Toward Individual Treatment in Cervical Artery Dissection: Subgroup Analysis of the TREAT-CAD Randomized Trial

OBJECTIVE

Uncertainty remains regarding antithrombotic treatment in cervical artery dissection. This analysis aimed to explore whether certain patient profiles influence the effects of different types of antithrombotic treatment.

METHODS

This was a post hoc exploratory analysis based on the per-protocol dataset from TREAT-CAD (NCT02046460), a randomized controlled trial comparing aspirin to anticoagulation in patients with cervical artery dissection. We explored the potential effects of distinct patient profiles on outcomes in participants treated with either aspirin or anticoagulation. Profiles included (1) presenting with ischemia (no/yes), (2) occlusion of the dissected artery (no/yes), (3) early versus delayed treatment start (median), and (4) intracranial extension of the dissection (no/yes). Outcomes included clinical (stroke, major hemorrhage, death) and magnetic resonance imaging outcomes (new ischemic or hemorrhagic brain lesions) and were assessed for each subgroup in separate logistic models without adjustment for multiple testing.

RESULTS

All 173 (100%) per-protocol participants were eligible for the analyses. Participants without occlusion had decreased odds of events when treated with anticoagulation (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.07-0.86). This effect was more pronounced in participants presenting with cerebral ischemia (n = 118; OR = 0.16, 95% CI = 0.04-0.55). In the latter, those with early treatment (OR = 0.26, 95% CI = 0.07-0.85) or without intracranial extension of the dissection (OR = 0.34, 95% CI = 0.11-0.97) had decreased odds of events when treated with anticoagulation.

INTERPRETATION

Anticoagulation might be preferable in patients with cervical artery dissection presenting with ischemia and no occlusion or no intracranial extension of the dissection. These findings need confirmation. ANN NEUROL 2024;95:886-897.

Spontaneous healing and complete disappearance of an intracranial vertebral artery dissecting aneurysm: A case report

RATIONALE

Intracranial vertebrobasilar dissecting aneurysms (VBDAs) are associated with a greater tendency to rupture and a greater risk of worse outcomes than anterior circulation aneurysms. Spontaneous healing of a VBDA is very rare, and there have been very few case reports of spontaneous healing of an aneurysm. We describe a case of intracranial vertebral artery dissecting aneurysm that healed spontaneously and disappeared completely on follow-up images.

PATIENT CONCERNS

A 40-years-old woman was referred to the neurology department because of a persistent headache, especially in the left occiput.

DIAGNOSES

Magnetic resonance angiography and computed tomography angiography showed a left vertebral artery dissection-like aneurysm (4.5 × 2.0 × 2.5 mm in size) with proximal parent artery mild stenosis (40%).

INTERVENTIONS

Flunarizine hydrochloride was administered for symptomatic treatment and follow-up angiography was performed.

OUTCOMES

Digital subtraction angiography and magnetic resonance angiography showed that the aneurysm had completely disappeared at 3 months follow-up. High-resolution magnetic resonance vessel wall imaging revealed intimal thickening and mild stenosis in the left intracranial vertebral artery without an aneurysm signal. In addition, enhancement scanning revealed that the aneurysm area was moderately enhanced. MR-vessel wall imaging at 7 months follow-up showed that the enhancement was slightly reduced compared with the previous time.

LESSONS

This case illustrates the relatively plastic nature of a vertebral dissecting aneurysm, indicating that spontaneous healing remains possible.

Blunt cerebrovascular injuries: early recognition and stroke prevention in the emergency department

Blunt cerebrovascular injuries include cervical carotid dissections and vertebral artery dissections that are due to blunt trauma. Although the overall incidence is low, dissections remain a common cause of stroke in children, young adults, and trauma patients. Symptoms of dissection, such as headache, neck pain, and dizziness, are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient or may not be recognized as being due to a dissection. A missed diagnosis of cervical artery dissection can result in devastating neurologic sequelae, and emergency clinicians must act quickly to recognize this diagnosis and begin treatment as soon as possible. This supplement reviews the application of advanced screening criteria, imaging options, and antithrombotic treatment for patients with blunt cerebrovascular injuries, with a focus on reducing the occurrence of ischemic stroke.

