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Yaghi S, Engelter S, Del Brutto VJ, Field TS, Jadhav AP, Kicielinski K, Madsen TE, Mistry EA, Salehi Omran S, Pandey A, Raz E. Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association. Stroke 2024; 55:e91-e106. [PMID: 38299330 DOI: 10.1161/str.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.
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Kara S, Gutierrez Munoz FG, Eckes J, Abdelmoneim SS, Nedd K. Posterior Inferior Cerebellar Artery Stroke Due to a Severe Right Vertebral Artery Stenosis With a Left Cervical Internal Carotid Artery Dissection: What's Next? Cureus 2024; 16:e55598. [PMID: 38586807 PMCID: PMC10994864 DOI: 10.7759/cureus.55598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/09/2024] Open
Abstract
Guidelines for the treatment and management of ischemic strokes triggered by stenosis versus dissection are well established. However, the presence of both entities in the same patient, although rare, poses challenges for short- and long-term treatment. Here, we describe the case of a 55-year-old man who presented to the emergency department with a 72-hour history of headache, dizziness, unbalanced gait, nausea, and two episodes of vomiting. Stroke was initially suspected, but the computerized tomography (CT) scan showed no hemorrhage. His magnetic resonance imaging (MRI) showed right inferior cerebellar acute ischemia in the territory of the right posterior inferior cerebellar artery (PICA), with smaller foci of early acute infarcts in the bilateral inferior cerebellum. Furthermore, magnetic resonance angiography (MRA) and CT angiography revealed right vertebral artery stenosis and left cervical internal carotid artery dissection (ICAD). This clinical report describes a rare case of stroke secondary to vertebral artery stenosis with concomitant carotid artery dissection. The treatment course and evolution are presented.
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Affiliation(s)
- Sam Kara
- Department of Neurology, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
| | | | - Jeremy Eckes
- Department of Neurology, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
| | - Sahar S Abdelmoneim
- Department of Internal Medicine, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
| | - Kester Nedd
- Department of Neurology, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
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Latacz P, Lasocha B, Pawel B, Tadeusz P, Marian S. Results of Angioplasty With Double-Layer Mesh Stent and Protection Systems of the Extra- and Intracranial Dissection of Cephalic Arteries. J Endovasc Ther 2023; 30:66-74. [PMID: 35000472 DOI: 10.1177/15266028211068767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE Although a majority of cervical artery dissections can be managed conservatively, patients presenting with cerebral embolization or significant stenosis require a more aggressive approach. However, complications associated with endovascular repair are quite frequent and optimal interventional technique still remains to be established. MATERIALS AND METHODS The aim of this post hoc survey was to analyze results of endovascular treatments for symptomatic dissections of the internal carotid and vertebral arteries, which were performed under protection and with the use of double-layer mesh stents. During endovascular procedure catheters, stents and protection systems were tailored according to the angioarchitecture of dissection, particularly to its location, length and coexisting stenotic or aneurysmatic lesions. We evaluated retrospectively midterm and late results of endovascular treatment of 25 patients presenting with symptomatic dissection of cervical arteries, including 11 patients with dissections of intracranial segments of the internal carotid artery. Follow-ups were scheduled 1, 3 and 6 after the procedure, and then every 6 months. Control computed tomography (CT) or digital subtraction angiography (DSA) arteriographies were performed 1-6 months and 12 months after endovascular repair. RESULTS There were no periprocedural major adverse events. All patients completed the 12-month follow-up. There were neither fatalities nor new neurologic adverse events at the 30-day follow-up, and no such adverse events during long-term follow-up. At 12-month follow-up, in all patients, angiographies revealed patent stents, full coverage of lesions by stents and complete thrombotic closure of the pseudoaneurysms. CONCLUSIONS A tailored endovascular management of symptomatic dissection of cervical arteries is safe and efficient, also in a long run.
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Affiliation(s)
- Pawel Latacz
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Bartlomiej Lasocha
- Chair of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Brzegowy Pawel
- Chair of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Popiela Tadeusz
- Chair of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Simka Marian
- Department of Anatomy, University of Opole, Opole, Poland
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Keser Z, Chiang CC, Benson JC, Pezzini A, Lanzino G. Cervical Artery Dissections: Etiopathogenesis and Management. Vasc Health Risk Manag 2022; 18:685-700. [PMID: 36082197 PMCID: PMC9447449 DOI: 10.2147/vhrm.s362844] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/19/2022] [Indexed: 11/23/2022] Open
Abstract
Cervical Artery Dissection (CeAD) is a frequent stroke etiology for patients younger than 50 years old. The most common immediate complications related to CeAD are headache and neck pain (65–95%), TIA/ischemic stroke (>50%), and partial Horner’s syndrome (25%). The prevailing hypothesis regarding the pathogenesis of sCeAD is that the underlying constitutional vessel wall weakness of patients with sCeAD is genetically determined and that environmental factors could act as triggers. The stroke prevention treatment of CeAD remains controversial, involving anticoagulation or antiplatelet therapy and potentially emergent stenting and/or thrombectomy or angioplasty for selected cases of carotid artery dissection with occlusion. The treatment of headache associated with CeAD depends on the headache phenotype and comorbidities. Radiographically, more than 75% of CeAD cases present with occlusion or non-occlusive stenosis. Many patients demonstrate partial and complete healing, more commonly in the carotid arteries. One-fifth of the patients develop dissecting pseudoaneurysm, but this is a benign clinical entity with an extremely low rupture and stroke recurrence risk. Good recovery is achieved in many CeAD cases, and mortality remains low. Family history of CeAD, connective tissue disorders like Ehlers-Danlos syndrome type IV, and fibromuscular dysplasia are risk factors for recurrent CeAD, which can occur in 3–9% of the cases. This review serves as a comprehensive, updated overview of CeAD, emphasizing etiopathogenesis and management.
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Affiliation(s)
- Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Correspondence: Zafer Keser, Department of Neurology – Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA, Email
| | | | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J 2021; 6:XXXIX-LXXXVIII. [PMID: 34746432 PMCID: PMC8564160 DOI: 10.1177/23969873211046475] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/26/2021] [Indexed: 11/15/2022] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.
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Affiliation(s)
- Stephanie Debette
- Bordeaux Population Health research
center, INSERM U1219, University of Bordeaux, Bordeaux, France
- Department of Neurology and
Institute for Neurodegenerative Diseases, Bordeaux University
Hospital, France
| | - Mikael Mazighi
- Department of Neurology, Hopital Lariboisière, Paris, France
- Interventional Neuroradiology
Department, Hôpital Fondation Ophtalmologique
Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- FHU NeuroVasc, Paris, France
- Laboratory of Vascular Translational
Science, INSERM U1148, Paris, France
| | - Philippe Bijlenga
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and
Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Masatoshi Koga
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - Anna Bersano
- Fondazione IRCCS Istituto Neurologico
'Carlo Besta', Milano
| | - Janika Kõrv
- Department of Neurology and
Neurosurgery, University of Tartu, Tartu, Estonia
- Department of Neurology, Tartu University
Hospital, Tartu, Estonia
| | - Julien Haemmerli
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | | | - Piotr Tekiela
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Kaori Miwa
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - David J Seiffge
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Sabrina Schilling
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Marcel Arnold
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Hugh S Markus
- Department of Clinical
Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan T Engelter
- Department of Neurology and
Stroke Center, University Hospital and University of
Basel, Basel, Switzerland
- Neurology and
Neurorehabilitation, University Department of Geriatric
Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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Tardivo V, Castaldi A, Baldino G, Siri G, Bruzzo M, Del Sette M, Romano N. Internal carotid artery dissection related to abnormalities of styloid process: is it only a matter of length? Neurol Sci 2021; 43:459-465. [PMID: 34059959 DOI: 10.1007/s10072-021-05350-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Vascular Eagle syndrome, due to impingement of the extracranial internal carotid artery (ICA) by the styloid process (SP), is an uncommon and not yet widely recognized cause of ICA dissection. Up to now, this diagnosis is still presumptive, based mainly on the length of the SP. However, given the discrepancy between the much higher prevalence of an elongated SP in the population compared to the reported rate of Eagle syndrome, other anatomical factors beyond the length itself of this bony structure seem to be involved. MATERIAL AND METHODS We performed a retrospective single center case-control study of ICA dissection related to abnormalities of styloid process and age- and sex-matched controls affected by ICA dissection not related to abnormal relationship with the styloid process. In our work instead of considering SP length as the main criteria to differentiate the two groups, we decided to consider styloid process-internal carotid artery distance (at the dissection point) as the main factor to define a styloid process related dissection (SPRD). In fact in some patients, the distance between the dissected artery and the bony prominence was virtual. RESULTS Our study showed that in patients with SPRD the styloid process angulation on the coronal plane tends to be more acute and that styloid process-C1 distance is significantly shorter at the side of the dissection. This data reinforces the idea that ICA dissection risk in the vascular Eagle syndrome has probably a multifactorial pathogenesis.
