Recurrent spontaneous cervical-artery dissection

Athletic participation after acute ischemic childhood stroke: a survey of pediatric stroke experts

Minimal evidence exists about the risk of recurrent childhood acute ischemic stroke in patients subjected to a subsequent head or neck injury. Recurrent or multiple dissections have been demonstrated in select cases. Minor head trauma has also been associated with acute ischemic stroke. The objective of this study was to survey pediatric stroke experts about participation of patients following acute ischemic stroke in high impact, medium impact, and low impact exercise. International Pediatric Stroke Study members were surveyed about athletic participation after stroke. Participants were asked about 2 scenarios: acute ischemic stroke with dissection, and acute ischemic stroke with a negative coagulation work-up and a negative angiogram. In these scenarios, most experts would eventually allow moderate impact sports, with some restrictions. Many experts would not allow high impact sports after a dissection, but disagree about recommendations after idiopathic acute ischemic stroke.

[Clinical treatment and therapy for dissected cervicocerebral artery]

Dissection of a cervicocerebral artery (CAD) is the second leading cause of stroke at younger ages. The pathogenesis of spontaneous CAD is not fully clarified. Defective connective tissue components may cause an arteriopathy predisposing to CAD in combination with certain trigger and risk factors. The clinical spectrum includes local pain in the neck, headaches, Horner's syndrome, isolated cranial nerve deficits, and hemispheric or brainstem infarction. Noninvasively, CAD is confirmed by Duplex sonography, MRI, and MRA. There is no controlled study for best treatment or management. Rational initial empiric treatment in acute CAD to prevent secondary embolism is partial thromboplastin time-guided anticoagulation by intravenous heparin followed by anticoagulation with warfarin. Carotid surgery for treating CAD is not recommended. The duration of anticoagulation is best guided by Doppler sonography follow-up and should extend until normalization of blood flow or at least 6 months after the vessel was occluded. Caution should be recommended for exercises that involve excessive head movements. The recurrence rate for CAD is low at <1%/year except for patients with known hereditary connective tissue disorders or in cases with familial dissections.

High-resolution magnetic resonance imaging (MRI) at 3.0 Tesla in the short-term follow-up of patients with proven cervical artery dissection

PURPOSE

For the imaging evaluation of patients with suspected cervical artery dissection (CAD) in the last decade, magnetic resonance imaging (MRI) has become the first line imaging modality. However, CAD is a highly dynamic process with rapid changes over time. Aim of this study was to assess the short-term morphologic changes in patients with proven CAD by MRI within 2 weeks after the initial diagnosis using a multicontrast high-resolution noninvasive vessel wall imaging approach at 3.0 T.

MATERIALS AND METHODS

Eighty-two patients with clinically suspected CAD were examined using a 3.0 T system (Gyroscan Intera, Philips). Imaging protocol consisted of 3-dimensional inflow MRA (repetition time [TR]/echo time [TE]/flip angle [FA] = 25 milliseconds/3.1 milliseconds/16 degrees, reconstructed voxel size 0.3 x 0.3 x 0.8 mm), black blood T1w 3-dimensional spoiled gradient echo (TR/TE/FA = 31 milliseconds/7.7 milliseconds/15 degrees, 0.3 x 0.3 x 1.0 mm), and fat suppressed T2w turbo spin echo (TSE) (TR/TE/echo train length = 3 heart beats/44 milliseconds/7, 0.3 x 0.3 x 2 mm). Three observers in consensus performed image analysis. Images were assessed with regard to presence and size of intramural hematoma, degree of stenosis, presence of intraluminal thrombus, development of pseudoaneurysm, and incidence of additional dissections. In 29 patients (35%) a dissection had initially been proven by direct visualization of an intramural hematoma. Twenty-one patients (72%; 7 male, 14 female; mean age 41.5 years) were available for follow-up studies leading to a total of 24 diseased cervical arteries being reevaluated 2 weeks later for prospective follow-up.

