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Keser Z, Seven NA, Bucak B, Pezzini A, Lanzino G. Necessary to continue imaging spontaneous cervical artery dissecting pseudoaneurysms after one year? J Stroke Cerebrovasc Dis 2024:107806. [PMID: 38839026 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107806] [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: 02/01/2024] [Revised: 05/28/2024] [Accepted: 06/02/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND PURPOSE The value of long-term serial imaging of dissecting pseudoaneurysm (dPSA) is poorly characterized. This study investigated the long-term radiographic evolution of dPSA. METHODS We performed a query in our institutional craniocervical artery dissection registry to identify cases with spontaneous dPSA who had at least one year of follow-up with serial angiographic imaging. We performed Wilcoxon rank-sum pairwise comparison test to determine if there was a significant change in the aneurysm size over time. RESULTS This observational cohort study included 76 patients (46 females; 64 dPSA in the internal carotid artery [ICA] and 12 in the vertebral artery [VA]) with a median age of 49.5 years (range 24-77). The initial median dPSA size was 8 mm (interquantile range(iqr)=5.88-11mm), and the final median dPSA size was 7 mm (iqr=4-11 mm). Most patients had either no change or reduction in dPSA size in the serial follow-up, with no significant change over time. All the patients had favorable outcomes at the last follow-up, and most patients were symptom-free from dPSA (92 %). Two patients (2.6%) experienced recurrent ischemic strokes in the same territory as the initial ischemic stroke without any change in dPSA size. CONCLUSION Further serial scans for dPSA after one year may be deferred in the absence of interim clinical symptoms as most dPSA either remains stable or decreases in size. Recurrent stroke, although a rare event, was not associated with an increase in dPSA size.
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Affiliation(s)
- Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Nathan A Seven
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Bilal Bucak
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Alessandro Pezzini
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Stroke Care Program, Department of Emergency, Parma University Hospital, Parma, Italy; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA; Department of Radiology, Mayo Clinic, Rochester, MN, USA.
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2
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Abou Diwan R, Kaadi L, Hachem S, Smayra T, Slaba S, Chalhoub B, Hachem K. Pseudoaneurysms: Different ultrasound patterns, aetiologies and locations. Australas J Ultrasound Med 2023; 26:258-266. [PMID: 38098621 PMCID: PMC10716566 DOI: 10.1002/ajum.12348] [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: 12/17/2023] Open
Abstract
Pseudoaneurysms are frequent vascular anomalies. This review article aims to describe the unique specific aspect of pseudoaneurysm (PSA) that allows to make the diagnosis using different modalities: colour Doppler ultrasound, computed tomographic angiography, magnetic resonance angiography and conventional angiography. It is essential to know the various aetiologies of PSA: iatrogenic, traumatic, dissecting and anastomotic; different locations and the possible complications, information to help clinicians choose the best treatment. Our review is supported by illustrated series of cases.
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Affiliation(s)
- Ralph Abou Diwan
- Medical Imaging Department, Hôtel‐Dieu de FranceAlfred Naccache BoulevardBeirutLebanon
| | - Lea Kaadi
- Medical Imaging Department, Hôtel‐Dieu de FranceAlfred Naccache BoulevardBeirutLebanon
| | - Samir Hachem
- Faculty of MedicineUniversity of Saint JosephBeirutLebanon
| | - Tarek Smayra
- Medical Imaging Department, Hôtel‐Dieu de FranceAlfred Naccache BoulevardBeirutLebanon
| | - Sami Slaba
- Medical Imaging Department, Hôtel‐Dieu de FranceAlfred Naccache BoulevardBeirutLebanon
| | - Berthe Chalhoub
- Laboratory Department, Hôtel‐Dieu de FranceAlfred Naccache BoulevardBeirutLebanon
| | - Kamal Hachem
- Medical Imaging Department, Hôtel‐Dieu de FranceAlfred Naccache BoulevardBeirutLebanon
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3
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van Laarhoven CJHCM, Arnold M, Danilova M, Dreval M, Ferrari E, Simonetti BG, Gralla J, Heldner M, Kalashnikova L, Mancuso M, Metso TM, Steinsiepe VK, Strbian D, Tatlisumak T, de Kleijn DPV, de Borst GJ. Delayed Development of Aneurysmal Dilatations in Patients with Extracranial Carotid Artery Dissections. Eur J Vasc Endovasc Surg 2022; 64:595-601. [PMID: 35977695 DOI: 10.1016/j.ejvs.2022.08.010] [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: 06/21/2021] [Revised: 06/22/2022] [Accepted: 08/06/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Dissection of the carotid artery (CaAD) may result in aneurysm formation. The present study was undertaken to evaluate the time of onset of post-dissection extracranial carotid artery aneurysms (ECAA) following CaAD, and to analyse independent risk factors for the development of these aneurysms. METHODS From four European stroke centres, 360 patients with extracranial CaAD were included. The time between the estimated dissection onset and aneurysm formation was analysed, and the clinical risk factors increasing the probability of aneurysm were assessed. RESULTS The median duration of follow up was 5.2 months (range 0 - 24 months). A total of 75 post-dissection ECAAs were identified in 70 patients (19.4%, 95% confidence interval [CI] 15.7 - 23.8). In 52 of 70 (74%) patients, the ECAA was diagnosed at the initial clinical work up of CaAD diagnosis, with the median estimated time of dissection onset to ECAA diagnosis being six days (interquartile range [IQR] 0 - 25). In the remaining 18 (26%) patients who had normal carotid arteries at the initial imaging, the aneurysm diagnosis was made a median of 6.2 months (189 days) from the original imaging (IQR 128 - 198). A Cox proportional hazards model showed that both multiple artery dissections (hazard ratio [HR] 2.58, 95% CI 1.54 - 4.33) and arterial tortuosity (HR 1.79, 95% CI 1.08 - 2.95) were associated with presence of ipsilateral ECAA. CONCLUSION This post hoc cohort analysis showed substantially delayed development of ipsilateral ECAA in patients with CaAD, months after baseline. Multiple dissections and arterial tortuosity are associated with the presence of ECAA and can be used in future prediction models of ECAA development in patients with CaAD.
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Affiliation(s)
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Maria Danilova
- Research Centre of Neurology, University Hospital Moscow, University of Moscow, Moscow, Russia
| | - Marina Dreval
- Research Centre of Neurology, University Hospital Moscow, University of Moscow, Moscow, Russia
| | - Elena Ferrari
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Barbara G Simonetti
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland; Department of Neuropaediatrics, Institute of Paediatrics of Southern Switzerland EOC, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Mirjam Heldner
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Ludmila Kalashnikova
- Research Centre of Neurology, University Hospital Moscow, University of Moscow, Moscow, Russia
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - Tiina M Metso
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Valentin K Steinsiepe
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dominique P V de Kleijn
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.