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Affiliation(s)
- Valentina Tardivo
- Neurosurgery Unit, Galliera Hospital, Via Mura delle Cappuccine 14, 16128, Genoa, Italy.
| | - Antonio Castaldi
- Department of Diagnostic and Interventional Neuroradiology, Galliera Hospital, Via Mura delle Cappuccine 14, 16128, Genoa, Italy
| | - Giuseppe Baldino
- Vascular and Endovascular Surgery Unit, Galliera Hospital, Via Mura delle Cappuccine 14, 16128, Genoa, Italy
| | - Giacomo Siri
- UCS Scientific Directorate, Galliera Hospital, Via Mura delle Cappuccine 14, 16128, Genoa, Italy
- Department of Mathematics, University of Genoa, Via Dodecaneso, 35, 16146, Genoa, Italy
| | - Mattia Bruzzo
- Neurosurgery Unit, Galliera Hospital, Via Mura delle Cappuccine 14, 16128, Genoa, Italy
| | - Massimo Del Sette
- Neurology Unit, Galliera Hospital, Via Mura delle Cappuccine 14, 16128, Genoa, Italy
| | - Nicola Romano
- Department of Diagnostic and Interventional Neuroradiology, Galliera Hospital, Via Mura delle Cappuccine 14, 16128, Genoa, Italy
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Abstract
Cervical carotid and vertebral artery traumatic injuries can have a devastating natural history. This article reviews the epidemiology, mechanisms of injury, clinical presentation, and classification systems pertinent to consideration of endovascular treatment. The growing role of modern endovascular techniques for the treatment of these diseases is presented to equip endovascular surgeons with a framework for critically assessing patients presenting with traumatic cervical cerebrovascular injury.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jayson Lavie
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam Rano Chatterjee
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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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. Maedica (Bucur) 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Latacz P, Simka M, Brzegowy P, Słowik A, Popiela T. Endovascular management of carotid and vertebral artery dissections with new generation double-mesh stent and protection systems - single-center early and midterm results. Adv Cardiol 2019; 15:321-7. [PMID: 31592256 DOI: 10.5114/aic.2019.84409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/21/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Symptomatic dissections (SD) of cervical arteries are still a therapeutic problem. Although endovascular management (EM) is currently a preferred method of treatment of SD, complications associated with this method of treatment in published reports are quite frequent (3-16%). AIM In this retrospective study we analyzed the results of EM with novel, double-mesh stent and protection systems (PS) for SD of the internal carotid (IC) or vertebral arteries (VA) that coexisted with hemodynamically significant stenosis or aneurysmatic dilatation of the dissected artery. MATERIAL AND METHODS We evaluated the results of EM in 19 patients (men 15, median age: 55, range: 25-83), presenting with SD of the IC or VA with coexisting stenosis and/or aneurysmatic dilatation of the artery in segments C1-C5 of IC or V0-V4 of VA. Twelve patients had a stroke, 6 TIA, and 3 patients a headache and/or a neck pain with Horner syndrome. Stents and PS were tailored according to the location, length of dissection and coexisting stenotic or aneurysmatic lesions. RESULTS There were no new strokes, in-hospital deaths or other serious morbidities during the procedure and postprocedural hospital stay. There were no fatalities during 6-40 months of follow-up. In control angiographies performed after interventions all patients demonstrated a patent target artery, complete coverage of the dissection and aneurysm by stents and no new lesions in the area of the previous dissection. CONCLUSIONS The results of this study indicate that EM of SD of IC and VA with the new stents and PS is safe and effective with good early and midterm results.
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Abstract
Cervical artery dissection refers to a tear in the internal carotid or the vertebral artery that results in an intramural haematoma and/or an aneurysmal dilatation. Although cervical artery dissection is thought to occur spontaneously, physical trauma to the neck, especially hyperextension and rotation, has been reported as a trigger. Headache and/or neck pain is the most common initial symptom of cervical artery dissection. Other symptoms include Horner's syndrome and lower cranial nerve palsy. Both headache and/or neck pain are common symptoms and leading causes of disability, while cervical artery dissection is rare. Patients often consult their general practitioner for headache and/or neck pain, and because manual-therapy interventions can alleviate headache and/or neck pain, many patients seek manual therapists, such as chiropractors and physiotherapists. Cervical mobilization and manipulation are two interventions that manual therapists use. Both interventions have been suspected of being able to trigger cervical artery dissection as an adverse event. The aim of this review is to provide an updated step-by-step risk-benefit assessment strategy regarding manual therapy and to provide tools for clinicians to exclude cervical artery dissection. Key messages Cervical mobilization and/or manipulation have been suspected to be able to trigger cervical artery dissection (CAD). However, these assumptions are based on case studies which are unable to established direct causality. The concern relates to the chicken and the egg discussion, i.e. whether the CAD symptoms lead the patient to seek cervical manual-therapy or whether the cervical manual-therapy provoked CAD along with the non-CAD presenting complaint. Thus, instead of proving a nearly impossible causality hypothesis, this study provide clinicians with an updated step-by-step risk-benefit assessment strategy tool to (a) facilitate clinicians understanding of CAD, (b) appraise the risk and applicability of cervical manual-therapy, and (c) provide clinicians with adequate tools to better detect and exclude CAD in clinical settings.
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Affiliation(s)
- Aleksander Chaibi
- a Head and Neck Research Group, Research Centre, Akershus University Hospital , Oslo , Norway.,b Institute of Clinical Medicine, Akershus University Hospital, University of Oslo , Nordbyhagen , Norway
| | - Michael Bjørn Russell
- a Head and Neck Research Group, Research Centre, Akershus University Hospital , Oslo , Norway.,b Institute of Clinical Medicine, Akershus University Hospital, University of Oslo , Nordbyhagen , Norway
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Shin J, Chung JW, Park MS, Lee H, Cha J, Seo WK, Kim GM, Bang OY. Outcomes after ischemic stroke caused by intracranial atherosclerosis vs dissection. Neurology 2018; 91:e1751-e1759. [PMID: 30291187 DOI: 10.1212/wnl.0000000000006459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/28/2018] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To compare the outcomes between patients with nontraumatic intracranial arterial dissection (ICAD) and intracranial atherosclerotic stenosis (ICAS) using high-resolution MRI (HR-MRI). METHODS We conducted a prospective study using HR-MRI in patients with acute symptomatic cerebrovascular disease due to intracranial occlusive disease and no dissection on luminal images. Patients were followed-up for 27.9 ± 19.3 months. We compared the functional outcome, recurrence, and changes in vascular status between patients with ICAD (dissection and no plaque on HR-MRI) and ICAS (atherosclerosis plaque on HR-MRI). RESULTS We included 312 patients (mean age, 59.0 ± 14.2 years; men, 58.3%), of whom 113 had ICAD and 199 had ICAS. The functional outcome (as measured by modified Rankin Scale score) on the 90th day after symptom onset was not different between the groups, after adjusted for other factors (p = 0.095). However, recurrent ischemic cerebrovascular disease on the relevant vascular territory was lower in the ICAD group (7 patients, 6.2%) than in the ICAS group (37 patients, 18.6%). ICAD was a significant independent determinant of disease recurrence (hazard ratio, 0.43; 95% confidence interval, 0.19-0.98). Improvement in vascular stenosis on follow-up vascular studies was more frequently observed in ICAD (50.7%) than in ICAS (11.6%). ICAD was an independent determinant of vascular improvement (odds ratio, 7.94; 95% confidence interval, 3.32-19.01). CONCLUSION Considering the high prevalence of ICAD in the patients with presumed ICAS and the differential outcomes between ICAD and ICAS, HR-MRI may be a useful diagnostic tool in this population.
