Endovascular recanalization of symptomatic flow-limiting cervical carotid dissection in an isolated hemisphere

Stenting as a treatment for cranio-cervical artery dissection: Improved major adverse cardiovascular event-free survival

INTRODUCTION

Cranio-cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement.

METHODS

COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥ 18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1 year evaluating MACE as the primary endpoint.

RESULTS

One-hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including sneezing, carrying heavy load, chiropractic manipulation. Stent was placed in 10 (10%) subjects (extracranial carotid n = 9; intracranial carotid n = 1; extracranial vertebral n = 1) at the physician's discretion along with medical management. Reasons for stent placement were early development of high-grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in-hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year.

CONCLUSION

In this single high-volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high-grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

[Fibromuscular dysplasia and its neurological manifestations]

The authors present the current data on the classification, epidemiology, etiology, neurological manifestations, prognosis, diagnosis, and treatment of patients with fibromuscular dysplasia (FMD). The review is based on the selection of publications by searching PubMed for keywords from the first sources until March 2019. FMD is a segmental non-atherosclerotic and non-inflammatory disease of large- and medium-caliber arteries leading to their stenosis. The disease occurs mostly in women (90%), and manifests itself in the 5th decade of life. In the cerebrovascular form of FMD, the extracranial internal carotid artery and the vertebral artery are usually affected. Diagnosis is based on the identification of alternation of narrowing and dilation of arteries using angiography (the string of beads sign (multifocal form)). Neurological manifestations include headache, tinnitus, and ischemic stroke, usually due to the dissection or stenosis, rarely, intracerebral or subarachnoid hemorrhages. The prognosis in most cases is favorable, relapses of strokes are rare. Treatment includes antiplatelet agents, if they are ineffective to prevent recurrence of ischemic stroke, endovascular treatment is carried out. Approaches to the treatment of intracranial aneurysms do not differ from those in patients without FMD.

First international consensus on the diagnosis and management of fibromuscular dysplasia

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD) which was commissioned by the Working Group 'Hypertension and the Kidney' of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

Fibromuscular Dysplasia and Its Neurologic Manifestations: A Systematic Review

Importance

Data on neurologic manifestations of fibromuscular dysplasia (FMD) are rare, and current knowledge remains limited.

Objectives

To present a comprehensive review of the epidemiologic characteristics, management, and prognosis of the neurologic manifestations associated with cerebrovascular FMD (ie, involving cervical or intracranial arteries) and to guide future research priorities.

Evidence Review

References were identified through searches of PubMed from inception to December 2017 using both the medical subject headings and text words. Additional sources were also identified by reviewing reference lists of relevant articles and through searches of the authors' personal files. Selected articles described at least 1 clinical or radiologic feature and/or outcome of cerebrovascular FMD. Isolated case reports could be included if they described interesting or noteworthy manifestations of FMD.

Findings

A total of 84 relevant references were identified. Diagnosis of cerebrovascular FMD is based on the appearance of alternating arterial dilatation and constriction ("string of beads") or of focal narrowing, with no sign of atherosclerotic or inflammatory lesions. Although the diagnosis is easily apparent on results of radiographic imaging, making a diagnosis can be challenging in children or individuals with atypical phenotypes, such as purely intracranial FMD and arterial diaphragm. Involvement of multiple arteries is common, and there is increased incidence of cervical artery dissection and intracranial aneurysms. A variant in the PHACTR1 gene has been associated with FMD as well as cervical artery dissection and migraine, although less than 5% of cases of FMD are familial. Headaches, mainly of the migraine type, are observed in up to 70% of patients with FMD. Cerebrovascular FMD is mostly asymptomatic, but the most frequent neurologic manifestations include transient ischemic attack and ischemic stroke, notably in the presence of associated cervical artery dissection. Other conditions associated with FMD include subarachnoid hemorrhage and, rarely, intracranial hemorrhage. Management relies on observational data and expert opinion. Antiplatelet therapy is considered reasonable to prevent thromboembolic complications. Endovascular therapy is typically restricted to cases with symptomatic stenosis despite optimal medical therapy or in those with rupture of an intracranial aneurysm.

Conclusions and Relevance

Longitudinal cohort studies of individuals of multiple ethnicities with biosampling are needed to better understand the risk factors, pathophysiological features, and outcomes of FMD. Patient advocacy groups could assist researchers in answering patient-centered questions regarding FMD.

First International Consensus on the diagnosis and management of fibromuscular dysplasia

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group ‘Hypertension and the Kidney’ of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

A case report of multiple cervical artery dissection after peripheral type facial palsy and use of steroids

Background

Cervical artery dissection is one of the most important causes of ischemic stroke in young age patients. However, multiple cervical artery dissection simultaneously involving the anterior and posterior circulation is uncommon. Here, we would like to report a case of a patient with bilateral vertebral artery (VA) and internal carotid artery dissection (ICA) after a use of systemic steroid due to peripheral facial palsy.

Case presentation

A 44-year-old man with hypertension visited emergency department due to recurrent vertigo. He was receiving methyl prednisolone for two weeks for the treatment of right peripheral type facial palsy which occurred after retro-orbital headache. Neurologic examination revealed severe ataxia at left side. Sensory for pain and temperature was declined in the right arm and leg. Diffusion-weighted image showed an acute ischemic lesion at the whole territory of posterior-inferior cerebellar artery. Severe stenosis was observed from bilateral VAs and ICAs on conventional magnetic resonance angiography. Intramural hematoma and intimal flap was observed from the high-resolution MRI.

Conclusions

Peripheral type facial palsy is an unusual presentation of carotid dissection. Steroids aggravate arterial dissection by increasing blood pressure and blood vessel fragility by its negative effect on connective tissue strength. Use of steroid in patients with peripheral type facial palsy with severe headache may need caution.

Stent recanalization of carotid tonsillar loop dissection using the Enterprise vascular reconstruction device

Although advances in endovascular techniques have permitted reconstruction of intimal dissections and related pseudoaneurysms of the extracranial cervical internal carotid artery, highly tortuous tonsillar loop anatomic variants still pose an obstacle to conventional extracranial self-expanding carotid stents. During a 12 year period, nine of 48 cases with cervical carotid dissections were associated with a tonsillar loop. Five patients required endovascular treatment, which was performed using a microcatheter-based technique with the low-profile Enterprise vascular reconstruction device (Codman Neurovascular, Raynham, MA, USA). Technical, radiographic, and clinical outcomes were analyzed for each patient. Dissection etiology was spontaneous in three patients, iatrogenic in one, and traumatic in one. Four near-occlusive tonsillar loop dissections were successfully recanalized during the acute phase. Dissection-related stenosis improved from 90±22% to 31±13%, with tandem stents needed in three instances to seal the inflow zone. There were no procedure-related transient ischemic attacks (TIA), minor/major strokes, or deaths. Angiographic follow-up for a mean of 28.0±21.6 months showed all stents were patent, with average stenosis of 25.2±12.2%. Focal ovalization and kinking of the closed-cell design was noted at the sharpest curve in one patient. Clinical outcome (follow-up of 28.1±21.5 months) demonstrated overall improvement with no clinical worsening, new TIA, or stroke. Tonsillar loop-associated carotid dissections can be successfully and durably recanalized using the low-profile Enterprise stent with an excellent long-term patency rate and low procedural risk. The possibility of stent kinking and low radial force should be considered when planning reconstruction with this device.