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4
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Pezzini D, Grassi M, Zedde ML, Zini A, Bersano A, Gandolfo C, Silvestrelli G, Baracchini C, Cerrato P, Lodigiani C, Marcheselli S, Paciaroni M, Rasura M, Cappellari M, Del Sette M, Cavallini A, Morotti A, Micieli G, Lotti EM, Delodovici ML, Gentile M, Magoni M, Azzini C, Calloni MV, Giorli E, Braga M, La Spina P, Melis F, Tassi R, Terruso V, Calabrò RS, Piras V, Giossi A, Locatelli M, Mazzoleni V, Sanguigni S, Zanferrari C, Mannino M, Colombo I, Dallocchio C, Nencini P, Bignamini V, Adami A, Costa P, Bella R, Pascarella R, Padovan A, Pezzini A. Antithrombotic therapy in the postacute phase of cervical artery dissection: the Italian Project on Stroke in Young Adults Cervical Artery Dissection. J Neurol Neurosurg Psychiatry 2022; 93:686-692. [PMID: 35508372 DOI: 10.1136/jnnp-2021-328338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/17/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the impact of antithrombotic therapy discontinuation in the postacute phase of cervical artery dissection (CeAD) on the mid-term outcome of these patients. METHODS In a cohort of consecutive patients with first-ever CeAD, enrolled in the setting of the multicentre Italian Project on Stroke in Young Adults Cervical Artery Dissection, we compared postacute (beyond 6 months since the index CeAD) outcomes between patients who discontinued antithrombotic therapy and patients who continued taking antithrombotic agents during follow-up. Primary outcome was a composite of ischaemic stroke and transient ischaemic attack. Secondary outcomes were (1) Brain ischaemia ipsilateral to the dissected vessel and (2) Recurrent CeAD. Associations with the outcome of interest were assessed by the propensity score (PS) method. RESULTS Of the 1390 patients whose data were available for the outcome analysis (median follow-up time in patients who did not experience outcome events, 36.0 months (25th-75th percentile, 62.0)), 201 (14.4%) discontinued antithrombotic treatment. Primary outcome occurred in 48 patients in the postacute phase of CeAD. In PS-matched samples (201 vs 201), the incidence of primary outcomes among patients taking antithrombotics was comparable with that among patients who discontinued antithrombotics during follow-up (5.0% vs 4.5%; p(log rank test)=0.526), and so was the incidence of the secondary outcomes ipsilateral brain ischaemia (4.5% vs 2.5%; p(log rank test)=0.132) and recurrent CeAD (1.0% vs 1.5%; p(log rank test)=0.798). CONCLUSIONS Discontinuation of antithrombotic therapy in the postacute phase of CeAD does not appear to increase the risk of brain ischaemia during follow-up.
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Affiliation(s)
- Debora Pezzini
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
| | - Mario Grassi
- Dipartimento di Scienze del Sistema Nervoso e del Comportamento, Unità di Statistica Medica e Genomica, Università di Pavia, Pavia, Italia
| | - Maria Luisa Zedde
- S.C Neurologia, Stroke Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italia
| | - Andrea Zini
- UOC Neurologia e Rete Stroke metropolitana, IRCCS Istituto di Scienze Neurologiche di Bologna, Ospedale Maggiore, Bologna, Italia
| | - Anna Bersano
- U.O Malattie Cerebrovascolari, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milano, Italia
| | - Carlo Gandolfo
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università di Genova, Genova, Italia
| | - Giorgio Silvestrelli
- Stroke Unit, Dipartimento di Neuroscienze, Ospedale "Carlo Poma", Mantova, Italia
| | - Claudio Baracchini
- UOSD Stroke Unit e Laboratorio di Neurosonologia, Azienda Ospedale-Università Padova, Padova, Italia
| | - Paolo Cerrato
- Stroke Unit, Dipartimento di Neuroscienze, Ospedale Molinette, Università di Torino, Torino, Italia
| | | | - Simona Marcheselli
- Neurologia d'urgenza e Stroke Unit, IRCCS Humanitas Research Hospital, Rozzano, Italia
| | - Maurizio Paciaroni
- Internal, Vascular and Emergency Medicine - Stroke Unit, Università degli Studi di Perugia - Azienda Ospedaliera Santa Maria della Misericordia, Perugia, Italia
| | - Maurizia Rasura
- Stroke Unit, Azienda Ospedaliera "Sant'Andrea", Università "La Sapienza", Roma, Italia
| | - Manuel Cappellari
- Sroke Unit, Azienda Ospedaliera Universitaria Integrata Borgo Trento, Verona, Italia
| | - Massimo Del Sette
- U,O Neurologia, IRCCS Ospedale Policlinico "San Martino", Genova, Italia
| | - Anna Cavallini
- U.O Malattie Cerebrovascolari e Stroke Unit, IRCCS Fondazione Istituto Neurologico Nazionale "C. Mondino", Pavia, Italia
| | - Andrea Morotti
- Dipartimento di Scienze Neurologiche e della Visione, ASST Spedali Civili, Brescia, Italia
| | - Giuseppe Micieli
- Neurologia d'Urgenza, IRCCS Fondazione Istituto Neurologico Nazionale "C. Mondino", Pavia, Italia
| | | | | | - Mauro Gentile
- UOC Neurologia e Rete Stroke metropolitana, IRCCS Istituto di Scienze Neurologiche di Bologna, Ospedale Maggiore, Bologna, Italia
| | - Mauro Magoni
- Dipartimento di Scienze Neurologiche e della Visione, Neurologia Vascolare, ASST Spedali Civili di Brescia, Brescia, Italia
| | - Cristiano Azzini
- U.O. Neurologia, Stroke Unit, Azienda Ospedaliera "S. Anna", Università di Ferrara, Ferrara, Italia
| | | | - Elisa Giorli
- U.O Neurologia, Ospedale "Sant'Andrea", La Spezia, Italia
| | | | - Paolo La Spina
- U.O.S.D Stroke Unit, Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italia
| | - Fabio Melis
- S.S Neurovascolare, ASL Città di Torino, Ospedale "Maria Vittoria", Torino, Italia
| | - Rossana Tassi
- U.O.C Stroke Unit, Dipartimento di Scienze Mediche, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italia
| | | | | | - Valeria Piras
- S.C Neurologia e Stroke Unit, Dipartimento di Neuroscienze e Riabilitazione, Azienda Ospedaliera "G. Brotzu", Cagliari, Italia
| | - Alessia Giossi
- U.O Neurologia, Istituti Ospedalieri, ASST Cremona, Cremona, Italia
| | - Martina Locatelli
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
| | - Valentina Mazzoleni
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
| | - Sandro Sanguigni
- Dipartimento di Neurologia, Ospedale "Madonna del Soccorso", San Benedetto del Tronto, Italia
| | - Carla Zanferrari
- U.O.C Neurologia - Stroke Unit, ASST Melegnano-Martesana, Vizzolo Predabissi, Italia
| | | | - Irene Colombo
- S.C Neurologia e Unità Neurovascolare, Ospedale di Desio, ASST Brianza, Desio, Italia
| | - Carlo Dallocchio
- Dipartimento di Area Medica, U.O.C Neurologia, Ospedale Civile di Voghera, ASST Pavia, Voghera, Italia
| | - Patrizia Nencini
- Stroke Unit, Università degli Studi di Firenze, Azienda Ospedaliero-Universitaria di Careggi, Firenze, Italia
| | - Valeria Bignamini
- U.O Neurologia, Stroke Unit, Ospedale "S. Chiara", APSS Trento, Trento, Italia
| | - Alessandro Adami
- Dipartimento di Neurologia, Stroke Center, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar, Italia
| | - Paolo Costa
- U.O Neurologia, Istituto Ospedaliero Poliambulanza, Brescia, Italia
| | - Rita Bella
- Dipartimento di Scienze Mediche e Chirurgiche e Tecnologie Avanzate, Sezione di Neuroscienze, Università di Catania, Catania, Italia
| | - Rosario Pascarella
- S.S.D Neuroradiologia, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italia
| | - Alessandro Padovan
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
| | - Alessandro Pezzini
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
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Letter to the Editor Regarding "Internal Carotid Artery Pseudoaneurysm Secondary to Spontaneous Dissection: Treatment with Endovascular Stentgraft Repair" Published by Zakeri et al. Cardiovasc Intervent Radiol 2022; 45:264-265. [PMID: 35001150 DOI: 10.1007/s00270-021-03027-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/17/2021] [Indexed: 11/02/2022]