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Affiliation(s)
- Jaewon Shin
- From the Departments of Neurology (J.S., J.-W.C., M.S.P., H.L., W.-K.S., G.-M.K., O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Departments of Radiology (J.C.), Severance Hospital, Yonsei University College of Medicine, Seoul; and Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B.), Samsung Medical Center, Seoul, Republic of Korea
| | - Jong-Won Chung
- From the Departments of Neurology (J.S., J.-W.C., M.S.P., H.L., W.-K.S., G.-M.K., O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Departments of Radiology (J.C.), Severance Hospital, Yonsei University College of Medicine, Seoul; and Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B.), Samsung Medical Center, Seoul, Republic of Korea
| | - Moo Seok Park
- From the Departments of Neurology (J.S., J.-W.C., M.S.P., H.L., W.-K.S., G.-M.K., O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Departments of Radiology (J.C.), Severance Hospital, Yonsei University College of Medicine, Seoul; and Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B.), Samsung Medical Center, Seoul, Republic of Korea
| | - Hanul Lee
- From the Departments of Neurology (J.S., J.-W.C., M.S.P., H.L., W.-K.S., G.-M.K., O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Departments of Radiology (J.C.), Severance Hospital, Yonsei University College of Medicine, Seoul; and Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B.), Samsung Medical Center, Seoul, Republic of Korea
| | - Jihoon Cha
- From the Departments of Neurology (J.S., J.-W.C., M.S.P., H.L., W.-K.S., G.-M.K., O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Departments of Radiology (J.C.), Severance Hospital, Yonsei University College of Medicine, Seoul; and Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B.), Samsung Medical Center, Seoul, Republic of Korea
| | - Woo-Keun Seo
- From the Departments of Neurology (J.S., J.-W.C., M.S.P., H.L., W.-K.S., G.-M.K., O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Departments of Radiology (J.C.), Severance Hospital, Yonsei University College of Medicine, Seoul; and Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B.), Samsung Medical Center, Seoul, Republic of Korea
| | - Gyeong-Moon Kim
- From the Departments of Neurology (J.S., J.-W.C., M.S.P., H.L., W.-K.S., G.-M.K., O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Departments of Radiology (J.C.), Severance Hospital, Yonsei University College of Medicine, Seoul; and Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B.), Samsung Medical Center, Seoul, Republic of Korea
| | - Oh Young Bang
- From the Departments of Neurology (J.S., J.-W.C., M.S.P., H.L., W.-K.S., G.-M.K., O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; Departments of Radiology (J.C.), Severance Hospital, Yonsei University College of Medicine, Seoul; and Translational and Stem Cell Research Laboratory on Stroke (J.-W.C., O.Y.B.), Samsung Medical Center, Seoul, Republic of Korea.
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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] [What about the content of this article? (0)] [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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Shimizu Y, Yagi M. Pulsatile tinnitus and carotid artery dissection. Auris Nasus Larynx 2018; 45:175-177. [DOI: 10.1016/j.anl.2016.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/26/2016] [Accepted: 12/24/2016] [Indexed: 11/16/2022]
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Janczak D, Ziomek A, Lesniak M, Malinowski M, Pormanczuk K, Janczak D, Dorobisz T, Chabowski M. The endovascular emergency treatment of an acute carotid artery dissection after Krav Maga training—a case report. HONG KONG J EMERG ME 2017. [DOI: 10.1177/1024907917745232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Carotid artery dissection accounts for 20%–30% of all ischemic strokes in young patients aged <50 years. Recent guidelines on carotid disease management do not differentiate between traumatic and spontaneous dissection. We present a case of a 36-year-old male patient with the right internal carotid artery dissection treated with two XACT Abbot 6–8 mm × 40 mm stents placement after he was strangled during Krav Maga training. It is the most effective way to prevent the imminent stroke in the penumbral region. The safety and outcome of stent placement in internal carotid artery dissection remains unclear and further randomized trials are needed.
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Affiliation(s)
- Dariusz Janczak
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
- Division of Surgical Procedures, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - Agnieszka Ziomek
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
- Division of Surgical Procedures, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - Michal Lesniak
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
- Division of Surgical Procedures, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - Maciej Malinowski
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
- Division of Surgical Procedures, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - Kornel Pormanczuk
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
- Division of Surgical Procedures, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - Dawid Janczak
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
- Division of Oncology and Palliative Care, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - Tadeusz Dorobisz
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
- Division of Oncology and Palliative Care, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - Mariusz Chabowski
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
- Division of Surgical Procedures, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
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Ramchand P, Mullen MT, Bress A, Hurst R, Kasner SE, Cucchiara BL, Messé SR. Recanalization after Extracranial Dissection: Effect of Antiplatelet Compared with Anticoagulant Therapy. J Stroke Cerebrovasc Dis 2017; 27:438-444. [PMID: 29100856 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/12/2017] [Accepted: 09/18/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cervical arterial dissection is a leading cause of stroke in young patients, yet optimal management remains controversial. Existing studies focusing on recurrent stroke were underpowered to demonstrate differences between antithrombotic strategies. Vessel recanalization is a more prevalent outcome and is potentially clinically important. We aimed to assess recanalization rates with anticoagulation compared with antiplatelet therapy. METHODS We studied a single-center retrospective cohort of patients with extracranial carotid or vertebral artery dissection. Subjects with baseline and follow-up imaging between 1999 and 2013 were included. Stenosis was measured using North American Symptomatic Carotid Endarterectomy Trial methodology. Univariate and multivariable analyses were performed to determine factors associated with recanalization, defined as ≥50% relative improvement in stenosis from baseline to follow-up imaging. Secondary analyses assessed absolute and relative stenosis change and limited the cohort to >50% stenosis at diagnosis. RESULTS We identified 75 patients with 84 dissections, mean age 47 years, 43% female, 39% non-white. Patients treated with anticoagulation had worse stenosis at baseline (median 99% versus 50%, P = .02). Comparing anticoagulation with antiplatelet therapy in the first month, there were no differences in the rates of ≥50% relative improvement in stenosis (50% versus 48%, P = .84) nor in absolute (median 16% versus 7%, P = .34) or relative (median 48% versus 43%, P = .92) change in stenosis from baseline to follow-up. In multivariable analysis, anticoagulation was not associated with recanalization (odds ratio [OR] 1.41, 95% confidence interval [CI]: .5-4.1, P = .52), whereas hypertension was negatively associated (OR .26, 95% CI: .09-.72, P = .009). CONCLUSIONS Anticoagulation was not associated with greater likelihood of recanalization compared with antiplatelet medication therapy.
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Affiliation(s)
- Preethi Ramchand
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aaron Bress
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Hurst
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brett L Cucchiara
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania.
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Amorim JM, Pereira D, Rodrigues MG, Beato-Coelho J, Lopes M, Cunha A, Figueiredo S, Mendes-Pinto M, Ferreira C, Sargento-Freitas J, Castro S, Pinho J. Anatomical characteristics of the styloid process in internal carotid artery dissection: Case-control study. Int J Stroke 2017; 13:400-405. [PMID: 28906206 DOI: 10.1177/1747493017730779] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Pathophysiology of cervical artery dissection is complex and poorly understood. In addition to well-known causative and predisposing factors, including major trauma and monogenic connective tissue disorders, morphological characteristics of the styloid process have been recently recognized as a possible risk factor for cervical internal carotid artery dissection. Aims To study the association of the anatomical characteristics of styloid process with internal carotid artery dissection. Methods Retrospective, multicenter, case-control study of patients with internal carotid artery dissection and age- and sex-matched controls. Consecutive patients with internal carotid artery dissection and controls with ischemic stroke or transient ischemic attack of any etiology excluding internal carotid artery dissection, who had performed computed tomography angiography, diagnosed between January 2010 and September 2016. Two independent observers measured styloid process length and styloid process distance to internal carotid artery. Results Sixty-two patients with internal carotid artery dissection and 70 controls were included. Interobserver agreement was good for styloid process length and styloid process-internal carotid artery distance (interclass correlation coefficient = 0.89 and 0.76, respectively). Styloid process ipsilateral to dissection was longer than left and right styloid process in controls (35.8 ± 14.4 mm versus 30.4 ± 8.9 mm and 30.3 ± 8.2 mm, p = 0.011 and p = 0.008, respectively). Styloid process-internal carotid artery distance ipsilateral to dissection was shorter than left and right distance in controls (6.3 ± 1.9 mm versus 7.2 ± 2.1 mm and 7.0 ± 2.3 mm, p = 0.003 and p = 0.026, respectively). Internal carotid artery dissection was associated with styloid process length (odds ratio = 1.04 mm-1, 95% confidence interval = 1.01-1.08, p = 0.015) and styloid process-internal carotid artery distance (OR = 0.77 mm-1, 95% confidence interval = 0.64-0.92, p = 0.004). Conclusion Longer styloid process and shorter distance between styloid process and cervical internal carotid artery are associated with cervical internal carotid artery dissection.