RESULTS

Mean interval between initial study and follow-up was 14.2 days (range 7-30 days). Eighteen patients had presented with an acute CAD in 1 artery, 3 patients with an acute CAD in 2 arteries. At follow-up, degree of stenosis had increased in 2 arteries, remained unchanged in 13, and decreased in 5 arteries. Four initially occluded arteries were recanalized at follow-up. In 3 arteries a pseudoaneurysm had been visible in the initial study and remained unchanged at follow-up; in 1 artery a new pseudoaneurysm was observed. In 3 arteries, new dissections were identified during follow-up.

CONCLUSION

High-resolution MRI of acute CAD at 3.0 T permits a refined cross-sectional and longitudinal analysis of the morphologic features of CAD. The increased signal-to-noise ratio at 3.0 T allows for a high spatial resolution permitting detailed analysis of the diseased vessel segment. An unequivocal distinction between intramural hematoma and thrombus was possible. Information could be gained with regard to recanalization, degree of stenosis, formation of pseudoaneurysm, and appearance of new dissections making short-term follow-up in pts with acute CAD recommendable. Further studies are needed to assess the relationship between short-term results and definite outcome.

Prognosis and Safety of Anticoagulation in Intracranial Artery Dissections in Adults

Background and Purpose— To characterize different forms of intracranial artery dissections (IADs), and to test the assumption that IADs are frequently associated with subarachnoid hemorrhage (SAH) and poor outcome, and that anticoagulant therapy is contraindicated in these patients.

Methods— We studied 81 consecutive non-SAH IAD patients and 22 IAD patients with SAH, diagnosed between 1994 and 2004 and 1998 and 2004, respectively, and treated the former patients immediately with heparin, followed with at least 3 months of warfarin. Outcomes were recorded at 3 months.

Results— Approximately one-third of all cervicocephalic artery dissections were identifiably either completely located intracranially or extended into the intracranial space. At 3 months, 64 of the 81 non-SAH patients (79%) had a favorable outcome (modified Rankin Scale, 0 to 2); 1 patient died of brain infarction in the acute stage. Only 1 aneurysm developed during follow-up in the non-SAH group, and no intracranial bleeding was observed during anticoagulant treatment. Those presenting with SAH formed ≈25% of all IADs, and 21 cases out of 22 (95%) were associated with ruptured fusiform dissecting aneurysm. This latter group displayed significantly worse outcomes: 7 died, and only 7 had modified Rankin Scale 0 to 2 at 3 months.

Conclusions— Our results provide important information for clinical practice. IADs appear to polarize into 2 groups: (1) nonaneurysmatic IADs presenting without SAH that are associated with favorable outcomes and safe anticoagulant therapy; and (2) aneurysmatic IADs, characterized by SAH and poorer prognosis. Literature on IADs may have been biased toward group 2.

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.

Diffusion-weighted imaging of intramural hematoma in vertebral artery dissection

BACKGROUND AND PURPOSE

Dissections of the carotid and vertebral arteries can be detected by several imaging modalities, but there is yet no consensus on the most efficient and effective choice.

METHODS

We performed diffusion-weighted imaging (DWI) in four patients with vertebral artery dissection documented with T2- and T1-weighted axial magnetic resonance imaging (MRI), and conventional angiography. Intervals from the onset of headache to evaluation ranged from one day to two weeks.

RESULTS

All the patients showed high signal intensity within the affected vertebral artery on DWI.

CONCLUSION

The movements of water molecules are more or less restricted within the clots according to the stage of thrombus formation in arterial dissection. Our study may provide another potential imaging method in the difficult task of proving arterial dissection.

Spontaneous and Endothelial-Independent Vasodilation Are Impaired in Patients With Spontaneous Carotid Dissection

Background and Purpose— We undertook this case-control study in patients with unilateral spontaneous dissection of the cervical internal carotid artery to investigate spontaneous and endothelium-independent dilation of the nondissected, contralateral carotid arteries and the ipsilateral brachial artery using high-resolution ultrasound.

Methods— Spontaneous and endothelial-independent (nitroglycerin-mediated) absolute and relative dilation were assessed in the internal and common carotid and brachial arteries of 27 patients with unilateral spontaneous dissection of the cervical internal carotid artery and 27 age- and sex-matched healthy controls.