The Use of Tissue Plasminogen Activator in the Treatment of Wallenberg Syndrome Caused by Vertebral Artery Dissection

BACKGROUND

Acute cerebrovascular accident (CVA) is a devastating cause of patient morbidity and mortality. Up to 10% of acute CVAs in young patients are caused by dissection of the vertebral or carotid artery. Wallenberg syndrome results from a CVA in the vertebral or posterior inferior artery of the cerebellum and manifests as various degrees of cerebellar dysfunction. The administration of a thrombolytic medication has been recommended in the treatment of patients with stroke caused by cervical artery dissection. Surprisingly, there is scant literature on the use of this medication in the treatment of this condition.

CASE REPORT

We describe a 42-year-old man with the sudden onset of headache, left-sided neck pain, vomiting, nystagmus, and ataxia 1 h after completing a weightlifting routine. Computed tomography angiography revealed a grade IV left vertebral artery injury with a dissection flap extending distally and resulting in complete occlusion. Subsequent magnetic resonance imaging and angiography demonstrated acute left cerebellar and lateral medullary infarcts, consistent with Wallenberg syndrome. The patient was treated with tissue plasminogen activator, which failed to resolve his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently manage patients with acute CVAs. For select patients, the administration of tissue plasminogen activator can improve outcomes. However, the risk of major hemorrhage with this medication is significant. Cervical artery dissection is an important cause of acute stroke in young patients and is often missed on initial presentation. It is imperative for the emergency physician to consider acute cervical artery dissection as a cause of stroke and to be knowledgeable regarding the efficacy of thrombolytic medications for this condition.

Vertebral artery dissection in hypertensive disorders of pregnancy: a case series and literature review

BACKGROUND

Arterial dissection is a rare complication of pregnancy and puerperium. There have been reports of aortic, coronary and cervical artery dissection in association with preeclampsia, however, vertebral artery dissection is rarely reported particularly in the antenatal setting in the presence of a Hypertensive Disorder of Pregnancy (HDP).The general annual incidence of symptomatic spontaneous cervicocephalic arterial dissection is 0.0026 % and a data registry reported that 2.4 % of these occurred in the post-partum period. The actual incidence of vertebral artery dissection in HDP is unknown as the current literature consists of case series and reports only with most documenting adverse outcomes. Given the presence of collateral circulation, unilateral vertebral artery dissections may go unrecognised and may be more common than suspected.

CASE PRESENTATION

We present a case series of four patients with vertebral artery dissection in association with HDP, two of which occurred in the antenatal setting and two in the post-partum setting. All our patients had favourable outcome with no maternal neurological deficit and live infants. Our discussion covers the proposed pathophysiology of vertebral artery dissection in HDP and the management of it.

CONCLUSION

Our case series highlights the need to consider VAD an important differential diagnosis when assessing pregnant women with headache and neck pain particularly in the context of HDP.

Cervical artery dissection: early recognition and stroke prevention

Cervical artery dissections involve the carotid or vertebral arteries. Although the overall incidence is low, they remain a common cause of stroke in children, young adults, and trauma patients. Symptoms such as headache, neck pain, and dizziness are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient. A missed diagnosis of cervical artery dissection can result in devastating neurological sequelae, so emergency clinicians must act quickly to recognize this event and begin treatment as soon as possible while neurological consultation is obtained. This issue reviews the evidence in applying advanced screening criteria and choosing imaging and antithrombotic treatment strategies for patients with cervical artery dissections to reduce the occurrence of ischemic stroke.

[Dissection of the cervical arteries]

Dissection of the cervical arteries is an important cause of stroke in young adults. A haematoma in the wall of the cervical vessel leads to stenosis or occlusion and thereby risk of stroke. The most frequent local symptoms in carotid-artery dissection are head- and neck pain accompanied by Horner's syndrome, while typical symptoms in vertebral-artery dissection are pain in the back of the neck and head. The mural haematoma is best visualized by magnetic resonance imaging. Antithrombotic versus anticoagulation treatment to prevent stroke have recently shown to be equally effective.