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Affiliation(s)
- José M Amorim
- 1 Neuroradiology Department, 389794 Hospital de Braga , Braga, Portugal
| | - Daniela Pereira
- 2 Medical Imaging Department, Neuroradiology Functional Unit, 58411 Centro Hospitalar e Universitário de Coimbra , Coimbra, Portugal
| | - Marta G Rodrigues
- 3 Neuroradiology Department, 59043 Centro Hospitalar de Vila Nova de Gaia/Espinho , Espinho, Portugal
| | - José Beato-Coelho
- 4 Neurology Department, 58411 Centro Hospitalar e Universitário de Coimbra , Coimbra, Portugal
| | | | - André Cunha
- 3 Neuroradiology Department, 59043 Centro Hospitalar de Vila Nova de Gaia/Espinho , Espinho, Portugal
| | - Sofia Figueiredo
- 6 Neurology Department, 59043 Centro Hospitalar de Vila Nova de Gaia/Espinho , Portugal
| | - Mafalda Mendes-Pinto
- 2 Medical Imaging Department, Neuroradiology Functional Unit, 58411 Centro Hospitalar e Universitário de Coimbra , Coimbra, Portugal
| | | | - João Sargento-Freitas
- 4 Neurology Department, 58411 Centro Hospitalar e Universitário de Coimbra , Coimbra, Portugal
| | - Sérgio Castro
- 3 Neuroradiology Department, 59043 Centro Hospitalar de Vila Nova de Gaia/Espinho , Espinho, Portugal
| | - João Pinho
- 5 Neurology Department, Hospital de Braga, Portugal
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Riou-Comte N, Mione G, Humbertjean L, Ottenin MA, Lacour JC, Richard S. Spontaneous cervical artery dissection in patients aged over 70 years: two cases and systematic literature review. Clin Interv Aging 2017; 12:1355-1362. [PMID: 28883716 PMCID: PMC5580704 DOI: 10.2147/cia.s138980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Spontaneous cervical artery dissection (CAD) is a cerebrovascular disease typically considered to affect the young population. Literature reports cases in the elderly only as incidental findings, making the diagnosis unlikely in older patients. Incidence and pathogeny in this specific population remain to be assessed. METHODS We reviewed patients aged over 70 years admitted for spontaneous CAD in the Stroke Unit of the University Hospital of Nancy (northeastern France) over a period of 12 years as well as all reported cases in literature. RESULTS During this period, only two patients aged over 70 years were diagnosed with internal carotid artery dissection in our center. The first patient was diagnosed with the typical radiological feature of long tapered stenosis due to mural hematoma. The second patient presented with the classic painful Horner syndrome. Literature review identified only two case reports and eight studies with an age range above 70 years. Headache was present in nearly all documented cases. Radiological features were the same as those usually described in younger patients. CONCLUSIONS Even if spontaneous CAD in patients aged over 70 years would appear to be rare, it does occur with comparable clinical and radiological features as in the younger population. CAD is probably underdiagnosed in this population due to a higher prevalence of more common causes of stroke at this age. However, a simple investigation into headache or the Horner syndrome during the patient's diagnostic workup would lead to adapted exploration of cervical arteries and improve detection of CAD in the elderly.
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Affiliation(s)
- Nolwenn Riou-Comte
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy Cedex, France
| | - Gioia Mione
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy Cedex, France
| | - Lisa Humbertjean
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy Cedex, France
| | | | | | - Sébastien Richard
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy Cedex, France.,Centre d'Invesigation Clinique Plurithématique Pierre Drouin CIC-P 1433 INSERM U1116, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Werre A, van der Vliet JA, Biert J, Blankensteijn JD, Kool LJS. Endovascular Management of a Gunshot Wound Injury to the Innominate Artery and Brachiocephalic Vein. Vascular 2016; 13:58-61. [PMID: 15895676 DOI: 10.1258/rsmvasc.13.1.58] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical repair of penetrating injuries of the thoracic outlet with combined arterial and venous involvement is associated with considerable morbidity and mortality. A 37-year-old man presented to the emergency room with a left-sided penetrating zone I neck injury caused by a close-range handgun shot. This had resulted in an injury to the innominate artery and the origin of the right common carotid artery, with shunting to the brachiocephalic vein. This was managed endovascularly by stenting of the innominate artery and by coiling of the origin of the carotid artery. An endovascular approach to this injury is feasible and has the advantage of appropriate visualization of the vascular lesions with limited blood loss during the repair.
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Affiliation(s)
- Andries Werre
- Department of Surgery, Division of Traumatology, University Medical Center, Nijmegen, The Netherlands, USA
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Prefasi D, Martínez-sánchez P, Fuentes B, Díez-tejedor E. Severity and outcomes according to stroke etiology in patients under 50 years of age with ischemic stroke. J Thromb Thrombolysis 2016; 42:272-82. [DOI: 10.1007/s11239-016-1336-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Abstract
Cervical artery dissection (CAD) is a major cause of stroke in the young. A mural hematoma is detected in most CAD patients. The intramural blood accumulation should not be considered a reason to withhold intravenous thrombolysis in patients with CAD-related stroke. Because intravenous-thrombolyzed CAD patients might not recover as well as other stroke patients, acute endovascular treatment is an alternative. Regarding the choice of antithrombotic agents, this article discusses the findings of 4 meta-analyses across observational data, the current status of 3 randomized controlled trials, and arguments and counterarguments favoring anticoagulants over antiplatelets. Furthermore, the role of stenting and surgery is addressed.
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Affiliation(s)
- Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH - 4031, Switzerland; Neurorehabilitation Unit, Felix Platter Hospital, University Center for Medicine of Aging and Rehabilitation, Burgfelderstrasse 101, Basel CH - 4012, Switzerland.
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH - 4031, Switzerland
| | - Alexander Von Hessling
- Department of Radiology, Neuroradiology and Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH - 4031, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel, Petersgraben 4, Basel CH - 4031, Switzerland
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Ben Hassen W, Machet A, Edjlali-Goujon M, Legrand L, Ladoux A, Mellerio C, Bodiguel E, Gobin-Metteil MP, Trystram D, Rodriguez-Regent C, Mas JL, Plat M, Oppenheim C, Meder JF, Naggara O. Imaging of cervical artery dissection. Diagn Interv Imaging. 2014;95:1151-1161. [PMID: 25632417 DOI: 10.1016/j.diii.2014.10.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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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23
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Abstract
Neuro-ophthalmological emergencies constitute vision or life-threatening conditions if diagnosis and treatment are not promptly undertaken. Even with immediate therapy, these clinical entities carry a high rate of morbidity. They may present with diplopia, visual loss, and/or anisocoria. Arteritic anterior ischemic optic neuropathy is an ominous condition, which can cause permanent and severe vision loss, stroke, or aortic dissection, requiring immediate steroid therapy. Pituitary apoplexy may go unnoticed if only computed axial tomography is performed. Diseases affecting the cavernous sinus and orbital apex region, such as cavernous sinus thrombosis or mucormycosis, can give rise to simultaneous vision loss and diplopia and, if not treated, may extend to the brain parenchyma causing permanent neurological sequela. An isolated third nerve palsy may be the harbinger of a cerebral aneurysm, carrying a significant risk of mortality. Horner syndrome can be the initial presentation of a carotid dissection, an important cause of stroke in the young adult. The neurohospitalist should be familiar with the workup and management of neuro-ophthalmological emergencies.