Results— Absolute and relative spontaneous and endothelial-independent dilation of the carotid, but not brachial arteries, were significantly lower in patients as compared with controls.

Conclusions— Vasodilation abnormalities may be a predisposing factor for spontaneous dissection of the cervical internal carotid artery.

Dissection of the temporal artery in a patient with giant cell arteritis

A 74-year-old woman presented to her rheumatologist with classic symptoms of giant cell arteritis. The temporal arteries were strikingly swollen, warm, and erythematous. On biopsy of the right temporal artery, a focal dissection was found associated with a pan-arteritis and giant cells. Isolated temporal artery dissection in giant cell arteritis has not been reported previously. We propose that the unusually intense vascular inflammation may have weakened the vessel wall, so that the dissection occurred during the routine physical exam or biopsy. We believe this case illustrates that physicians should take special care in the examination of floridly inflamed vessels, because vigorous palpation might lead to dissection. In the case of patients with giant cell arteritis, dissection may result in an increased risk of ischemic complications, such as scalp necrosis.

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.

Trauma-induced extracranial internal carotid artery dissection leading to multiple infarcts in a young girl

Carotid artery dissections (CADs) represent an uncommon clinical condition that should be considered in the differential diagnosis of young individuals presenting with symptoms of stroke. The basic pathological changes in CAD include a disruption in the media or intima of arterial wall, through which the affected vasculature is predisposed to aneurysm or stenosis, and subsequent stroke. Carotid artery dissection may occur spontaneously or result from trauma, an underlying arteriopathic condition, or predisposing risk factors. The heterogeneous clinical presentations of CAD represent significant diagnostic difficulties, which often lead to delays in diagnosis and treatment. Further complicating the clinical picture is the lack of consensus regarding effective treatment modalities. Because of the often-subtle findings present in CAD, the treating physician must have a high index of suspicion to accurately diagnose and manage the condition. We report extracranial internal CAD in a 17-year-old girl leading to multiple infarcts that was successfully managed with initial antiplatelet therapy and subsequent anticoagulation.

Pain as the only symptom of cervical artery dissection

BACKGROUND

Headache or neck pain is a frequent symptom of spontaneous cervical artery dissection (sCAD).

PATIENTS AND METHODS

Patients were drawn from an ongoing hospital-based registry of consecutive cases diagnosed with sCAD. Only patients with isolated pain were included in this series. Pain topography, dynamics, severity and quality, imaging findings and outcome were analysed.

RESULTS

20 of 245 (8%) patients with sCAD presented with pain as the only symptom (mean (SD) age 39 (8) years; 14 (70%) women). Of them, 12 had vertebral artery dissection, 3 had internal carotid dissection and 5 had multiple dissections. The median delay from symptom onset to diagnosis was 7 days (range 4 h to 29 days). 6 patients presented with headache, 2 with neck pain and 12 with both. Onset of headache was progressive in 6, acute in 8 and thunderclap-type in 4 patients; neck pain was progressive in 7 and acute in 7. Headache was throbbing in 13 and constrictive in 5 patients; neck pain was throbbing in 4 and constrictive in 10. Pain was unilateral in 11 and bilateral in 9. Pain was different from earlier episodes in all but one case. All patients were pain free at 3 months.

CONCLUSION

Pain may be the only symptom in sCAD, even when multiple arteries are dissected. Pain topography, dynamics, quality and intensity were heterogeneous. Data from this study lend support to recommendations favouring imaging studies of the cervical arteries in patients with new-onset unexplained headache or neck pain.

Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment

Extracranial arterial dissections are a recognised cause of stroke, particularly in young adults. Clinical diagnosis may be difficult, and the classical triad of symptoms is uncommon. Imaging plays a pivotal role in the diagnosis of extracranial arterial dissections, and this review provides a detailed discussion of the relative merits and limitations of currently available imaging modalities. Conventional arteriography has been the reference standard for demonstrating an intimal flap and double lumen, which are the hallmarks of a dissection, and for detecting complications such as stenosis, occlusion or pseudoaneurysm. Noninvasive vascular imaging methods, such as ultrasound (US), magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are increasingly replacing conventional angiography for the diagnosis of carotid and vertebral dissections. Ultrasound provides dynamic and "real-time" information regarding blood flow. Source data of MRA and CTA and additional cross-sectional images can provide direct visualisation of the mural haematoma and information about the vessel lumen. Anticoagulation to prevent strokes is the mainstay of medical treatment, but randomised trials to define the optimal treatment regime are lacking. Surgery has a limited role in management of dissections, but endovascular procedures are gaining importance for treatment of complications and if medical management fails.