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Tarsia J, Vidal G, Zweifler RM. Arterial Dissection, Fibromuscular Dysplasia, and Carotid Webs. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cucchiara BL, Kasner SE. Treatment of “Other” Stroke Etiologies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sultan S, Hynes N, Acharya Y, Kavanagh E, Jordan F. Systematic review of the effectiveness of carotid surgery and endovascular carotid stenting versus best medical treatment in managing symptomatic acute carotid artery dissection. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1212. [PMID: 34430653 PMCID: PMC8350712 DOI: 10.21037/atm-20-7279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/04/2021] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland Galway, Galway, Ireland.,Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Teaching Hospitals, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Teaching Hospitals, Galway, Ireland
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland Galway, Galway, Ireland.,Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Teaching Hospitals, Galway, Ireland
| | - Edel Kavanagh
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Teaching Hospitals, Galway, Ireland
| | - Fionnuala Jordan
- College of Nursing and Midwifery, National University of Ireland, Galway, Ireland
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Beaty N, Patel M, Martinez C, Hollis L. Use of flow diverter stent for treatment of a cervical carotid artery dissection and pseudoaneurysm causing Horner's syndrome. BMJ Case Rep 2021; 14:14/5/e241156. [PMID: 33972299 PMCID: PMC8112441 DOI: 10.1136/bcr-2020-241156] [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: 11/04/2022] Open
Abstract
A 28-year-old man in 2004 was identified with a spontaneous pseudoaneurysm and distal left cervical internal carotid artery (ICA) dissection. The patient was followed conservatively for 12 years with cross-sectional imaging. The patient was initially diagnosed with an acute left ICA dissection, with significant luminal narrowing. Follow-up imaging revealed the dissection was not completely healed, and a small pseudoaneurysm, about 4 mm in size, was formed in the distal left cervical ICA. During the 12-year observation period, the patient's pseudoaneurysm expanded from 4.0 mm to 9.0 mm, and the patient presented with ptosis, anisocoria and myosis. Flow diverter embolisation resulted in a radiographic cure of the pseudoaneurysm and resolution of Horner's syndrome.
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Affiliation(s)
- Narlin Beaty
- Department of Neurosurgery, Tallahassee Neurological Clinic, Tallahassee, Florida, USA
| | - Monisha Patel
- Department of Neurosurgery, Tallahassee Neurological Clinic, Tallahassee, Florida, USA
| | - Christian Martinez
- Department of Neurosurgery, Tallahassee Neurological Clinic, Tallahassee, Florida, USA
| | - Lutheria Hollis
- Department of Neurosurgery, Tallahassee Neurological Clinic, Tallahassee, Florida, USA
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Bratu IF, Ribigan AC, Stefan D, Davidoiu CR, Badea RS, Antochi FA. Internal Carotid Artery Dissection - A Case for Antithrombotic Therapy in the Era of (Minimally) Invasive Procedures. MÆDICA 2021; 15:536-542. [PMID: 33603914 DOI: 10.26574/maedica.2020.15.4.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objectives: Carotid artery dissection represents a common cause of stroke among people aged 30-45. We present two clinical cases and a review of the literature concerning the management of internal carotid artery dissections (ICADs). Materials and methods: The two patients are a 54-year-old male and a 40-year-old female. The first patient presented to our Neurology Department for one-week-old intense occipital headache. His clinical examination revealed left-sided miosis and upper eyelid ptosis. He underwent cerebral-cervical computed tomography (CT) and computed tomography angiography (CTA) scans and the latter revealed hemodynamically significant narrowing of both ICAs (right C1-C5 and left C1-C2 segments). Transcranial Doppler ultrasonography and Doppler ultrasonography (DUS) of the cervical-cerebral arteries showed right ICA occlusion at its origin (dissection fold and intraluminal thrombosis). Cervical magnetic resonance imaging (MRI) and time-of-flight magnetic resonance angiography (MRA) revealed a semilunar-shaped T2-weighted hypersignal present in the walls of the C1-C5 segments of the right ICA and of the C1-C2 segments of the left ICA, with bilaterally reduced intraluminal flow (right more than left). These findings indicated the presence of bilateral ICA intramural hematomas caused by subacute bilateral ICAD. The second patient presented to our Neurology Department for recurrent episodes of headache and lateral cervical pain on both sides. She underwent transcranial DUS and DUS of the cervicalcerebral arteries. They revealed right ICAD fold in its upper cervical segments. The CTA scan of the supra-aortic trunks showed hemodynamically significant narrowing with subsequent diminished blood flow in the upper cervical segments of right ICA. The patient was diagnosed with right ICAD. Results:Both patients were treated using antiplatelet therapy for primary prevention of ischaemic events. Follow-up at seven months and at six months, respectively, by means of CTA of the supra-aortic trunks or MRA of the cervical region, revealed the restoration of arterial patency with subsequent normal blood flow in both cases. Conclusions: The long-term outcomes of ICADs should be kept in mind when assigning medical or endovascular management on a case-by-case basis. Antiplatelet or anticoagulant therapy is a safe and effective first-line strategy in such patients, especially in cases that do not warrant particular management.
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Affiliation(s)
| | | | - Daniela Stefan
- Department of Neurology, Emergency University Hospital, Bucharest, Romania
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Kalashnikova L, Danilova M, Gubanova M, Dobrynina L, Dreval M, Krotenkova M. Aneurysms and pathological tortuosity of the internal carotid and vertebral arteries in patients with dissection of these vessels: a results of long-term study. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:7-12. [DOI: 10.17116/jnevro20211211217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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López O, Piñana C, Gramegna LL, Rodríguez J, Hernández D, Tomasello A. Endovascular management of internal carotid artery dissection with associated aneurysm using a multilayer flow modulator. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:374-380. [PMID: 32715174 PMCID: PMC7371615 DOI: 10.1016/j.jvscit.2020.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/24/2020] [Indexed: 11/29/2022]
Abstract
Extracranial carotid artery dissection represents up to 22% of acute neurovascular disease in young patients. There are no specific guidelines regarding indication for endovascular management of carotid artery dissection with stenting and its complications. We describe three patients with carotid artery dissection and associated dissecting aneurysm who underwent endovascular stenting with the multilayer flow modulator. At 12-month follow-up, the dissecting aneurysms were resolved, and positive clinical outcome was achieved in all patients. Our results suggest that the multilayer flow modulator may be an alternative option for endovascular interventions in patients with carotid artery dissection and pseudoaneurysms because it favors laminar flow, and it may promote spontaneous healing of the wall by progressively reducing the vascular stress in the aneurysm wall. However, further studies are needed to confirm these findings.