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Affiliation(s)
- João Lemos
- Michigan State University, East Lansing, MI, USA
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Lee W, Jung K, Moon J, Lee S, Chu K, Lee S, Roh J. Prognosis of spontaneous cervical artery dissection and transcranial Doppler findings associated with clinical outcomes. Eur Radiol 2016; 26:1284-91. [DOI: 10.1007/s00330-015-3944-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/06/2015] [Accepted: 07/23/2015] [Indexed: 11/27/2022]
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Brzezicki G, Rivet DJ, Reavey-Cantwell J. Pipeline Embolization Device for treatment of high cervical and skull base carotid artery dissections: clinical case series. J Neurointerv Surg 2015; 8:722-8. [PMID: 26089401 DOI: 10.1136/neurintsurg-2015-011653] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/29/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Most cervical dissections are treated with anticoagulation or antiplatelet agents with very good results; however, some patients may benefit from endovascular intervention. High cervical and skull base dissections are often more challenging to treat because of the distal location and tortuous anatomy. The Pipeline Embolization Device (PED) may be a reasonable treatment option for this indication. OBJECTIVES To report a case series of patients treated with the PED for high cervical and skull base dissections, focusing on their presentation, indications for treatment, dissection revascularization success, and pseudoaneurysm obliteration evaluated by imaging, and to review available pertinent literature. METHODS We retrospectively reviewed all cases of high cervical and skull base dissections treated with a PED at our institution. Patient clinical characteristics, presentation, procedural and follow-up imaging, and clinical course were analyzed to evaluate for procedure complications, dissection revascularization success, pseudoaneurysm obliteration, and clinical outcome. RESULTS This is a retrospective case series including 11 patients with 13 carotid dissections treated in our center. There were nine traumatic and four spontaneous dissections. The most common presentation was cerebrovascular accident/transient ischemic attack (CVA/TIA; 5 patients) and headache/face pain (4 patients). Eleven dissections were associated with pseudoaneurysms. Three patients failed medical management with anticoagulation, although flow-limiting stenosis was the main indication for endovascular intervention. Up to three PEDs per vessel were deployed. Angioplasty was used in 10 cases. Complete revascularization (<10% residual stenosis) was achieved in 91% of vessels and 50% of pseudoaneurysms were completely or near completely obliterated immediately after PED(s) deployment. Proximal iatrogenic dissection was the only intraoperative complication. Follow-up imaging was available for nine treated vessels and demonstrated patent PEDs without significant in-stent stenosis up to 9 months after intervention. 75% of pseudoaneurysms were completely obliterated at follow-up. One PED partially collapsed but had no neurological consequences. There were no new CVA/TIAs. CONCLUSIONS Our initial experience with treatment of high cervical and skull base dissections with the PED appears to show that this technique may be a safe and viable treatment option. However, long-term results are needed to fully evaluate the efficacy of such treatment.
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Affiliation(s)
- Grzegorz Brzezicki
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Dennis J Rivet
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Reavey-Cantwell
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
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26
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Juszkat R, Liebert W, Stanisławska K, Tomczyk T, Wronka J, Wąsik N, Perek B. Extracranial Internal Carotid Artery Dissection Treated with Self-expandable Stents: A Single-Centre Experience. Cardiovasc Intervent Radiol 2015; 38:1451-7. [PMID: 25902858 DOI: 10.1007/s00270-015-1101-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/30/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE Treatment of choice for the internal carotid artery dissection (ICAD) is anticoagulation for three to 6 months. Endovascular procedures may be a promising alternative for patients (pts) with haemodynamic impairment, recurrent ischaemic symptoms or symptomatic pseudoaneurysms. Thus, the purpose of this study was to evaluate the efficacy and safety of carotid artery stenting in treatment of selected pts with extracranial ICAD. METHODS This study involved 18 symptomatic pts with the mean age of 44.6 ± 10.4 years with ICAD treated with the use of self-expandable stents. Six months after primary procedures, pts were readmitted to hospital and physical examination followed by cerebral angiography was performed. In the late follow-up period, clinical evaluations completed by duplex Doppler ultrasonography were carried out every 6 months and at the end of the follow-up period. RESULTS Nobody died and no life-threatening adverse events were observed during either the in-hospital stay or post-discharge follow-up period (median 21 months). Stent deployment immediately restored flow in the true lumen of ICA in all cases. However, residual blood flow through the false lumen was observed in one pt. Complete resolution of clinical symptoms was observed in 14 pts (78%), partial improvement in 2 (11%) and persistence of neurological deficit in 2 (11%). CONCLUSIONS Implantation of self-expandable stents in treatment of selected extracranial ICAD cases is safe. This method may enable us to restore immediately and usually permanently proper arterial blood flow in the ICA and in consequence lead to significant clinical improvement in the late follow-up period.
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Affiliation(s)
- Robert Juszkat
- Department of General and Interventional Radiology, Poznań University of Medical Sciences, 1/2 Długa St., 61-848, Poznan, Poland. .,Department of Neurosurgery, Poznań University of Medical Sciences, 49 Przybyszewskiego St., 60-355, Poznan, Poland.
| | - Włodzimierz Liebert
- Department of Neurosurgery, Poznań University of Medical Sciences, 49 Przybyszewskiego St., 60-355, Poznan, Poland.
| | - Katarzyna Stanisławska
- Department of General and Interventional Radiology, Poznań University of Medical Sciences, 1/2 Długa St., 61-848, Poznan, Poland. .,Department of Neurosurgery, Poznań University of Medical Sciences, 49 Przybyszewskiego St., 60-355, Poznan, Poland.
| | - Tomasz Tomczyk
- Stroke Intensive Care Unit, 7/19 Juraszów St., 60-479, Poznan, Poland.
| | - Jarosław Wronka
- Department of Neurology, HCP Medical Centre, 194 28 Czerwca 1956 r. St., 61-485, Poznan, Poland.
| | - Norbert Wąsik
- Department of General and Interventional Radiology, Poznań University of Medical Sciences, 1/2 Długa St., 61-848, Poznan, Poland.
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznań University of Medical Sciences, 1/2 Długa St., 61-848, Poznan, Poland.
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27
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Korya D, Jeck D, LaWall J. Carotid artery dissection treated with stenting after anticoagulation failure. Pract Neurol 2015; 15:216-7. [PMID: 25617404 DOI: 10.1136/practneurol-2014-000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2015] [Indexed: 11/03/2022]
Affiliation(s)
| | - David Jeck
- Department of Neuroradiology, Tucson Medical Center, Arizona, USA
| | - John LaWall
- Department of Neurology, University of Arizona, Arizona, USA
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Kim DJ, Kim BM, Suh SH, Kim DI. Self-Expanding Stent Placement for Anterior Circulation Intracranial Artery Dissection Presenting With Ischemic Symptoms. Neurosurgery 2014; 76:158-64; discussion 164. [DOI: 10.1227/neu.0000000000000582] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
The prognosis of ischemic anterior circulation intracranial dissection (AC-ICD) is poor and its optimal management is still controversial.
OBJECTIVE:
To evaluate the safety and efficacy of a self-expanding stent for ischemic AC-ICD.
METHODS:
Eight patients (mean age, 36 years) underwent self-expanding stenting for ischemic AC-ICD. Imaging findings of ischemic AC-ICD, the reason for stenting, and the clinical and angiographic outcomes were retrospectively evaluated.
RESULTS:
AC-ICD involved intracranial internal carotid artery to middle cerebral artery (MCA) in 2, intracranial internal carotid artery alone in 3, and MCA alone in 3 patients. Six AC-ICDs showed complete or near occlusions while 2 had a severe degree of stenosis. Six AC-ICDs showed an intimal flap and 3 had intramural hematomas. Six patients underwent emergent stenting for acute stroke within 6 hours (n = 2) or crescendo-type stroke within 24 hours (n = 4), while 2 patients had stenting for recurrent ischemia on dual antiplatelet and/or anticoagulation after the initial attack. The mean dissection-related stenosis improved from 93.1% to 20.3% after stenting (P < .05). The mean National Institutes of Health Stroke Scale score improved from 7.5 to 1.4 (P < .05). All patients had excellent or favorable outcomes at 3 months: modified Rankin Scale score, 0 in 3, 1 in 3, and 2 in 1 patient(s). No patients had subarachnoid hemorrhage or ischemic symptom recurrence during the clinical follow-up (mean, 27 months). All stented arteries were patent without significant in-stent stenosis on angiographic follow-up (range, 3–12 months).
