16 subjects 3D Time-of-Flight (TOF-3D) MRA was performed and in 20 subjects a Contrast-Enhanced MRA (CEMRA) of neck and head arteries. Thirty-one patients underwent a MRA follow-up. Dissection involved ICA in 30 and VA in 8. MR showed ischemic signs in 25 cases, wall hematoma in 19, and was normal in 11. MRA showed 25 vessels stenosis, 12 occlusions, and 9 aneurysm. Follow-up MRA showed 6 cases of complete resolution of stenosis, 17 partial resolution, 2 aneurysmal dissecanting, 6 luminal alteration unchanged, 1 aneurysma enlarged. MRA represented a non-invasive technique as investigation in suspected cervicocephalic arteries dissection.

Genetic Analysis of Familial Connective Tissue Alterations Associated With Cervical Artery Dissections Suggests Locus Heterogeneity

Background and Purpose— Cervical artery dissections (CAD) can be associated with connective tissue aberrations in skin biopsies. The analysis of healthy relatives of patients suggested that the connective tissue phenotype is familial with an autosomal dominant inheritance.

Methods— We performed genetic linkage studies in 3 families of patients with CAD. Connective tissue phenotypes for the patients and all family members were assessed by electron microscopic study of skin biopsies. A genome-wide linkage analysis of 1 family (1 patient with 8 healthy relatives) indicated 2 candidate loci. Three genes were subsequently studied by sequence analysis. Part of the genome was also studied by linkage analysis in 2 further families.

Results— The genome-wide scan in a single family suggested linkage between the hypothetical mutation causing the connective tissue phenotype and informative genetic markers on chromosome 15q24 (logarithm of the odds score: Z = +2.1). A second possible candidate locus ( Z =+1.9) was found on chromosome 10q26. Sequence analysis of 3 candidate genes in the suggestive locus (chondroitin sulfate proteoglycan4 [ CSPG4 ], lysyl oxidase-like1 [ LOXL1 ] and fibroblast growth factor receptor2 [ FGFR2 ]) did not lead to the identification of a mutation responsible for connective tissue alterations. In 2 additional smaller families the loci on chromosome 15q24 and 10q26 were excluded by linkage analysis.

Conclusions— Linkage analysis of a large family with CAD-associated connective tissue alterations suggested the presence of a candidate locus on chromosome 15q2 or on chromosome 10q26. Sequence analysis did not lead to the identification of a mutated candidate gene in 1 of these loci. The study of 2 additional pedigrees indicated locus heterogeneity for the connective tissue phenotype of CAD patients.

Dissection of the V4 segment of the vertebral artery: clinicoradiologic manifestations and endovascular treatment

Intracranial vertebral artery (VA) dissection has three clinical presentations: ischemia, hemorrhage, and mass effect. Imaging findings of intracranial VA dissections vary according to clinical presentation. Irregular stenosis or occlusion of the VA is the most common finding in patients with posterior fossa infarction, whereas a dissecting aneurysm is the main feature in those with acute subarachnoid hemorrhage. A chronic, giant, dissecting aneurysm can cause mass effect on the brain stem or cranial nerves, as well as distal embolism. Magnetic resonance imaging is useful for detection of intramural hematomas and intimal flaps, both of which are diagnostic of VA dissection. Multidetector computed tomography angiography is increasingly used for diagnosis of VA dissection. Catheter angiography is still beneficial for evaluation of precise endoluminal morphology of the dissection before surgical or endovascular intervention. Endovascular treatment is now considered a major therapeutic option for patients with a ruptured dissecting aneurysm or a chronic dissecting aneurysm. Anticoagulation therapy is currently considered the initial treatment of choice in patients with posterior circulation ischemic symptoms. Endovascular treatment, such as stent-assisted angioplasty or coil occlusion at the dissection site, can be performed in selected patients with posterior fossa ischemic symptoms.

Craniocervical arterial dissection in children: clinical and radiographic presentation and outcome

Craniocervical arterial dissection is a recognized cause of arterial ischemic stroke in children. Whether children with craniocervical arterial dissection have dissection characteristics different from those of adults is unclear. A retrospective review of children, 1 month to 18 years of age, with dissection from two Canadian pediatric ischemic stroke registry centers was conducted. From 213 patients with arterial ischemic stroke, 16 (7.5%) were identified with dissection, 37.5% had warning symptoms, and 50% had a history of head or neck trauma. The clinical presentation included headache (44%), altered consciousness (25%), seizures (12.5%), and focal deficits (87.5%). Dissection involved extracranial vessels in 75% and anterior circulation in 56%. Follow-up included complete recovery in 43%, mild to moderate deficits in 44%, and severe deficits in 13%. Fourteen (87.5%) children received antithrombotic treatment. Follow-up angiography showed resolution of abnormalities in 60% of vessels. Total occlusion had the worst outcome for recanalization. In conclusion, the etiology of arterial dissection in the majority of children appears to be either trauma or idiopathic. Long-term angiography shows variable outcomes, depending on the initial findings. The relationship of angiographic outcomes with recurrent strokes requires further study in pediatric dissection. (J Child Neurol 2006;21:8-16).

An Analysis of the Etiology of Cervical Artery Dissections: 1994 to 2003

OBJECTIVE

To provide a literature review of the etiologic breakdown of cervical artery dissections.

METHODS

A literature search of the MEDLINE database was conducted for English-language articles published from 1994 to 2003 using the search terms cervical artery dissection (CAD), vertebral artery dissection, and internal carotid artery dissection. Articles were selected for inclusion only if they incorporated a minimum of 5 case reports of CAD and contained sufficient information to ascertain a plausible etiology.

RESULTS

One thousand fourteen citations were identified; 20 met the selection criteria. There were 606 CAD cases reported in these studies; 321 (54%) were internal carotid artery dissection and 253 (46%) were vertebral artery dissection, not including cases with both. Three hundred seventy-one (61%) were classified as spontaneous, 178 (30%) were associated with trauma/trivial trauma, and 53 (9%) were associated with cervical spinal manipulation. If one apparently biased study is dropped from the data pool, the percentage of CADs related to cervical spinal manipulation drops to approximately 6%.

CONCLUSIONS

The case series that were reviewed in this article indicated that most CADs reported in the previous decade were spontaneous but that some were associated with trauma/trivial trauma, and a minority with cervical spine manipulation. This etiologic breakdown of CAD does not differ significantly from what has been portrayed by most other authors.

Non-Atherosclerotic Vascular Disease in the Young

There are a large variety of non-atherosclerotic causes of ischemic stroke in the young. Arterial dissection, most commonly associated with non-traumatic causes, is among the most common. Both the carotid and vertebrobasilar circulations can be affected. The vasculitidies represent a rare, but potentially treatable series of conditions that can lead to stroke through diverse mechanisms. Moyamoya is a nonatherosclerotic, noninflammatory, nonamyloid vasculopathy characterized by chronic progressive stenosis or occlusion of the distal internal carotid arteries and/or proximal portions of the middle and/or anterior cerebral arteries. Moyamoya can be idiopathic (moyamoya disease) or the result of other conditions. An appreciation of the unusual causes of stroke in the young is important when considering secondary prevention measures.