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Affiliation(s)
- Orlando López
- Department of Radiology, Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Barcelona, Spain.,University Foundation of Health Sciences, Bogotá, Colombia
| | - Carlos Piñana
- Department of Radiology, Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Laura Ludovica Gramegna
- Department of Biomedical and Motor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - José Rodríguez
- Department of Radiology, Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Hernández
- Department of Radiology, Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alejandro Tomasello
- Department of Radiology, Interventional Neuroradiology Section, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Barcelona, Spain
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Saal-Zapata G, Durand W, Valer D, Rodríguez R. Internal Carotid Artery Dissection Treated with C-Guard Stent. Int J Angiol 2020; 31:61-66. [PMID: 35221855 DOI: 10.1055/s-0040-1708839] [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: 10/24/2022] Open
Abstract
Internal carotid dissection is the most common cause of stroke in the young population. Stroke, the presence of a pseudoaneurysm, and decreased artery lumen with cerebral flow impairment are indications for treatment. Medical therapy with antithrombotic drugs and endovascular therapy with stenting are the main available options. The C-Guard stent is an open cell mesh-covered dual layer stent that has been mainly used in cases of internal carotid artery stenosis with a post-operative reduction in stroke incidence. Thus, we present two cases of internal carotid artery dissections of the cervical segment treated with the open cell dual-layer C-Guard stent without complications.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru
| | - Walter Durand
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru
| | - Dante Valer
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru
| | - Rodolfo Rodríguez
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru
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Poli L, Mardighian D, Gamba M, Padovani A, Pezzini A. Short-term outcome of carotid dissecting pseudoaneurysm: is it always benign? Acta Neurol Belg 2018; 118:537-539. [PMID: 29637474 DOI: 10.1007/s13760-018-0917-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
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16
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Kloss M, Grond-Ginsbach C, Ringleb P, Hausser I, Hacke W, Brandt T. Recurrence of cervical artery dissection. Neurology 2018; 90:e1372-e1378. [DOI: 10.1212/wnl.0000000000005324] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 01/10/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo explore the recurrence of cervical artery dissection (CeAD).MethodsA 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.ResultsMedian 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).ConclusionTwenty-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.
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Mehdi E, Aralasmak A, Toprak H, Yıldız S, Kurtcan S, Kolukisa M, Asıl T, Alkan A. Craniocervical Dissections: Radiologic Findings, Pitfalls, Mimicking Diseases: A Pictorial Review. Curr Med Imaging 2018; 14:207-222. [PMID: 29853818 PMCID: PMC5902863 DOI: 10.2174/1573405613666170403102235] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Craniocervical Dissections (CCD) are a crucial emergency state causing 20% of strokes in patients under the age of 45. Although DSA (digital substraction angiography) is regarded as the gold standard, noninvasive methods of CT, CTA and MRI, MRA are widely used for diagnosis. Aim: Our aim is to illustrate noninvasive imaging findings in CCD. Conclusion: Emphasizing on diagnostic pitfalls, limitations and mimicking diseases.
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Affiliation(s)
- Elnur Mehdi
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Ayse Aralasmak
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Huseyin Toprak
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Seyma Yıldız
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Serpil Kurtcan
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Mehmet Kolukisa
- Bezmialem Vakif University, Department of Neurology, Istanbul, Turkey
| | - Talip Asıl
- Bezmialem Vakif University, Department of Neurology, Istanbul, Turkey
| | - Alpay Alkan
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
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Larsson SC, King A, Madigan J, Levi C, Norris JW, Markus HS. Prognosis of carotid dissecting aneurysms: Results from CADISS and a systematic review. Neurology 2017; 88:646-652. [PMID: 28087823 DOI: 10.1212/wnl.0000000000003617] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/15/2016] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To determine the natural history of dissecting aneurysm (DA) and whether DA is associated with an increased recurrent stroke risk and whether type of antithrombotic drugs (antiplatelets vs anticoagulants) modifies the persistence or development of DA. METHODS We included 264 patients with extracranial cervical artery dissection (CAD) from the Cervical Artery Dissection in Stroke Study (CADISS), a multicenter prospective study that compared antiplatelet with anticoagulation therapy. Logistic regression was used to estimate age- and sex-adjusted odds ratios. We conducted a systematic review of published studies assessing the natural history of DA and stroke risk in patients with non-surgically-treated extracranial CAD with DA. RESULTS In CADISS, DA was present in 24 of 264 patients at baseline. In 36 of 248 patients with follow-up neuroimaging at 3 months, 12 of the 24 baseline DAs persisted, and 24 new DA had developed. There was no association between treatment allocation (antiplatelets vs anticoagulants) and whether DA at baseline persisted at follow-up or whether new DA developed. During 12 months of follow-up, stroke occurred in 1 of 48 patients with DA and in 7 of 216 patients without DA (age- and sex-adjusted odds ratio 0.84; 95% confidence interval 0.10-7.31; p = 0.88). Published studies, mainly retrospective, showed a similarly low risk of stroke and no evidence of an increased stroke rate in patients with DA. CONCLUSIONS The results of CADISS provide evidence suggesting that DAs may have benign prognosis and therefore medical treatment should be considered.
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Affiliation(s)
- Susanna C Larsson
- From the Stroke Research Group (S.C.L., H.S.M.), Department of Clinical Neurosciences, University of Cambridge; Primary Care and Public Heath (A.K.), School of Public Health, Imperial College London; Neuroradiology (J.M.), Atkinson Morley Neuroscience Centre, St. George's Healthcare Foundation Trust, London, UK; Department of Neurology (C.L.), John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Australia; and St. George's (J.W.N.), University of London, UK
| | - Alice King
- From the Stroke Research Group (S.C.L., H.S.M.), Department of Clinical Neurosciences, University of Cambridge; Primary Care and Public Heath (A.K.), School of Public Health, Imperial College London; Neuroradiology (J.M.), Atkinson Morley Neuroscience Centre, St. George's Healthcare Foundation Trust, London, UK; Department of Neurology (C.L.), John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Australia; and St. George's (J.W.N.), University of London, UK
| | - Jeremy Madigan
- From the Stroke Research Group (S.C.L., H.S.M.), Department of Clinical Neurosciences, University of Cambridge; Primary Care and Public Heath (A.K.), School of Public Health, Imperial College London; Neuroradiology (J.M.), Atkinson Morley Neuroscience Centre, St. George's Healthcare Foundation Trust, London, UK; Department of Neurology (C.L.), John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Australia; and St. George's (J.W.N.), University of London, UK
| | - Christopher Levi
- From the Stroke Research Group (S.C.L., H.S.M.), Department of Clinical Neurosciences, University of Cambridge; Primary Care and Public Heath (A.K.), School of Public Health, Imperial College London; Neuroradiology (J.M.), Atkinson Morley Neuroscience Centre, St. George's Healthcare Foundation Trust, London, UK; Department of Neurology (C.L.), John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Australia; and St. George's (J.W.N.), University of London, UK
| | - John W Norris
- From the Stroke Research Group (S.C.L., H.S.M.), Department of Clinical Neurosciences, University of Cambridge; Primary Care and Public Heath (A.K.), School of Public Health, Imperial College London; Neuroradiology (J.M.), Atkinson Morley Neuroscience Centre, St. George's Healthcare Foundation Trust, London, UK; Department of Neurology (C.L.), John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Australia; and St. George's (J.W.N.), University of London, UK
| | - Hugh S Markus
- From the Stroke Research Group (S.C.L., H.S.M.), Department of Clinical Neurosciences, University of Cambridge; Primary Care and Public Heath (A.K.), School of Public Health, Imperial College London; Neuroradiology (J.M.), Atkinson Morley Neuroscience Centre, St. George's Healthcare Foundation Trust, London, UK; Department of Neurology (C.L.), John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Australia; and St. George's (J.W.N.), University of London, UK.