CONCLUSION:
Self-expanding stents seem to be safe and effective for AC-ICD presenting with acute/crescendo-type stroke or recurrent ischemia despite adequate medication.
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Affiliation(s)
- Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Sang Hyun Suh
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, South Korea
| | - Dong Ik Kim
- Department of Radiology, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
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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] [What about the content of this article? (0)] [Affiliation(s)] [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: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Jindal G, Fortes M, Miller T, Scalea T, Gandhi D. Endovascular stent repair of traumatic cervical internal carotid artery injuries. J Trauma Acute Care Surg 2013; 75:896-903. [PMID: 24158213 DOI: 10.1097/TA.0b013e3182a686be] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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34
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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35
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Renard D, Azakri S, Arquizan C, Swinnen B, Labauge P, Thijs V. Styloid and Hyoid Bone Proximity Is a Risk Factor for Cervical Carotid Artery Dissection. Stroke 2013; 44:2475-9. [DOI: 10.1161/strokeaha.113.001444] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Carotid artery dissection (CAD) is more common with increased styloid process length. Our goal was to determine whether proximity of the styloid process and the hyoid bone to the internal carotid artery (ICA) was a risk factor for CAD.
Methods—
We studied axial slices on computed tomography angiograms of 88 patients with nonaneurysmal CAD, from 88 age- and sex-matched controls without dissection, and from 32 nonage-/sex-matched nonaneurysmal vertebral artery dissection control patients. We measured the nearest distance between the ICA and both the styloid and the hyoid bones, blinded to clinical information and radiological reports.
Results—
Styloid-ICA and hyoid-ICA distances were significantly shorter on the side of the CAD as compared with nondissection control patients (
P
<0.0001 for the styloid-ICA distance; and
P
=0.0037 for the hyoid-ICA distance). Styloid-ICA distances, regardless of the side of the dissection, were shorter in CAD patients compared with the nondissection control group (right side,
P
=0.001; left side,
P
=0.0002) and the vertebral artery dissection control group (right side,
P
=0.0031; left side,
P
=0.0067). Direct mechanical contact of the styloid with the ICA was more common in CAD patients.
Conclusions—
Shorter distances between the styloid and ICA (and possibly also the hyoid and the ICA) are important risk factors for CAD. Further study is needed to determine whether dissections result from direct injury to the outer vessel wall of the carotid artery.
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Affiliation(s)
- Dimitri Renard
- From the Department of Neurology, CHU Nîmes, Hôpital Caremeau, France (D.R., S.A.); Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, France (C.A., P.L.); Department of Neurology, University Hospitals Leuven, Leuven, Belgium (B.S., V.T.); Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium (V.T.); and Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neurodegenerative Diseases (LIND), University of Leuven (KU Leuven),
| | - Souhayla Azakri
- From the Department of Neurology, CHU Nîmes, Hôpital Caremeau, France (D.R., S.A.); Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, France (C.A., P.L.); Department of Neurology, University Hospitals Leuven, Leuven, Belgium (B.S., V.T.); Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium (V.T.); and Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neurodegenerative Diseases (LIND), University of Leuven (KU Leuven),
| | - Caroline Arquizan
- From the Department of Neurology, CHU Nîmes, Hôpital Caremeau, France (D.R., S.A.); Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, France (C.A., P.L.); Department of Neurology, University Hospitals Leuven, Leuven, Belgium (B.S., V.T.); Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium (V.T.); and Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neurodegenerative Diseases (LIND), University of Leuven (KU Leuven),
| | - Bart Swinnen
- From the Department of Neurology, CHU Nîmes, Hôpital Caremeau, France (D.R., S.A.); Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, France (C.A., P.L.); Department of Neurology, University Hospitals Leuven, Leuven, Belgium (B.S., V.T.); Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium (V.T.); and Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neurodegenerative Diseases (LIND), University of Leuven (KU Leuven),
| | - Pierre Labauge
- From the Department of Neurology, CHU Nîmes, Hôpital Caremeau, France (D.R., S.A.); Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, France (C.A., P.L.); Department of Neurology, University Hospitals Leuven, Leuven, Belgium (B.S., V.T.); Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium (V.T.); and Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neurodegenerative Diseases (LIND), University of Leuven (KU Leuven),
| | - Vincent Thijs
- From the Department of Neurology, CHU Nîmes, Hôpital Caremeau, France (D.R., S.A.); Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, France (C.A., P.L.); Department of Neurology, University Hospitals Leuven, Leuven, Belgium (B.S., V.T.); Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium (V.T.); and Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neurodegenerative Diseases (LIND), University of Leuven (KU Leuven),
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36
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Abstract
Dissection of the internal carotid or vertebral artery has been recognized as a cause of stroke in young patients. It is disproportionate in its representation as a cause of stroke in this age group. Intimal tears, intramural hematomas, and dissection aneurysms may be the result of trauma or may occur spontaneously. Spontaneous dissection may be the result of inherent arterial weakness or in association with other predisposing factors. Clinical diagnosis is often difficult, but increased awareness and a range of modern investigations such as computerized tomography or magnetic resonance imaging may aid in diagnosis. Management options include antiplatelet therapy, anticoagulation, thrombolysis, and surgical or endovascular procedures. Prognosis is variable, and dissection may be asymptomatic but may lead to profound neurological deficit and death.
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Affiliation(s)
- Irwin V Mohan
- 1Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
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37
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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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Lackland DT, Elkind MSV, D'Agostino R, Dhamoon MS, Goff DC, Higashida RT, McClure LA, Mitchell PH, Sacco RL, Sila CA, Smith SC, Tanne D, Tirschwell DL, Touzé E, Wechsler LR. Inclusion of stroke in cardiovascular risk prediction instruments: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012; 43:1998-2027. [PMID: 22627990 DOI: 10.1161/str.0b013e31825bcdac] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Current US guideline statements regarding primary and secondary cardiovascular risk prediction and prevention use absolute risk estimates to identify patients who are at high risk for vascular disease events and who may benefit from specific preventive interventions. These guidelines do not explicitly include patients with stroke, however. This statement provides an overview of evidence and arguments supporting (1) the inclusion of patients with stroke, and atherosclerotic stroke in particular, among those considered to be at high absolute risk of cardiovascular disease and (2) the inclusion of stroke as part of the outcome cluster in risk prediction instruments for vascular disease. METHODS AND RESULTS Writing group members were nominated by the committee co-chairs on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee and the AHA Manuscript Oversight Committee. The writers used systematic literature reviews (covering the period from January 1980 to March 2010), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and, when appropriate, formulate recommendations using standard AHA criteria. All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive AHA internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. There are several reasons to consider stroke patients, and particularly patients with atherosclerotic stroke, among the groups of patients at high absolute risk of coronary and cardiovascular disease. First, evidence suggests that patients with ischemic stroke are at high absolute risk of fatal or nonfatal myocardial infarction or sudden death, approximating the ≥20% absolute risk over 10 years that has been used in some guidelines to define coronary risk equivalents. Second, inclusion of atherosclerotic stroke would be consistent with the reasons for inclusion of diabetes mellitus, peripheral vascular disease, chronic kidney disease, and other atherosclerotic disorders despite an absence of uniformity of evidence of elevated risks across all populations or patients. Third, the large-vessel atherosclerotic subtype of ischemic stroke shares pathophysiological mechanisms with these other disorders. Inclusion of stroke as a high-risk condition could result in an expansion of ≈10% in the number of patients considered to be at high risk. However, because of the heterogeneity of stroke, it is uncertain whether other stroke subtypes, including hemorrhagic and nonatherosclerotic ischemic stroke subtypes, should be considered to be at the same high levels of risk, and further research is needed. Inclusion of stroke with myocardial infarction and sudden death among the outcome cluster of cardiovascular events in risk prediction instruments, moreover, is appropriate because of the impact of stroke on morbidity and mortality, the similarity of many approaches to prevention of stroke and these other forms of vascular disease, and the importance of stroke relative to coronary disease in some subpopulations. Non-US guidelines often include stroke patients among others at high cardiovascular risk and include stroke as a relevant outcome along with cardiac end points. CONCLUSIONS Patients with atherosclerotic stroke should be included among those deemed to be at high risk (≥20% over 10 years) of further atherosclerotic coronary events. Inclusion of nonatherosclerotic stroke subtypes remains less certain. For the purposes of primary prevention, ischemic stroke should be included among cardiovascular disease outcomes in absolute risk assessment algorithms. The inclusion of atherosclerotic ischemic stroke as a high-risk condition and the inclusion of ischemic stroke more broadly as an outcome will likely have important implications for prevention of cardiovascular disease, because the number of patients considered to be at high risk would grow substantially.