[Dissection in the vertebral arteries is uncommon and may be misdiagnosed]

Spontaneous dissection of a vertebral artery is uncommon, but potentially harmful and initially easily misdiagnosed as ordinary headache, neck pain or dizziness. The condition may progress with infarctions in the brainstem and cerebellar areas and ataxia, nystagmus, Horner syndrome, dysarthria, cranial nerve palsy or hemiparesis. We report an initially misdiagnosed case and remind about the clinical clues which lead to a correct diagnosis: young age, no risk factors for thromboembolism, the typical clinical findings and the presence of neck pain.

Hyperdense posterior cerebral artery sign in a setting of spontaneous vertebral artery dissection: a blessing in disguise?

OBJECTIVE

To report a case of a hyperdense posterior cerebral artery (PCA) sign in the setting of spontaneous vertebral artery dissection.

CLINICAL PRESENTATION AND INTERVENTION

A 28-year-old, previously healthy female presented with rapidly progressive coma. A noncontrast computerized tomographic (CT) scan showed a hyperdense PCA sign, which prompted an urgent arteriogram. She was found to have spontaneous vertebral artery dissection with an occluding thrombus. She underwent intra-arterial thrombolysis with tissue plasminogen activator. Follow-up magnetic resonance imaging showed an area of acute infarction in the medial temporal and occipital regions corresponding to the area supplied by the left PCA. The patient was started on systemic anticoagulation therapy with intravenous heparin. She showed slow and continued recovery but was left with significant neurological deficits that required posthospital discharge to a long-term rehabilitation facility.

CONCLUSION

This case showed that the hyperdense PCA sign on a noncontrast CT scan necessitated an emergent CT angiogram that showed vertebral artery dissection and a devastating vascular occlusion. Hence, we suggest an early intervention that may allow for potential revascularization therapy.

Vertebral artery dissection: an unusual cause of transient ataxia, vertigo, and sensorineural hearing loss

We present the case of a 33-year-old man who was admitted with intermittent ataxia, vertigo, and sensorineural hearing loss as a result of a vertebral artery dissection following minor neck trauma. Our aim is to highlight the importance of obtaining magnetic resonance imaging, magnetic resonance angiography, and/or duplex color-flow imaging when presented with a case of fluctuating vertigo and sensorineural hearing loss with side-specific ataxia. Likewise, it is important to obtain the input of neurologists to optimize a patient's prognosis and minimize long-term sequelae.

Antiplatelets versus anticoagulants for the treatment of cervical artery dissection: Bayesian meta-analysis

OBJECTIVE

To compare the effects of antiplatelets and anticoagulants on stroke and death in patients with acute cervical artery dissection.

DESIGN

Systematic review with Bayesian meta-analysis.

DATA SOURCES

The reviewers searched MEDLINE and EMBASE from inception to November 2012, checked reference lists, and contacted authors.

STUDY SELECTION

Studies were eligible if they were randomised, quasi-randomised or observational comparisons of antiplatelets and anticoagulants in patients with cervical artery dissection.

DATA EXTRACTION

Data were extracted by one reviewer and checked by another. Bayesian techniques were used to appropriately account for studies with scarce event data and imbalances in the size of comparison groups.

DATA SYNTHESIS

Thirty-seven studies (1991 patients) were included. We found no randomised trial. The primary analysis revealed a large treatment effect in favour of antiplatelets for preventing the primary composite outcome of ischaemic stroke, intracranial haemorrhage or death within the first 3 months after treatment initiation (relative risk 0.32, 95% credibility interval 0.12 to 0.63), while the degree of between-study heterogeneity was moderate (τ(2) = 0.18). In an analysis restricted to studies of higher methodological quality, the possible advantage of antiplatelets over anticoagulants was less obvious than in the main analysis (relative risk 0.73, 95% credibility interval 0.17 to 2.30).