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Paraskevas K, Batchelder A, Naylor A. Fate of Distal False Aneurysms Complicating Internal Carotid Artery Dissection: A Systematic Review. Eur J Vasc Endovasc Surg 2016; 52:281-6. [DOI: 10.1016/j.ejvs.2016.03.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 03/17/2016] [Indexed: 11/24/2022]
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20
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Abstract
Background Clinical, pathological and radiological advances in recent years have considerably advanced our understanding of the incidence and underlying mechanisms producing dissection of the cervical arteries, which should have implications for medical and, surgical therapy in the near future. This review is a summary of progress to date. Summary of review Numerous published studies, primarily over the last decade, have generated a rapidly evolving data base especially in the areas of etiology, neuroimaging and more recently, arterial pathology and its genetic basis. Conclusion Dissection of the carotid and vertebral arteries, both intracranially and extracranially, is a major and frequently underdiagnosed cause of stroke, especially in the young. These advances in clinical epidemiological observations, and new radiological and pathological data, are gradually providing an evidence-based rationale for future trials of therapeutic interventions, using both drugs and devices.
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Affiliation(s)
- John W. Norris
- Division of Clinical Neuroscience, St Georges Hospital Medical School, University of London, SW17 0RE, UK
| | - Tobias Brandt
- Kliniken Schnieder/University of Heidelberg, Heidelberg, Germany
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21
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Giorgianni A, Pellegrino C, Micieli C, Mercuri A, Minotto R, Baruzzi F, Valvassori L. Endovascular Treatment of Extracranial Internal Carotid Pseudoaneurysm: Description of Three Cases. Surg J (N Y) 2016; 2:e15-e18. [PMID: 28824985 PMCID: PMC5553467 DOI: 10.1055/s-0036-1584168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/23/2016] [Indexed: 10/27/2022] Open
Abstract
The aim of this study is to explore the possibility of endovascular treatment of internal carotid artery pseudoaneurysm (PSA). These lesions are difficult to treat with a surgical approach, especially if they are located extracranially and close to the skull base. Endovascular stent placement in symptomatic and unstable extracranial internal carotid PSA was found to be safe and effective. Depending on hemodynamic aspects, complete local exclusion of aneurysmal formation is achieved in few months. We present three patients with carotid dissection and PSA formation that have been successfully treated by stent placement.
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Affiliation(s)
- Andrea Giorgianni
- Department of Neuroradiology, Circolo Varese Hospital, Varese, Italy
| | - Carlo Pellegrino
- Department of Neuroradiology, Circolo Varese Hospital, Varese, Italy
| | - Camilla Micieli
- Department of Radiology, Circolo Varese Hospital, Varese, Italy
| | - Anna Mercuri
- Department of Neuroradiology, Circolo Varese Hospital, Varese, Italy
| | - Renzo Minotto
- Department of Neuroradiology, Circolo Varese Hospital, Varese, Italy
| | - Fabio Baruzzi
- Department of Neuroradiology, Circolo Varese Hospital, Varese, Italy
| | - Luca Valvassori
- Department of Neuroradiology, Niguarda Ca' Granda Milano Hospital, Milano, Italy
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Daou B, Hammer C, Chalouhi N, Starke RM, Jabbour P, Rosenwasser RH, Tjoumakaris S. Dissecting pseudoaneurysms: predictors of symptom occurrence, enlargement, clinical outcome, and treatment. J Neurosurg 2016; 125:936-942. [PMID: 26824374 DOI: 10.3171/2015.10.jns151846] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Dissection of the carotid and vertebral arteries can result in the development of aneurysmal dilations. These dissecting pseudoaneurysms can enlarge and cause symptoms. The objective of this study is to provide insight into the progression of dissecting pseudoaneurysms and the treatments required to manage them. METHODS A review of the electronic medical records was conducted to detect patients with carotid and vertebral artery dissection. An imaging review was conducted to identify patients with dissecting pseudoaneurysms. One hundred twelve patients with 120 dissecting pseudoaneurysms were identified. Univariate and multivariate analyses were conducted to assess the factors associated with undergoing further interventions other than medical treatment, pseudoaneurysm enlargement, pseudoaneurysms resulting in ischemic and nonischemic symptoms, and clinical outcome. RESULTS Overall, 18.3% of pseudoaneurysms were intracranial and 81.7% were extracranial, and the average size was 7.3 mm. The mean follow-up time was 29.3 months; 3.3% of patients had a recurrent transient ischemic attack, no patients had a recurrent stroke, and 14.2% of patients had recurrence of nonischemic symptoms (headache, neck pain, Horner syndrome, or cranial nerve palsy). Follow-up imaging demonstrated that 13.8% of pseudoaneurysms had enlarged, 30.2% had healed, and 56% had remained stable. In total, 20.8% of patients had an intervention other than medical treatment. Interventions included stenting, coiling, flow diversion, and clipping. Predictors of intervention included increasing size, size > 10 mm, location in the C2 (petrous) segment of the internal carotid artery (ICA), younger age, hyperlipidemia, pseudoaneurysm enlargement, and any symptom development. Significant predictors of enlargement included smoking, history of trauma, C2 location, hyperlipidemia, and larger initial pseudoaneurysm size. Predictors of pseudoaneurysm resulting in recurrent ischemic and nonischemic symptoms included increasing size and location in the petrous segment of the ICA. Smoking was a predictor of unfavorable outcome. CONCLUSIONS Dissecting pseudoaneurysms have a benign course and most will not cause symptoms or enlarge on follow-up. Medical treatment can be a sufficient, initial treatment for dissecting pseudoaneurysms.
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Affiliation(s)
- Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Christine Hammer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M Starke
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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24
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Kasner SE, Cucchiara BL. Treatment of “Other” Stroke Etiologies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Cervical artery dissection (CAD) may affect the internal carotid and/or the vertebral arteries. CAD is the leading cause of ischemic stroke in patients younger than 45 years. Specific treatment (aspirin or anticoagulants) can be implemented once the diagnosis of CAD has been confirmed. This diagnosis is based on detection of a mural haematoma on ultrasound or on MRI. The diagnosis can be suspected on contrast-enhanced MRA (magnetic resonance angiography) or CT angiography, in case of long stenosis, sparing the internal carotid bulb, or suspended, at the junction of V2 and V3 segments of the vertebral artery, in patients with no signs of atheroma of the cervical arteries. MRI is recommended as the first line imaging screening tool, including a fat suppressed T1 weighted sequence, acquired in the axial or oblique plane at 1.5T, or 3D at 3T. Complete resolution of the lumen abnormality occurred in 80% of cases, and CAD recurrence is rare, encountered in less than 5% of cases. Interventional neuroradiology (angioplasty and/or stenting of the dissected vessel) may be envisaged in rare cases of haemodynamic effects with recurring clinical infarctions in the short-term.
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26
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Blum CA, Yaghi S. Cervical Artery Dissection: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome. ARCHIVES OF NEUROSCIENCE 2015; 2. [PMID: 26478890 DOI: 10.5812/archneurosci.26670] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Cervical artery dissection (CAD) is a common cause of stroke in young adults. There is controversy over whether anticoagulation is superior to antiplatelet therapy in preventing stroke in patients with CAD, although meta-analyses to date have not shown any difference between the two treatments. EVIDENCE ACQUISITION We performed a PubMed search using each of the keywords: "Cervical artery dissection", "Dissection", "Carotid dissection", and "Vertebral dissection" between January 1st, 1990 and July 1st 2015. We identified evidence-based peer-reviewed articles, including randomized trials, case series and reports, and retrospective reviews that encompass the epidemiology, clinical manifestations, pathophysiology, treatment, and outcome of cervical artery dissection. RESULTS This paper highlights the mechanisms of cervical artery dissection and stroke in patients with dissection as well as the natural history and treatment. CONCLUSION Given the relatively rare incidence of this disease, multicenter studies with collaborative effort among stroke centers worldwide should be considered to enroll patients with cervical artery dissection in a randomized trial comparing the two treatments.