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Hassan AE, Zacharatos H, Rodriguez GJ, Suri MFK, Tariq N, Vazquez G, Tummala RP, Qureshi AI. Long-term Clinical and Angiographic Outcomes in Patients with Spontaneous Cervico-Cranial Arterial Dissections Treated with Stent Placement. J Neuroimaging 2012; 22:384-93. [DOI: 10.1111/j.1552-6569.2012.00724.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Hassan AE, Zacharatos H, Souslian F, Suri MFK, Qureshi AI. Long-term clinical and angiographic outcomes in patients with cervico-cranial dissections treated with stent placement: a meta-analysis of case series. J Neurotrauma 2012; 29:1342-53. [PMID: 22188127 DOI: 10.1089/neu.2011.1963] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Limited clinical and angiographic data exists for patients with spontaneous or traumatic cervico-cranial dissections treated with stent placement. We reviewed clinical and angiographic data on consecutive patients admitted to our hospital with spontaneous, traumatic, and iatrogenic cervico-cranial dissections treated with stent placement to study immediate and long-term clinical and angiographic outcomes. Additional patients were identified using pertinent studies published between 1980 and 2009, using a search of the PubMed, Cochrane, and Ovid libraries. Post-procedure complications and clinical outcomes were documented. Angiographic abnormalities collected at follow-up included presence of in-stent restenosis or pseudoaneurysm. After applying our strict search criteria, four studies including our series were used in the meta-analysis, representing 46 patients (mean age [standard deviation] 47 ± 14 years; 24 [52%] male) treated with stent placement for dissection. Overall, 72 stents were placed to treat 28 spontaneous, 11 traumatic, and 7 iatrogenic dissection patients with 51 dissections, involving 51 vessels; with a mean pre-stent stenosis of 71 ± 26% and mean post-stent stenosis of 6 ± 15%. The immediate and follow-up post-procedure complication rates per stent placed was 8 (11%) and 8 (11%), respectively. Among the 36 patients who underwent follow-up angiography, in-stent restenosis or pseudoaneurysms were present in 3 (8%) and 2 (6%) patients, respectively. A high rate of sustained resolution of angiographic abnormalities during long-term follow-up was noted, with a low rate of new transient ischemic attack, ischemic stroke, or death, supporting the feasibility, safety, and effectiveness of endovascular stent reconstruction.
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Affiliation(s)
- Ameer E Hassan
- Zeenat Qureshi Stroke Research Center, Departments of Neurology, Neurosurgery, and Radiology, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Fuentes B, Masjuan J, de Leciñana MA, Simal P, Egido J, Díaz-Otero F, Gil-Nuñez A, Martínez-Sánchez P, Díez-Tejedor E. Benefits of Intravenous Thrombolysis in Acute Ischemic Stroke Related to Extra Cranial Internal Carotid Dissection. Dream or Reality? Int J Stroke 2011; 7:7-13. [DOI: 10.1111/j.1747-4949.2011.00637.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Small clinical series have reported the safety of intravenous thrombolysis in ischemic stroke related to extracranial internal carotid dissection. However, no studies specifically analyzing the effects on stroke outcome are available. Aims Our goal was to evaluate whether patients with ischemic stroke related to extracranial internal carotid dissection obtain any benefit from intravenous thrombolysis. Methods Multicenter, prospective and observational study conducted in four university hospitals from the Madrid Stroke Network. Consecutive ischemic stroke patients who received intravenous thrombolysis were included, as well as patients with extracranial internal carotid dissection regardless of intravenous thrombolysis treatment. Stroke severity (NIHSS) and three-month outcome (modified Rankin Scale) were compared between the following groups: ( 1 ) intravenous thrombolysis-treated patients with ischemic stroke related to extracranial internal carotid dissection vs. other causes of stroke; ( 2 ) intravenous thrombolysis-treated extracranial internal carotid dissection patients vs. nonintravenous thrombolysis treated. Outcome was rated at three-months using the modified Rankin Scale. A good outcome was defined as a modified Rankin Scale score ≤2. Results A total of 625 intravenous thrombolysis-treated patients were included; 16 (2·56%) had extracranial internal carotid dissection. Besides, 27 patients with extracranial internal carotid dissection and ischemic stroke who did not receive intravenous thrombolysis were also included. As compared with other etiologies, patients with extracranial internal carotid dissection were younger, had similar stroke severity and showed less improvement in their NIHSS score at Day 7 (1·38; (95% CI −3·77 to 6·54) vs. 6·81; (95% CI −5·99 to 7·63) P=0·004), but without differences in good outcomes at three-months (43·8% vs. 58·2%; NS). Extracranial internal carotid dissection intravenous thrombolysis-treated patients had more severe strokes at admission than those who were nonintravenous thrombolysis treated (median NIHSS: 15 vs. 7; P=0·031). Intravenous thrombolysis was safe in extracranial internal carotid dissection with no symptomatic hemorrhagic events; however, without differences in good outcome compared with the natural course of extracranial internal carotid dissection (nonintravenous thrombolysis treated) after adjustment for stroke severity (46·7% vs. 64·3%; NS). Conclusions As compared with other etiologies, stroke due to extracranial internal carotid dissection seems to obtain similar benefits from intravenous thrombolysis in outcome at three-months. Although intravenous thrombolysis is safe in stroke attributable to extracranial internal carotid dissection, no differences in outcome were found when comparing intravenous thrombolysis treated with nonintravenous thrombolysis-treated patients, even after adjustment for stroke severity.
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Affiliation(s)
- Blanca Fuentes
- Stroke Centre, Department of Neurology, Neurosciences Research, IdiPAZ Health Research Institute, University Hospital La Paz, Madrid Autónoma University, Madrid, Spain
| | - Jaime Masjuan
- Stroke Unit, Department of Neurology, University Hospital Ramón y Cajal, IRYCIS Health Research Institute, Alcalá de Henares University, Madrid, Spain
| | - María Alonso de Leciñana
- Stroke Unit, Department of Neurology, University Hospital Ramón y Cajal, IRYCIS Health Research Institute, Alcalá de Henares University, Madrid, Spain
| | - Patricia Simal
- Stroke Unit, Department of Neurology, University Hospital Clínico San Carlos, Madrid Complutense University, Madrid, Spain
| | - José Egido
- Stroke Unit, Department of Neurology, University Hospital Clínico San Carlos, Madrid Complutense University, Madrid, Spain
| | - Fernando Díaz-Otero
- Stroke Unit, Department of Neurology, University Hospital Gregorio Marañón, Madrid Complutense University, Madrid, Spain
| | - Antonio Gil-Nuñez
- Stroke Unit, Department of Neurology, University Hospital Gregorio Marañón, Madrid Complutense University, Madrid, Spain
| | - Patricia Martínez-Sánchez
- Stroke Centre, Department of Neurology, Neurosciences Research, IdiPAZ Health Research Institute, University Hospital La Paz, Madrid Autónoma University, Madrid, Spain
| | - Exuperio Díez-Tejedor
- Stroke Centre, Department of Neurology, Neurosciences Research, IdiPAZ Health Research Institute, University Hospital La Paz, Madrid Autónoma University, Madrid, Spain
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Schirmer CM, Atalay B, Malek AM. Endovascular recanalization of symptomatic flow-limiting cervical carotid dissection in an isolated hemisphere. Neurosurg Focus 2011; 30:E16. [DOI: 10.3171/2011.2.focus1139] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Object
Internal carotid artery dissection (ICAD) is a common cause of stroke in young patients, which may lead to major transient or permanent disability. Internal carotid artery dissection may occur spontaneously or after trauma and may present with a rapid neurological deterioration or with hemodynamic compromise and a delayed and unstable neurological deficit. Endovascular intervention using stent angioplasty can be used as an alternative to anticoagulation and open surgical therapy in this setting to restore blood flow through the affected carotid artery.