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.

[Imaging techniques in diagnosis of brainstem infarction]

Twenty per cent of cerebral ischaemic infarctions involve tissue, supplied by the vertebrobasilar circulation. This overview of the current literature and our own experiences present the value of different imaging techniques (CT and MRI) and new developments for diagnosing brainstem infarction. Furthermore, the roles of invasive and noninvasive vascular imaging methods (computed tomographic angiography, magnetic resonance angiography, intra-arterial angiography, ultrasound) for evaluating vertebrobasilar stenosis and occlusion are described. The diagnostic workup of the most severe form of brainstem infarction, basilar artery thrombosis, is shown.

Segmental disruption of internal elastic lamina in spontaneous vertebral artery dissection combined with redundancy of multiple cervical arteries

A 49-year-old man developed a spontaneous vertebral artery dissection leading to cerebellar and brain stem infarction. Cerebral angiograph demonstrated redundancy, including kinks, loops and coils, in multiple cervicocephalic arteries, in addition to the dissecting artery. Histological examination of the superficial temporal artery revealed segmental disruptions of the internal elastic lamina and intimal abnormalities. These ultrastructural abnormalities may impair vessel wall integrity and predispose to nontraumatic arterial dissection and vascular tortuosity.

Pediatric stroke: the child is not merely a small adult

Arterial ischemic stroke and sinovenous thrombosis are a significant yet under-recognized causes of mortality and morbidity in the pediatric population. With increasingly complex etiologies yet urgency for rapid diagnosis and treatment, pediatric stroke teams likely will become the standard of care. A common terminology must be developed to avoid confusing types of acute cerebral insults--such as focal arterial ischemic stroke and global hypoxia and ischemia--that have different causes and pathophysiologic mechanisms of injury. Increased awareness of unique pediatric stroke subtypes, their clinical presentation, and their imaging findings will facilitate early identification and development of optimal treatment strategies.

Elevated inflammatory laboratory parameters in spontaneous cervical artery dissection as compared to traumatic dissection

Several studies have reported infection as a possible risk factor for cervical artery dissection (CAD). We retrospectively analyzed several inflammatory parameters of CAD patients with the aim of detecting differences between spontaneous (n = 25) and traumatic (n = 18) CAD. In this case-control study, we observed significantly higher absolute leucocyte values (10.3 versus 8.1 G/L; p = 0.02) as well as an elevated frequency of leucocytosis (64% versus 28%; p = 0.02) and elevated CRP (60% versus 28%; p = 0.04) in patients without a history of trauma ("spontaneous" CAD) compared with patients with trauma-related CAD. As the elevated inflammatory laboratory parameters were not associated with an elevated infection rate, these findings imply a role of an acute inflammation as a pathogenetic factor in spontaneous CAD. The cause and mechanism of the inflammatory process remain unknown.

Vertebral artery dissections after chiropractic neck manipulation in Germany over three years

Vertebral artery dissection (VAD) has been observed in association with chirotherapy of the neck. However, most publications describe only single case reports or a small number of cases. We analyzed data from neurological departments at university hospitals in Germany over a three year period of time of subjects with vertebral artery dissections associated with chiropractic neck manipulation. We conducted a country-wide survey at neurological departments of all medical schools to identify patients with VAD after chirotherapy followed by a standardized questionnaire for each patient. 36 patients (mean age 40 + 11 years) with VAD were identified in 13 neurological departments. Clinical symptoms consistent with VAD started in 55% of patients within 12 hours after neck manipulation. Diagnosis of VAD was established in most cases using digital subtraction angiography (DSA), magnetic resonance angiography (MRA) or duplex sonography. 90% of patients admitted to hospital showed focal neurological deficits and among these 11 % had a reduced level of consciousness. 50% of subjects were discharged after 20 +/- 14 hospital days with focal neurological deficits, 1 patient died and 1 was in a persistent vegetative state. Risk factors associated with artery dissections (e. g. fibromuscular dysplasia) were present in only 25% of subjects. In summary, we describe the clinical pattern of 36 patients with vertebral artery dissections and prior chiropractic neck manipulation.

