A review of carotid and vertebral artery dissection

Comparative efficacy of drug-eluting stents vs. bare-metal stents in symptomatic vertebral artery stenosis: A prospective single-center study

OBJECTIVE

To explore the safety, efficacy of drug-eluting stents and bare-metal stents in the treatment of vertebral artery stenosis, and the influencing factors of in-stent restenosis.

METHODS

From June 2022 to October 2023, 129 patients undergoing vertebral artery stent implantation in the Department of Neurosurgery of the First Hospital of Hebei Medical University were randomly divided into the drug-eluting stent group and the bare-metal stent group using a randomized controlled method and followed up. The clinical data of the patients were recorded and divided into the stenosis group and the non-stenosis group according to whether in-stent restenosis occurred after surgery. Through Logistic regression analysis, the risk factors affecting in-stent restenosis were analyzed.

RESULTS

All stents were successfully implanted, and there were no puncture site hematoma, intracranial hemorrhage, or death events after surgery. The incidence of in-stent restenosis in the drug-eluting stent group was significantly lower than that in the bare-metal stent group (4.8% vs 31.1%). Multivariate regression analysis confirmed that the bare-metal stent group was an independent risk factor for in-stent restenosis. In addition, contralateral vertebral artery stenosis is also an important risk factor.

CONCLUSION

Stent implantation is a safe and effective method for treating patients with symptomatic vertebral artery stenosis who are poorly controlled by drugs, and drug-eluting stents can significantly reduce the incidence of in-stent restenosis.

Risk of Raynaud's Phenomenon Among Workers in the Occupational Disease Surveillance System

INTRODUCTION

Raynaud's phenomenon (RP) is linked to occupational exposures such as vibration, cold temperature, and chemicals. However, large cohort studies examining RP by occupation and sex are scarce. To address this gap, this study aimed to assess risk of RP by both occupation and sex in a large cohort of workers in Ontario, Canada.

METHODS

Workers with accepted lost-time compensation claims were linked to physician billing records to identify diagnoses of RP between 2002 and 2020. A 3-year washout (disease-free) period was applied, and follow-up was limited to 5 years. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for diagnoses of RP, adjusted for age at start of follow-up, birth year, and stratified by sex.

RESULTS

A total of 7,131 RP cases were identified among 810,739 workers. Among men, higher risks were observed for truck drivers (HR = 1.23, 95% CI = 1.08-1.41), driver-salesmen (HR = 2.54, 95% CI = 1.21-5.34), those in mining and quarrying-related cutting, handling, and loading (HR = 2.57, 95% CI = 1.29-5.15), and construction trades laboring and elemental work (HR = 1.70, 95% CI = 1.24-2.34). Among women, higher risks were observed for those working in waitressing and related (HR = 1.70, 95% CI = 1.22-2.38), food and beverage preparation (HR = 1.34, 95% CI = 1.02-1.76), and electrical equipment fabricating and assembling (HR 1.96, 95% CI = 1.08-3.55).

CONCLUSION

Study findings show elevated risks of RP among various occupations, with notable differences between men and women. These differences may be attributable to variations in potential exposures and susceptibility to RP. Findings underscore the need for large cohort studies to examine RP across various occupational groups and both sexes.

High-resolution magnetic resonance imaging in the diagnosis and management of vertebral artery dissection: A case report

BACKGROUND

Vertebral artery dissection (VAD) is a rare but life-threatening condition characterized by tearing of the intimal layer of the vertebral artery, leading to stenosis, occlusion or rupture. The clinical presentation of VAD can be heterogeneous, with common symptoms including headache, dizziness and balance problems. Timely diagnosis and treatment are crucial for favorable outcomes; however, VAD is often missed due to its variable clinical presentation and lack of robust diagnostic guidelines. High-resolution magnetic resonance imaging (HRMRI) has emerged as a reliable diagnostic tool for VAD, providing detailed visualization of vessel wall abnormalities.