Methods
The authors present the cases of 2 patients with flow-limiting symptomatic ICAD leading to near-complete occlusion and without sufficient collateral supply. Both patients had isolated cerebral hemispheres without significant blood flow from the anterior or posterior communicating arteries. In both cases, the patients demonstrated blood pressure–dependent subacute unstable neurological deficits as a result of the hemodynamic compromise resulting from the dissection.
Results
Both patients underwent careful microwire-based selection of the true lumen followed by confirmatory microinjection and subsequent exchange-length microwire-based recanalization using tandem telescoping endovascular stenting. In both cases the neurological state improved, and no permanent neurological deficit ensued.
Conclusions
The treatment of ICAD may be difficult in patients with subacute unstable neurological deficits related to symptomatic hypoperfusion, especially in the setting of a hemodynamically isolated hemisphere. Anticoagulation alone may be insufficient in these patients. Although there is no widely accepted guideline for the treatment of ICAD, the authors recommend stent-mediated endovascular recanalization in cases of symptomatic flow-limiting hemodynamic compromise, especially in cases of an isolated hemisphere lacking sufficient communicating artery compensatory perfusion.
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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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Pham MH, Rahme RJ, Arnaout O, Hurley MC, Bernstein RA, Batjer HH, Bendok BR. Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature. Neurosurgery 2011; 68:856-66; discussion 866. [DOI: 10.1227/neu.0b013e318209ce03] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Abstract
BACKGROUND:
Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.
OBJECTIVE:
To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.
METHODS:
We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.
RESULTS:
For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).
CONCLUSION:
Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.
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Affiliation(s)
- Martin H. Pham
- Departments of *Neurological Surgery, ‡Radiology, and §Neurology, Northwestern University Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois
| | - Rudy J. Rahme
- Departments of *Neurological Surgery, ‡Radiology, and §Neurology, Northwestern University Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois
| | - Omar Arnaout
- Departments of *Neurological Surgery, ‡Radiology, and §Neurology, Northwestern University Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois
| | - Michael C. Hurley
- Departments of *Neurological Surgery, ‡Radiology, and §Neurology, Northwestern University Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois
| | - Richard A. Bernstein
- Departments of *Neurological Surgery, ‡Radiology, and §Neurology, Northwestern University Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois
| | - H. Hunt Batjer
- Departments of *Neurological Surgery, ‡Radiology, and §Neurology, Northwestern University Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois
| | - Bernard R. Bendok
- Departments of *Neurological Surgery, ‡Radiology, and §Neurology, Northwestern University Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois
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Lanzino G, D'Urso PI. Carotid dissections. J Neurosurg 2011; 115:89-90; discussion 90. [PMID: 21417708 DOI: 10.3171/2010.11.jns10696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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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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Silvestrini M, Altamura C, Cerqua R, Pedone C, Balucani C, Luzzi S, Bartolini M, Provinciali L, Vernieri F. Early Activation of Intracranial Collateral Vessels Influences the Outcome of Spontaneous Internal Carotid Artery Dissection. Stroke 2011; 42:139-43. [DOI: 10.1161/strokeaha.110.595843] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Mauro Silvestrini
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
| | - Claudia Altamura
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
| | - Raffaella Cerqua
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
| | - Claudio Pedone
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
| | - Clotilde Balucani
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
| | - Simona Luzzi
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
| | - Marco Bartolini
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
| | - Leandro Provinciali
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
| | - Fabrizio Vernieri
- From the Department of Neuroscience (M.S., R.C., S.L., M.B., L.P.), Marche Polytechnic University, Ancona; Department of Clinical Neurology (C.A., F.V.), University Campus Bio-Medico, Rome; Department of Geriatric Medicine (C.P.), University Campus Bio-Medico, Rome; and Department of Clinical Neurology (C.B.), University of Perugia, Perugia, Italy
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Nicosia A, Nikas D, Castriota F, Biamino G, Cao P, Cremonesi A, Mathias K, Moussa I, Hopkins LN, Setacci C, Sievert H, Reimers B. Classification for carotid artery stenting complications: manifestation, management, and prevention. J Endovasc Ther 2010; 17:275-94. [PMID: 20557164 DOI: 10.1583/09-2943.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Carotid artery stenting is a rapidly evolving method for treating carotid artery disease. Various intraprocedural and postprocedural complications have been reported in the literature. However, the absence of a unified classification scheme for these complications makes it difficult, if not impossible, to study their precise incidence, predictors, and management. The aim of this article is to propose the first joint classification of periprocedural complications, to analyze their incidence and etiology, and suggest possible ways to manage and prevent them. This classification is intended to be used as a common platform for prompt recognition, evaluation, treatment, and universal study of the complications during carotid stenting procedures. For this purpose, the opinions of the major experts on carotid interventions worldwide were merged with all the available information reported in the English-language literature to present as accurately as possible the management and prevention of carotid stenting complications according to this proposed classification.
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Affiliation(s)
- Antonino Nicosia
- Cardiac Catheterization Laboratory, M.P. Arezzo Hospital, Ragusa, Italy
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Jeon P, Kim BM, Kim DI, Shin YS, Kim KH, Park SI, Kim DJ, Suh SH. Emergent self-expanding stent placement for acute intracranial or extracranial internal carotid artery dissection with significant hemodynamic insufficiency. AJNR Am J Neuroradiol 2010; 31:1529-32. [PMID: 20430849 DOI: 10.3174/ajnr.a2115] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE ICAD with hemodynamic insufficiency may present with either fulminant infarct or with progressive neurologic deterioration. The purpose of this study was to evaluate the safety and efficacy of emergent self-expanding stent placement for acute intracranial or extracranial ICAD with significant hemodynamic insufficiency. MATERIALS AND METHODS Eight patients (7 men and 1 woman; age range, 20-55 years; NIHSS score, 5-21) underwent emergent self-expanding stent placement for treatment of significant hemodynamic insufficiency due to acute ICAD. The safety and efficacy of emergent self-expanding stent placement were retrospectively evaluated. RESULTS All patients presented with progressive (n = 6) or fluctuating (n = 2) neurologic deficits and revealed markedly decreased perfusion on CT or MR perfusion studies. Conventional angiography revealed acute occlusion (n = 2) or critical stenosis (n = 6) in intracranial (n = 3) or extracranial (n = 5) carotid arteries with a lack of sufficient collaterals. Stent placement was successful in all patients without any procedure-related complications. In all patients, hemodynamic insufficiency was corrected immediately after stent placement, and neurologic symptoms were completely resolved during several days. Mean improvement of the NIHSS score between baseline and discharge was 11.6 (range, 5-21). All patients remained neurologically intact (mRS, 0) during clinical follow-up for a mean of 21 months (range, 8-50 months). Angiographic follow-up was available for 6 patients at 3-12 months. None of the 6 patients revealed residual or in-stent restenosis. CONCLUSIONS Self-expanding stent placement is a safe and effective option for selected patients with significant hemodynamic insufficiency due to acute intracranial or extracranial ICAD.
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Affiliation(s)
- P Jeon
- Department of Radiology, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Spontaneous and traumatic cervical artery dissection is a common cause of stroke in the young. It generally carries an excellent prognosis if treatment is initiated early. Antiplatelet therapy may be as effective as or safer than warfarin, although no randomized prospective studies have addressed the issue of optimal medical therapy. Rarely, endovascular therapy may be indicated for the treatment of ruptured aneurysms or to prevent recurrent ischemia.
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Affiliation(s)
- Alex Abou-Chebl
- Section of Stroke and Neurological Critical Care, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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