CONCLUSION

In view of these results and the safety advantages, easier usage and lower cost of antiplatelets, we conclude that antiplatelets should be given precedence over anticoagulants as a first line treatment in patients with cervical artery dissection unless results of an adequately powered randomised trial suggest the opposite.

[A spontaneous dissection of cervical arteries]

Presenting two cases of spontaneous dissection of cervical arteries. A 54 year-old male suffered from left-sided Horner syndrome and severe headache. MR cerebrum revealed a left internal carotid artery dissection. A 57 year-old female with left vertebral artery dissection was admitted to hospital due to repeated attacks of total blindness preceded by weeks of moderate headache.

Bilateral vertebral artery dissection caused by atlantoaxial dislocation

Craniovertebral anomalies are rare causes of vertebral artery dissection. Therefore, appropriate evaluation is necessary in vertebrobasilar strokes, specially in the young. This is particularly true for patients with vertebral stroke without risk factors.

RESULTS

Here we report a 24-year-old male presenting with posterior circulation infarcts. The patient had no obvious vascular risk factors. However, digital subtraction angiography showed chronic dissection of both vertebral arteries with partial recanalization. Further evaluation with computed tomogram of neck revealed atlantoaxial dislocation. This is a rare case in which atlantoaxial dislocation has resulted in bilateral vertebral artery dissection and stroke in young.

Dental procedures and stroke: a case of vertebral artery dissection

As vertebral artery dissections may cause stroke, they must be identified and treated promptly. The association of arterial dissection with dental procedures has been previously observed. In this article, we report on a patient presenting with posterior circulation stroke secondary to vertebral artery dissection following a dental procedure. The clinical course, radiologic findings and management are described and the literature regarding vertebral dissections is reviewed.

Vertebral artery dissection: not a rare cause of stroke in the young

We hereby describe a 42-year-old lady who developed vertebral artery dissection following a head injury. The clinical features and management of the condition are discussed.

Vertebral artery dissection presenting as isolated vertigo

Vertigo is not an uncommon presentation to the emergency department. It is most commonly caused by benign peripheral processes, such as inner ear or vestibular nerve dysfunction, but can be due to central brain lesions. In this report, we present a central cause of isolated vertigo: brainstem infarct secondary to vertebral artery dissection (VAD). VAD is increasingly being recognised as an important cause of stroke in young people. We discuss the important features that need to be elicited to distinguish central from peripheral disease and the relevance of VAD.

Fibromuscular Dysplasia May Herald Symptomatic Recurrence of Cervical Artery Dissection

BACKGROUND

The prevalence of fibromuscular dysplasia (FMD) in patients with cervical artery dissection (CAD) is unknown. Our objectives were to assess the risk of CAD recurring as a stroke or a transient ischemic attack and the association of these events with FMD.

METHODS

We prospectively included and followed 103 consecutive patients who had been admitted for a CAD. The median follow-up was 4 years (range 4 months to 10 years). The main criteria for inclusion were a mural hematoma demonstrated by cervical magnetic resonance imaging and/or signs suggesting CAD on 2 other investigations. FMD was diagnosed on the so-called string of beads pattern by digital subtraction angiography.

RESULTS

Five patients had CAD recurrence (60% occurred late). Four of these 5 patients had FMD. In 4 patients, CAD recurrence involved another cervical artery.

CONCLUSION

The rate of symptomatic CAD recurrence was 1% per year and was often related to FMD.