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Affiliation(s)
- Christina A Blum
- University of Pennsylvania Health System, Department of Neurology, Stroke division
| | - Shadi Yaghi
- Columbia University Medical Center, Department of Neurology, Stroke division
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27
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Welleweerd JC, den Ruijter HM, Nelissen BGL, Bots ML, Kappelle LJ, Rinkel GJE, Moll FL, de Borst GJ. Management of extracranial carotid artery aneurysm. Eur J Vasc Endovasc Surg 2015; 50:141-7. [PMID: 26116488 DOI: 10.1016/j.ejvs.2015.05.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 05/06/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Aneurysms of the extracranial carotid artery (ECAA) are rare. Several treatments have been developed over the last 20 years, yet the preferred method to treat ECAA remains unknown. This paper is a review of all available literature on the risk of complications and long-term outcome after conservative or invasive treatment of patients with ECAA. METHODS Reports on ECAA treatment until July 2014 were searched in PubMed and Embase using the key words aneurysm, carotid, extracranial, and therapy. RESULTS A total of 281 articles were identified. Selected articles were case reports (n = 179) or case series (n = 102). Papers with fewer than 10 patients were excluded, resulting in the final selection of 39 articles covering a total of 1,239 patients. Treatment consisted of either conservative treatment in 11% of the cases or invasive treatment in 89% of the cases. Invasive treatment comprised surgery in 94%, endovascular approach in 5%, and a hybrid approach in 1% of the patients. The most common complication described after invasive therapy was cranial nerve damage, which occurred in 11.8% of patients after surgery. The 30 day mortality rate and stroke rate in conservatively treated patients was 4.67% and 6.67%, after surgery 1.91% and 5.16%. Information on confounders in the present study was incomplete. Therefore, adjustments to correct for confounding by indication could not be done. CONCLUSIONS This review summarizes the largest available series in the literature on ECAA management. The number of ECAAs reported in current literature is scarce. The early and long-term outcome of invasive treatment in ECAA is favorable; however, cranial nerve damage after surgery occurs frequently. Unfortunately, due to limitations in reporting of results and confounding by indication in the available literature, it was not possible to determine the optimal treatment strategy. There is a need for a multicenter international registry to reveal the optimal treatment for ECAA.
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Affiliation(s)
- J C Welleweerd
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H M den Ruijter
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B G L Nelissen
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L J Kappelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G J E Rinkel
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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28
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Welleweerd JC, Nelissen BGL, Koole D, de Vries JPPM, Moll FL, Pasterkamp G, Vink A, de Borst GJ. Histological analysis of extracranial carotid artery aneurysms. PLoS One 2015; 10:e0117915. [PMID: 25635813 PMCID: PMC4312019 DOI: 10.1371/journal.pone.0117915] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 12/31/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction Extracranial carotid artery aneurysms (ECAA) are rare but may be accompanied with significant morbidity. Previous studies mostly focused on diagnostic imaging and treatment. In contrast, the pathophysiological mechanisms and natural course of ECAA are largely unknown. Understanding the pathophysiological background may add to prediction of risk for adverse outcome and need for surgical exclusion. The aim of this study was to investigate the histopathological characteristics of ECAA in patients who underwent complete surgical ECAA resection. Material and Methods From March 2004 till June 2013, 13 patients were treated with open ECAA repair. During surgery the aneurysm sac was resected and processed for standardized histological analysis. Sections were stained with routine hematoxylin and eosin and special stains to detect elastin, collagen, different types of inflammatory cells, vascular smooth muscle cells and endothelial cells. Results Histopathological characterization revealed two distinct categories: dissection (abrupt interruption of the media; n = 3) and degeneration (general loss of elastin fibers in the media; n = 10). In the degenerative samples the elastin fibers in the media were fragmented and were partly absent. Inflammatory cells were observed in the vessel wall of the aneurysms. Conclusion Histological analysis in this small sample size revealed dissection and degeneration as the two distinct underlying mechanisms in ECAA formation.
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Affiliation(s)
- Janna C. Welleweerd
- Vascular Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | - Bastiaan G. L. Nelissen
- Vascular Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
- Experimental Cardiology laboratory, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | - Dave Koole
- Vascular Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
- Experimental Cardiology laboratory, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | | | - Frans L. Moll
- Vascular Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | - Gerard Pasterkamp
- Experimental Cardiology laboratory, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | - Aryan Vink
- Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
| | - Gert Jan de Borst
- Vascular Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, the Netherlands
- * E-mail:
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29
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Abstract
Dissection of the extracranial carotid and vertebral arteries is increasingly recognized as a cause of transient ischemic attacks and stroke. The annual incidence of spontaneous carotid artery dissection is 2.5 to 3 per 100,000, while the annual incidence of spontaneous vertebral artery dissection is 1 to 1.5 per 100,000. Traumatic dissection occurs in approximately 1% of all patients with blunt injury mechanisms, and is frequently initially unrecognized. Overall, dissections are estimated to account for only 2% of all ischemic strokes, but they are an important factor in the young, and account for approximately 20% of strokes in patients less than 45 years of age. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe stenosis or occlusion. Available evidence strongly favors embolism as the most common cause. Both anticoagulation and antiplatelet agents have been advocated as treatment methods, but there is limited evidence on which to base these recommendations. A Cochrane review on the topic of antithrombotic drugs for carotid dissection did not identify any randomized trials, and did not find that anticoagulants were superior to antiplatelet agents for the primary outcomes of death and disability. Healing of arterial dissections occurs within three to six months, with resolution of stenosis seen in 90%, and recanalization of occlusions in as many as 50%. Dissecting aneurysms resolve on follow-up imaging in 5- 40%, decrease in size in 15-30%, and remain unchanged in 50-65%. Resolution is more common in vertebral dissections than in carotid dissections. Aneurysm enlargement occurs rarely. The uncommon patient presenting with acute hemodynamic insufficiency should be managed with measures to increase cerebral blood flow, and in this setting emergency stent placement to restore cerebral perfusion may be considered, provided that irreversible infarction has not already occurred.
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30
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Lee JI, Jander S, Oberhuber A, Schelzig H, Hänggi D, Turowski B, Seitz RJ. Stroke in patients with occlusion of the internal carotid artery: options for treatment. Expert Rev Neurother 2014; 14:1153-67. [PMID: 25245575 DOI: 10.1586/14737175.2014.955477] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic stroke may occur in patients in whom vascular imaging shows the ipsilateral internal carotid artery (ICA) to be occluded. In younger patients this is often due to carotid artery dissection, while in older people this most likely results from cardiac embolism or thrombosis secondary to high-grade stenosis at the carotid bifurcation. Interventional techniques aim at recanalization of the carotid artery for early restoration of cerebral blood flow and secondary prevention of future strokes. In chronic ICA occlusion the ischemic infarct may be related to hemodynamic compromise. In this situation, extracranial-intracranial bypass surgery was introduced, but its role remains still unclear. Ischemic stroke may also occur in patients with a chronic occlusion of the contralateral ICA. This situation demands the usual stroke treatment, but surgical and neuroradiological interventions face a higher risk than unilateral vascular pathology. Medical treatment supports stroke prevention in carotid artery occlusion.