CASE SUMMARY

A young male patient presented with an acute onset of severe headache, vomiting, and seizures, followed by altered consciousness. Imaging studies revealed bilateral VAD, basilar artery thrombosis, multiple brainstem and cerebellar infarcts, and subarachnoid hemorrhage. Digital subtraction angiography (DSA) revealed vertebral artery stenosis but failed to detect the dissection, potentially because intramural thrombosis obscured the VAD. In contrast, HRMRI confirmed the diagnosis by revealing specific signs of dissection. The patient was managed conservatively with antiplatelet therapy and other supportive measures, such as blood pressure control and pain management. After 5 mo of rehabilitation, the patient showed significant improvement in swallowing and limb strength.

CONCLUSION

HR-MRI can provide precise evidence for the identification of VAD.

Native valve endocarditis caused by Corynebacterium striatum without underlying structural heart disease or indwelling cardiovascular medical devices: a case report

BACKGROUND

Corynebacterium striatum (C. striatum) is a gram-positive, anaerobic bacillus found both environmentally and in human skin and nasal mucosa flora. It is reportedly the etiologic agent of community-acquired and nosocomial diseases and is significantly associated with bacteremia and medical endovascular devices. This is the rare case of mitral valve native valve endocarditis (NVE) caused by C. striatum occurring in a young adult without underlying structural heart disease or indwelling cardiovascular medical devices successfully treated with multidisciplinary therapy.

CASE PRESENTATION

The patient was a 28-year-old female with no medical history. She was transferred our hospital due to sudden onset of vertigo and vomit. A computed tomography on day 2 revealed the hydrocephalus due to the cerebellar infarction, and she underwent posterior fossa decompression for cerebellar infarction. An angiography on day 8 revealed a left vertebral artery dissection, which was suspected be the etiology. Afterwards, a sudden fever of 39 degrees developed on day 38. She was diagnosed with aspiration pneumonia and treated with ampicillin/sulbactam but was still febrile at the time of transfer for rehabilitation. Treatment continued with levofloxacin, the patient had no fever decline, and she was readmitted to our hospital. Readmission blood cultures (3/3 sets) revealed C. striatum, and an echocardiogram revealed an 11 mm long mitral valve vegetation, leading to NVE diagnosis. On the sixth illness day, cardiac failure symptoms manifested. Echocardiography revealed mitral valve rupture. She was transferred again on the 11th day of illness, during which time her mitral valve was replaced. C. striatum was detected in the vegetation. Following surgery, she returned to our hospital, and vancomycin administration continued. The patient was discharged after 31 total days of postoperative antimicrobial therapy. The patient experienced no exacerbations thereafter.

CONCLUSIONS

We report the rare case of C. striatum mitral valve NVE in a young adult without structural heart disease or indwelling cardiovascular devices.

CLINICAL TRIAL NUMBER

Not applicable.

An Atypical Presentation of Ischemic Stroke in a Middle-Aged Adult

Stroke-like symptoms are a common complaint in the emergency department; however, signs of an acute cerebrovascular event in a patient under the age of 50 can be both alarming and unexpected. In this case, a 41-year-old male presented to the emergency department with vague symptoms of intermittent weakness and paresthesias for 4 days. Originally deemed a "stroke code" in the field, the patient was immediately transferred to the computerized tomography scanner. The patient was later found to have a right-sided internal carotid dissection and subsequent right parietal lobe ischemic infarcts. This article highlights the need to maintain a high suspicion for acute cerebrovascular events, even in atypical presentations. The key features of caring for a patient experiencing carotid dissection, as well as their expected prognosis and care course, are also expounded upon. Early recognition of stroke-like symptoms in young, otherwise healthy, patients is critical to providing the needed care in a timely manner and to preserve future function and quality of life.