Spontaneous Dissection of the Carotid and Vertebral Arteries: the 10-year UCSD Experience

The etiology of spontaneous dissection of the carotid and vertebral arteries without antecedent trauma remains unclear. The goal of this 10-year review was to examine factors regarding presentation, diagnosis, treatment, and outcome for all patients at our institution who were diagnosed with spontaneous carotid dissections (SCD) or spontaneous vertebral dissections (SVD) with no prior trauma history. A retrospective chart analysis was performed involving all discharges from UCSD Medical Center from 1995 to 2005. Patients were selected for inclusion based on the diagnosis of carotid or vertebral dissection with no associated traumatic or iatrogenic cause for their presentation. Characteristics of these patients' medical risk factors, presenting symptoms, diagnostic method and time, treatment, and outcomes were analyzed. A total of 20 patients (10 male, age 44.8 +/- 12.9 yrs; 10 female, age 39.6 +/- 14.9 yrs) were included for study. These patients represented 12 cases of SCD and nine SVD. On presentation, a majority of patients with both SVD and SCD reported headache as their primary complaint while a significantly higher rate of nausea (25% vs. 67%, p < 0.01) was reported in SVD. SVD was associated with a significantly longer diagnostic time (11 hr vs. 16 hr, p < 0.01). The most commonly performed diagnostic exam in both SCD and SVD was magnetic resonance angiography (MRA). Anticoagulation was the primary treatment in 11 of 12 SCD and all nine SVD. One patient with persistent, symptomatic bilateral carotid dissection after anticoagulation was treated with stent placement resulting in unilateral intracranial hemorrhage (ICH). Length of stay was significantly longer in SVD (5 d vs. 7 d, p < 0.02). A significantly higher incidence of persistent neurologic deficits on discharge was seen in SCD (71% vs. 33%, p < 0.02). Radiographic evidence of cerebral infarction on discharge had a stronger correlation with clinical deficits in SCD. Although there were only two cases, those treated with endovascular therapy in the setting of SCD suffered complications related to the intervention. On discharge, there did not seem to be a correlation between persistent neurologic deficits and radiographic evidence of infarction in SVD reflecting that recovery after these episodes may not be predictable based on the appearance of the infarction.

Vertebral Artery Dissection

Background and Purpose— Few data exist about clinical, radiologic findings, clinical outcome, and its predictors in patients with spontaneous vertebral artery dissection (sVAD).

Methods— Clinical characteristics, imaging findings, 3-month outcomes, and its predictors were investigated in consecutive patients with sVAD.

Results— One hundred sixty-nine patients with 195 sVAD were identified. Brain ischemia occurred in 131 patients (77%; ischemic stroke, n=114, 67%; transient ischemic attack, n=17, 10%). Three patients with ischemic stroke showed also signs of subarachnoid hemorrhage (SAH); 3 (2%) had SAH without ischemia. The 134 patients with brain ischemia or SAH had head and/or neck pain in 118 (88%) and pulsatile tinnitus in seven (5%) patients. The remaining 35 patients (21%) had isolated head and/or neck pain in 21 (12%) cases, asymptomatic sVAD in 13 (8%), and cervical radiculopathy in one case (1%). Location of sVAD was more often in the pars transversaria (V2; 35%) or atlas loop (V3; 34%) than in the prevertebral (V1; 20%) or intracranial (V4; 11%) segment ( P =0.0001). Outcome was favorable (modified Rankin scale score 0 or 1) in 88 (82%) of 107 ischemic stroke patients with follow up. Two (2%) patients died. Low baseline National Institutes of Health Stroke Scale score ( P <0.0001) and younger age ( P =0.007) were independent predictors of favorable outcome.

Conclusions— sVAD is predominantly located in the pars transversaria (V2) or the atlas loop (V3). Most patients show posterior circulation ischemia. Favorable outcome is observed in most ischemic strokes and independently predicted by low National Institutes of Health Stroke Scale score and younger age.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spontaneous artery dissection in a patient with Human Immunodeficiency Virus (HIV) infection

BACKGROUND

The relationship between human immunodeficiency virus infection and stroke may be attributed in some cases to an underlying vasculopathy such as in spontaneous cervical arteries dissections.

CASE REPORT

We report the case of an HIV-infected patient who developed a Wallemberg's syndrome due to a vertebral artery dissection. Screening laboratory exams showed hyperhomocysteinemia and also high C-reactive protein plasma levels.

CONCLUSIONS

This is the first case describing the association between arterial dissection (AD) and HIV-infection. We suggest that AD should also be remembered as a possible mechanism of ischemic stroke in HIV-infected patients.