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Affiliation(s)
- John Ih Lee
- LVR-Klinikum Düsseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
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31
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Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, Noorollah LD, Panagos PD, Schievink WI, Schwartz NE, Shuaib A, Thaler DE, Tirschwell DL. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke 2014; 45:3155-74. [PMID: 25104849 DOI: 10.1161/str.0000000000000016] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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32
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Seward CJ, Dumont TM, Levy EI. Endovascular therapy of extracranial carotid artery pseudoaneurysms: case series and literature review. J Neurointerv Surg 2014; 7:682-9. [DOI: 10.1136/neurintsurg-2014-011252] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 07/07/2014] [Indexed: 11/04/2022]
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33
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Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SCC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160-236. [PMID: 24788967 DOI: 10.1161/str.0000000000000024] [Citation(s) in RCA: 2819] [Impact Index Per Article: 281.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.
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34
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Surgical and Endovascular Treatment of Extracranial Carotid Artery Aneurysms: Early and Long-Term Results of a Single Center. Ann Vasc Surg 2014; 28:659-64. [DOI: 10.1016/j.avsg.2013.05.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/10/2013] [Accepted: 05/23/2013] [Indexed: 11/23/2022]
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35
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Rouchaud A, Klein I, Amarenco P, Mazighi M, Pacchioni A, Torsello G, Reimers B, van Sambeek MRHM, Tielbeek AV, Teijink JAW, Cuypers PW. How should I treat a symptomatic post dissection carotid aneurysm? EUROINTERVENTION 2014; 9:1121-3. [PMID: 24457283 DOI: 10.4244/eijv9i9a187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Aymeric Rouchaud
- INSERM U-698 and Denis Diderot University-Paris VII, Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France
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36
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Asif KS, Lazzaro MA, Teleb MS, Fitzsimmons BF, Lynch J, Zaidat O. Endovascular reconstruction for progressively worsening carotid artery dissection. J Neurointerv Surg 2014; 7:32-9. [DOI: 10.1136/neurintsurg-2013-010864] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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37
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Lee SR, Metwalli ZA, Yevich SM, Whigham CJ, Benndorf G. Variability in evolution and course of gunshot injuries to the neck and impact on management. A case report. Interv Neuroradiol 2013; 19:489-95. [PMID: 24355155 DOI: 10.1177/159101991301900414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/01/2013] [Indexed: 11/15/2022] Open
Abstract
This study reports the differences in evolution and course of multiple pseudoaneurysms (PAs) and an axillary arteriovenous fistula (AVF) after penetrating vascular trauma due to shotgun injury to the head and neck. We describe the unusual case of a young man who, following penetrating shotgun injuries to the head and neck, developed multiple PAs of the common carotid, vertebral and superficial temporal arteries as well as an axillary AVF. Serial angiographic follow-up studies documented differences in time of occurrence, evolution and course of these lesions. This allowed for tailored management using endovascular (AVF, superficial temporal artery PAs) and conservative (carotid and vertebral PAs) treatment. No complication occurred and complete cure of all lesions was achieved and documented after seven months. Time of occurrence, evolution and regression of penetrating vascular injuries can differ significantly even in the same patient. Close angiographic follow-up helps not only detect a lesion with delayed occurrence, but also provides a practical basis for decision-making for optimal therapeutic management.
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Affiliation(s)
- Stephen R Lee
- Department of Radiology, Baylor College of Medicine; Houston, TX, USA -
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38
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Rahme RJ, Aoun SG, McClendon J, El Ahmadieh TY, Bendok BR. Spontaneous Cervical and Cerebral Arterial Dissections. Neuroimaging Clin N Am 2013; 23:661-71. [DOI: 10.1016/j.nic.2013.03.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Davey PT, Rychlik I, O’Donnell M, Baker R, Rennie I. An internal carotid artery aneurysm presenting with dysarthria. Ann R Coll Surg Engl 2013; 95:112-4. [DOI: 10.1308/003588413x13629960047713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 72-year-old woman presented to her general practitioner with a 4-week history of right neck swelling. Clinical examination elicited a pulsatile mass consistent with a carotid artery aneurysm. Five days later the patient noticed her tongue movements had become awkward with associated dysarthria. Computed tomography confirmed a 4cm internal carotid artery aneurysm arising just distally to the carotid bifurcation. She proceeded to transfemoral diagnostic carotid angiography. Balloon occlusion of the right internal carotid artery origin was performed for a ten-minute period without any neurological deficit. The decision was taken to proceed to surgical ligation of the origin of the internal carotid artery. Her symptoms of dysarthria have resolved.
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Affiliation(s)
- PT Davey
- Belfast Health and Social Care Trust, UK
| | - I Rychlik
- Belfast Health and Social Care Trust, UK
| | | | - R Baker
- Belfast Health and Social Care Trust, UK
| | - I Rennie
- Belfast Health and Social Care Trust, UK
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40
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Cohen JE, Rajz G, Valarezo J, Umansky F, Spektor S. Endovascular stenting for the treatment of post-traumatic aneurysms of the extracranial internal carotid artery. Neurol Res 2013; 26:662-5. [PMID: 15327756 DOI: 10.1179/016164104225016001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Aneurysmal dilatations occur at any level of carotid dissection, but typically at the distal subcranial segment. These aneurysms may grow, compress cervical structures, rupture or constitute a potential source of thrombo-embolic complications. When conservative and/or medical treatment failed or is contraindicated, a more aggressive therapy, such as endovascular stenting should be considered. We report the successful use endovascular stenting for the treatment of post-traumatic dissecting aneurysms of the extracranial internal carotid artery and discuss the potential of different stents types.
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Affiliation(s)
- José E Cohen
- Department of Neurosurgery, Hadassah University Hospital, Jerusalem, Israel
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41
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Marschner-Preuth N, Warnecke T, Niederstadt TU, Dittrich R, Schäbitz WR. Juvenile stroke: cervical artery dissection in a patient after a polytrauma. Case Rep Neurol 2013; 5:21-5. [PMID: 23466599 PMCID: PMC3573792 DOI: 10.1159/000347001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Dissections of the cervical arteries cause about 20% of total juvenile strokes. Approximately 4% of the carotid artery dissections are due to a (poly)trauma such as car accidents. Despite improved diagnostic facilities, traumatic dissections are often underdiagnosed or diagnosed too late due to a lack of awareness of potential initial signs and symptoms. We report here a case of a delayed embolic stroke after a car accident caused by a dissection of the carotid artery and subsequent pseudoaneurysm. To reduce the long-term morbidity or mortality of multiple trauma patients, an early detection of cervical carotid and vertebral dissections is strictly necessary.