Cervical Artery Dissections-A Demographical Analysis of Risk Factors, Clinical Characteristics Treatment Procedures, and Outcomes-A Single Centre Study of 54 Consecutive Cases

Cervical artery dissections (CAD) are a common cause of ischemic cerebrovascular events among the younger and middle-aged population. Altogether, CAD counts for up to 15% of all causes of stroke in patients aged 50 or younger. Among the known etiological causes, especially addressing the younger population with mechanical traumas and whiplash injuries are regarded as the main culprits. However, cases of spontaneous dissection are also widespread, with risk factors such as hypertension, migraine, and lifestyle factors increasing the risk of occurrence. Clinically, the symptoms associated with a cerebrovascular event caused by CADs are highly variable and can be classified as either compressive symptoms (such as Horner's syndrome and cervical pain) or stroke syndromes attributable to cerebral ischemia. Therefore, establishing an early diagnosis might be particularly challenging as it requires particular attention and quick clinical reasoning when interviewing the patient. With these certain particularities, our main focus was to conduct a prospective study involving up to 54 patients who were diagnosed with CAD in our clinical facility between January 2015 and December 2022, with the focus of assessing certain individual parameters attributable to each patient and their influence and prognosis value for their short and long term evolution. An important emphasis was placed on parameters such as topographical localization, clinical presentation, severity of the questioned cerebrovascular event, outcomes, and causative factors. Statistical validity tools were applied when possible.

Top of basilar syndrome due to vertebral artery dissection: How high-resolution MRI and CD31 analysis of thrombus could help

INTRODUCTION AND IMPORTANCE

Vertebral artery dissection is a rare but serious condition that can lead to neurological deficits and even death. It is commonly associated with trauma or underlying vascular diseases. Top of basilar syndrome (TOBS) is a neurological condition that can result from vertebral artery dissection, either by direct ischemia or secondary occlusion due to distal embolization of injured inner vascular tissue. We here present a patient who was initially suffering from seizure then had TOBS due to a progressive vertebral artery dissection, with emphasis of high-resolution MRI imaging and immunohistochemistry study of the thrombus.

CASE PRESENTATION

A young male presented to the emergency department with sudden onset of seizure. A history of recent neck exercise was reported. The patient had gaze palsy, adduction disability, and dysarthria. High-resolution MRI showed a vertebral artery dissection with evidence of occlusion of the top of basilar artery. After the thrombectomy, a pathologic study revealed CD31[+] tissue in the thrombus, indicating an origin from dissected vertebral artery.

CLINICAL DISCUSSION AND CONCLUSION

It's important to recognize and treat vertebral artery dissection promptly due to its varying symptoms. Using high-resolution MRI at early stage and conducting pathologic analysis of CD31 on the thrombus can assist in the diagnosis, potentially leading to more precise treatment plans and better outcomes for patients.

Initial clinical experience with Xpert-Pro peripheral self-expanding stent system for internal carotid artery dissection: Two case reports

Background

The standard treatment for internal carotid artery (ICA) dissection is obscure. Current therapeutic strategies include the use of antiplatelet drugs, anticoagulant drugs, intravenous thrombolysis, and endovascular treatment. Endovascular treatment is important in acute internal carotid artery dissection. This study reports two acute internal carotid artery dissection cases that were treated successfully using the Xpert-Pro peripheral self-expanding stent system.

Case summary

The first case was of a 38-year-old male patient with transient speechlessness and paralysis of the right limb in July 2021. Cervical computed tomographic angiography (CTA) showed ICA occlusion on the left side. Digital subtraction angiography (DSA) showed severe stenosis of the C1 segment of the left internal carotid artery with intermural hematoma. The patient subsequently underwent Xpert-Pro peripheral self-expanding stent implantation, and his condition stabilized. The second case was of a 56-year-old male patient with speechlessness and paralysis of the right limb. Cervical CTA showed a dissected left ICA, and DSA showed an occluded left ICA and middle cerebral artery. The patient subsequently underwent stent implantation, and his condition stabilized.