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

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

Accident vasculaire cérébral sur dissection artérielle, au cours des mastocytoses systémiques : une association non fortuite ? À propos de deux cas

INTRODUCTION

Neuropsychiatric symptoms in systemic mastocytosis are usually cognitive and affective changes.

EXEGESIS

We describe here two systemic mastocytosis patients without eosinophilia presenting strokes associated with cervical artery dissection.

CONCLUSION

These observations are the first reported and they suggest that systemic mastocytosis could be add to the predisposing factors of spontaneous cervical artery dissections.

Antithrombotic therapy for cervical artery dissection

Antithrombotic therapy in patients with cervical artery dissection (CAD) is empiric rather than evidence based. The routine use of anticoagulants in each CAD patient cannot be recommended. A randomized controlled trial comparing antiplatelets with anticoagulation is clearly needed. However, due to the large sample size, which is required to gather meaningful results, such a trial is a huge venture. Thus, the matter of antithrombotic treatment in CAD is not expected to be solved in the near future. What should clinicians do in the meantime? There are several pathophysiological arguments in favor as well as against anticoagulants or antiplatelets. Until more data are available, it is our personal recommendation that treatment decisions should be geared to several clinical and paraclinical features of individual patients. The chapter compiles putative arguments in favor versus against immediate anticoagulation and may be helpful for individually tailored antithrombotic treatment decisions in CAD patients.

Cervical Artery Dissection: A 5-Year Prospective Study in the Belluno District

BACKGROUND

Artery dissection is an unusual cause of ischemic stroke, particularly frequent among young patients. The aim of this study was to collect epidemiological data on artery dissection in a hospital-based community, set up a diagnostic protocol and discover outcome predictors.

METHODS

Among patients suffering from cerebral infarction resident in our country, those with clinical and radiological features suggestive of artery dissection were selected. Risk factors, investigative techniques and treatment were evaluated. Patients were subjected to clinical examinations and were regularly tested neuradiologically.

RESULTS

Out of 895 ischemic stroke patients, 10 patients with cervical artery dissection (1.1%) were found. Seven patients were treated with anticoagulants and 3 received antiplatelet agents. One posttraumatic artery dissection patient died within a few days of the stroke. None of the patients suffered from a recurrence, while serious disability occurred in 4 of them.

CONCLUSIONS

Artery dissection should be suspected in any cerebral infarction patient, especially in young patients without risk factors for cerebrovascular diseases. The treatment of choice consists of anticoagulants. An early clinical diagnosis, strongly supported by radiological tests, is mandatory to start the proper treatment and achieve the best possible outcome.

[Intracranial extension of extracranial vertebral artery dissections. A review of 16 cases]

INTRODUCTION

Vertebral artery (VA) dissections can involve both the extracranial and intracranial portions of the VA. Intradural extension explains the occurrence of subarachnoid hemorrage (SAH). We have studied the rate of this extension, the risk of associated SAH and the therapeutic repercussions at the acute stage.

METHODS

From 1985 to 2001, 42 patients with a recent extracranial VA dissection were admitted to our department of neurology. When the diagnosis of extracranial VA dissection (involving the first, second or third segment of the VA) was established, we looked for an ipsilateral intracranial extension (involving the fourth segment of the VA and/or the basilar artery). VA dissections strictly located at the intracranial level were excluded.

RESULTS

Among 42 patients with angiographically diagnosed extracranial VA dissections, 16 patients (38 percent) had an ipsilateral intradural extension. Two of them developed an inaugural and spontaneous SAH. After a mean follow-up of 4 Months under antithrombotic treatment, none of the patients has developed SAH or recurrent SAH.

CONCLUSIONS

Because of the potential risk for spontaneous SAH at the acute stage, it seems important to exclude an intracranial extension. Lumbar puncture should be undertaken to exclude SAH before consideration of antithrombotic therapy.