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Affiliation(s)
- Nicole Marschner-Preuth
- Department of Neurology, University Hospital of Münster, Münster, Bielefeld, Germany ; Department of Department of Neurology, Bethel Evangelisches Krankenhaus of Bielefeld, Bielefeld, Germany
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42
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Anticoagulants versus antiplatelet drugs for cervical artery dissection: case for anticoagulants. J Neural Transm (Vienna) 2012; 120:333-4. [DOI: 10.1007/s00702-012-0940-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 11/29/2012] [Indexed: 11/26/2022]
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43
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Caplan LR, Gonzalez RG, Buonanno FS. Case records of the Massachusetts General Hospital. Case 18-2012. A 35-year-old man with neck pain, hoarseness, and dysphagia. N Engl J Med 2012; 366:2306-13. [PMID: 22694002 DOI: 10.1056/nejmcpc1110050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Louis R Caplan
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, USA
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44
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Abstract
Carotid artery dissection is a cause of stroke, especially in young and middle-aged patients. A dissection occurs when there is an intimal tear or rupture of the vasa vasorum, leading to an intramural hematoma, which is thought to result from trauma or can occur spontaneously, and is likely multifactorial, involving environmental and intrinsic factors. The clinical diagnosis of carotid artery dissection can be challenging, with common presentations including pain, partial Horner syndrome, cranial nerve palsies, or cerebral ischemia. With the use of noninvasive imaging, including magnetic resonance and computed tomography angiography, the diagnosis of carotid dissection has increased in frequency. Treatment options include thrombolysis, antiplatelet or anticoagulation therapy, endovascular or surgical interventions. The choice of appropriate therapy remains controversial as most carotid dissections heal on their own and there are no randomized trials to compare treatment options.
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45
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Fusco MR, Harrigan MR. Cerebrovascular dissections: a review. Part II: blunt cerebrovascular injury. Neurosurgery 2011; 68:517-30; discussion 530. [PMID: 21135751 DOI: 10.1227/neu.0b013e3181fe2fda] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Traumatic cerebrovascular injury (TCVI) is present in approximately 1% of all blunt force trauma patients and is associated with injuries such as head and cervical spine injuries and thoracic trauma. Increased recognition of patients with TCVI in the past quarter century has been because of aggressive screening protocols and noninvasive imaging with computed tomography angiography. Extracranial carotid and vertebral artery injuries demonstrate a spectrum of severity, from intimal disruption to traumatic aneurysm formation or vessel occlusion. The most common intracranial arterial injuries are carotid-cavernous fistulae and traumatic aneurysms. Data on the long-term natural history of TCVI are limited, and management of patients with TCVI is controversial. Although antithrombotic medical therapy is associated with improved neurological outcomes, the optimal medication regimen is not yet established. Endovascular techniques have become more popular than surgery for the treatment of TCVI; endovascular options include stenting of dissections, intra-arterial thrombolysis for acute ischemic stroke caused by trauma, and embolization of traumatic aneurysms.
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Affiliation(s)
- Matthew R Fusco
- Department of Surgery, Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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46
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Manjila S, Masri T, Shams T, Chowdhry SA, Sila C, Selman WR. Evidence-based review of primary and secondary ischemic stroke prevention in adults: a neurosurgical perspective. Neurosurg Focus 2011; 30:E1. [DOI: 10.3171/2011.2.focus1164] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this paper, the authors' aim is to provide an evidence-based review of primary and secondary ischemic stroke prevention guidelines covering most of the common risk factors and stroke etiologies for the practicing neurosurgeon. The key to stroke prevention is in the identification and treatment of the major risk factors for stroke. These include hypertension, heart disease, diabetes mellitus, dyslipidemia, and tobacco smoking. An updated approach to secondary prevention of stroke in the setting of intracranial and extracranial large vessel atherosclerosis and cardioembolism is provided along with a brief overview of pertinent clinical trials. Novel pharmacological options for prevention of cardioembolic strokes, such as new alternatives to warfarin, are addressed with recommendations for interruption of therapy for elective surgical procedures. In addition, the authors have reviewed the anticoagulation guidelines and the risk of thromboembolic complications of such therapies in the perioperative period, which is an invaluable piece of information for neurosurgeons. Less common etiologies such as arterial dissections and patent foramen ovale are also briefly discussed. Finally, the authors have outlined the quality measures in the Medicare Physician Quality Reporting System and essential guidelines for Primary Stroke Center certification, which have implications for day-to-day neurosurgical practice.
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Affiliation(s)
| | - Tony Masri
- 2Neurology, The Neurological Institute, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Tanzila Shams
- 2Neurology, The Neurological Institute, University Hospitals Case Medical Center, Cleveland, Ohio
| | | | - Cathy Sila
- 2Neurology, The Neurological Institute, University Hospitals Case Medical Center, Cleveland, Ohio
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47
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Arnold M, Fischer U, Bousser MG. Treatment Issues in Spontaneous Cervicocephalic Artery Dissections. Int J Stroke 2011; 6:213-8. [DOI: 10.1111/j.1747-4949.2011.00605.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The management of cervicocephalic arterial dissections raises many unsolved issues such as: how to best acutely treat patients who present with ischemic stroke or occasionally with sub-arachnoid hemorrhage? How to best prevent ischemic stroke in patients who present with purely local signs such as headache, painful Horner Syndrome or neck pain? How long and how should patients be treated after cervicocephalic arterial dissections? Can patients resume their sports activities and when? The consensus is that, given the well-established initial thromboembolic risk, an urgent antithrombotic treatment is required in patients with a recent nonhemorrhagic cervicocephalic arterial dissection, but the type of antithrombotic treatment – anticoagulants or aspirin – as well as the indication for a local arterial treatment such as angioplasty/stenting remain debated. Evidence from a randomized clinical trial would be welcome but such a trial raises major issues of methodology, feasibility and funding. Meanwhile, cervicocephalic arterial dissection remains a situation when a bedside clinician should use, on a case-by-case basis, best clinical judgment and adopt a stepped care approach in the minority of patients who deteriorate despite initial treatment.
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Affiliation(s)
- Marcel Arnold
- Department of Neurology, University Hospital Berne, Inselspital, Berne, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Berne, Inselspital, Berne, Switzerland
| | - Marie-Germaine Bousser
- Assistance Publique Hôpitaux de Paris, Department of Neurology, University Hospital, Lariboisière, Paris, France
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48
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Zweifler RM, Silverboard G. Arterial Dissections and Fibromuscular Dysplasia. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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49
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Treatment of “Other” Stroke Etiologies. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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50
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Fusco MR, Harrigan MR. Cerebrovascular Dissections—A Review Part I: Spontaneous Dissections. Neurosurgery 2011; 68:242-57; discussion 257. [DOI: 10.1227/neu.0b013e3182012323] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
abstract
Spontaneous cerebrovascular dissections are subintimal or subadventitial cervical carotid and vertebral artery wall injuries and are the cause of as many as 2% of all ischemic strokes. Spontaneous dissections are the leading cause of stroke in patients younger than 45 years of age, accounting for almost one fourth of strokes in this population. A history of some degree of trivial trauma is present in nearly one fourth of cases. Subsequent mortality or neurological morbidity is usually the result of distal ischemia produced by emboli released from the injury site, although local mass effect produced by arterial dilation or aneurysm formation also can occur. The gold standard for diagnosis remains digital subtraction angiography. Computed tomography angiography, magnetic resonance angiography, and ultrasonography are complementary means o evaluation, particularly for injury screening or treatment follow-up. The annual rate of stroke after injury is approximately 1% or less per year. The currently accepted method of therapy remains antithrombotic medication, either in the form of anticoagulation or antiplatelet agents; however, no class I medical evidence exists to guide therapy. Other options for treatment include thrombolysis and endovascular therapy, although the efficacy and indications for these methods remain unclear.
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Affiliation(s)
- Matthew R. Fusco
- Department of Surgery, Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark R. Harrigan
- Department of Surgery, Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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