Traumatische Vertebralisdissektion bei einem 8-J�hrigen

Dissections of extracranial brain supplying arteries are a common cause of ischemic strokes in young patients. Accidents are often accountable for that. We report the case of an 8 year old boy with traumatic vertebral dissection after he was bumped while playing football. He developed an ischemia on both sides of the thalamus which was caused by a bilateral system of the vertebral artery. He showed motor eye and progressive neuropsychological deficits. The CT and MRI scan confirmed the diagnosis. The symptoms ameliorated under anticoagulation treatment with intravenous heparin. At the end of the hospital stay, neuropsychological deficits persisted. Doppler ultrasound showed recanalization of the vertebral artery. Further treatment consisted of anticoagulation with marcumar for 6 months.

[Locked-in syndrome due to a vertebral dissection and therapeutic options with intraarterial fibrinolysis in acute phase]

INTRODUCTION

Dissection of vertebral artery is an unusual pathology but sometimes is the cause of stroke in young patients. Since last years, and with the rise of some chiropractic technics, some authors have related these ones with the dissection of vertebral artery.

CASE REPORT

We show a case of a 37 years old woman that after a chiropractic session began symptoms of posterior circulation dysfunction as decrease level of sense, tetraparesis and alteration of cranial nerves. The arteriography confirmed the existence of a vertebral dissection of V2 portion and thrombosis of basilar and contralateral vertebral arteries. Intraarterial fibrinolysis was performed with complete recanalization of the artery. Although this, the patient had parenchimal lesions in pons, cerebellum and territory of posterior cerebral artery that produced a locked-in syndrome. All the complementary exams were normal.

DISCUSSION

We discuss the relationship between cervical manipulation as an aetiology of vertebral dissection, locked-in syndrome and therapeutic options in these patients

[Bilateral vertebral artery dissection and its chronological changes detected by MR angiography: a case report]

A case of intracranial bilateral vertebral artery (VA) dissection presenting with ischemic symptoms which following unilateral dissection is presented. A 42-year-old male with an occipital headache was pointed out right vertebral artery stenosis with magnetic resonance (MR) angiography 8 day before admission. He admitted to our hospital complaining of severe vertigo and tinnitus. MR images and cerebral angiograms revealed bilateral VA dissection with infarcts in light lower surface of cerebellum perfused by posterior inferior cerebellar artery and right hypothalamus. Conservative therapy was adopted and serial MR angiography was performed. His symptoms were improved gradually and MR angiograms obtained 2 months later revealed improvement of bilateral VA stenosis. It is generally accepted that VA dissection presenting ischemic symptoms has good outcome by conservative therapy only. However, its pathological process of progression is still unknown. Based on the serial MR findings, we discuss the mechanisms of bilateral VA dissection. In this case, we consider that unilateral VA dissection extended to contralateral vertebral artery through the vertebrobasilar junction. Frequent MR angiography in acute phase could be of great use for monitoring the progression of dissection.

Recanalization of Cervical Artery Dissection: Influencing Factors and Role in Neurological Outcome

BACKGROUND AND PURPOSE

Generally, the prognosis for cervical artery dissection (CAD) is uncertain. The recanalization rate of CAD can be up to 85% within 3 months. This study evaluates the variables that might affect recanalization and the role of recanalization as a predictor for neurological outcome.

PATIENTS AND RESULTS

This study prospectively included 38 patients with acute stroke following occlusion due to CAD (18 males, 20 females, median age 50.5 years, range 16-82). Vertebral and carotid dissections were equally distributed (19 carotid dissections). The recanalization rate was influenced by the presence of hypertension (p = 0.001). Outcomes were dependent on infarct location. Patients with lateral medullary infarction returned to functional independence (p = 0.026), while patients with deep hemispheric infarction tended to have a disabling stroke (p = 0.068). The presence of good collaterals seemed to influence functional independence (p = 0.03).

CONCLUSION

There seemed to be no relationship between outcome and the rate of recanalization following CAD. Recanalization appeared to be a spontaneous mechanism, which could have depended on the intrinsic condition of the vessels. Finally, neurological outcome was dependent on lesion localization and the presence of good collaterals.