Accuracy of Color Duplex Ultrasound Diagnosis of Spontaneous Carotid Dissection Causing Ischemia

Background and Purpose— Spontaneous dissection of the cervical internal carotid artery (sICAD) is mainly assessed with MRI and magnetic resonance angiography (MRA), which are not always at hand. In contrast, color duplex sonography (CDS) is readily available. We undertook this prospective study to examine the accuracy of CDS to diagnose sICAD in patients with first carotid territory ischemia.

Methods— Consecutive patients with first carotid territory stroke or transient ischemic attack or retinal ischemia underwent clinical and laboratory examinations, ECG, CDS of the cerebral arteries, cranial computed tomography in case of stroke or transient ischemic attack, and echocardiography and 24-hour ECG in selected cases. Patients were included, if they were <65 years of age, CDS showed a probable sICAD (cervical internal carotid artery stenosed or occluded), or had no determined etiology of ischemia. All of the included patients underwent cervical MRI and MRA±cerebral catheter angiography. The sonographer was blinded to the results of MRI and angiography studies.

Results— We included 177 of 1652 screened patients. Excluded patients (n=1475) were ≥65 years old (n=818), had another determined cause of ischemia (n=1475), and had intracranial hemorrhage (n=58). CDS diagnosed sICAD in 77 of 177 patients, and the etiology of ischemia was undetermined in the remaining 100 patients. Cervical MRI and angiography showed 74 sICAD; there were 6 falsely positive and 3 falsely negative CDS findings. Thus, sensitivity, specificity, and positive and negative predictive values for CDS diagnosis of patients with sICAD causing carotid territory ischemia was 96%, 94%, 92%, and 97%, respectively.

Conclusions— Color duplex ultrasound allows the reliable exclusion of sICAD in patients with carotid territory ischemia, whereas diagnosis of CDS of sICAD must be confirmed with cervical MRI and MRA.

[Long-lasting, refractory headache after bilateral dissection of the internal carotid artery]

Headache is usually the first and the most frequent symptom of cervicocephalic arterial dissection. Besides headache ipsilateral Horner's syndrome, cranial nerve palsies, or pulsatile tinnitus are observed. Serious complications of arterial dissection are ischemic strokes, which mostly occur later in the course of time. We report on a patient with spontaneous bilateral carotid artery dissection, who suffered from atypically prolonged, severe, and refractory headache. High-dose administration of nonsteroidal anti-inflammatory drugs as well as opioids were ineffective. Pain relief was only achieved after a 3-day course of corticosteroids (100 mg methylprednisolone/day).

Negative ultrasound findings in patients with cervical artery dissection

BACKGROUND

Cervical artery dissection (CAD) is a common cause of ischemic stroke in the younger age group. Modern imaging techniques allow the depiction of the mural hematoma, even in CADs with only subtle vessel alterations. The aim of this retrospective study was (1) to characterize the angiological features in CAD and (2) to determine the frequency of initially normal ultrasonography (US) findings.

METHODS

86 patients aged 44 +/- 11 years with CAD of the internal carotid (ICA), (n = 55) or the vertebral artery (VA), (n = 31), admitted to our hospital within 8 days (mean 1.6 days) of symptom onset, were included. CAD was confirmed either by CT-angiography, MRI of the neck, MR-angiography or digital substraction angiography (DSA) and was compared with the results of the initial as well as repeated US examinations of the arteries supplying the brain.

RESULTS

In 75 patients (81.2 %) signs of vessel stenosis or occlusion were found while 11 patients (12.8%) with CAD of the ICA (n = 9) and the VA (n = 2) had normal US findings. The site of dissection in the US negative patients was highly variable without a predilection site. In 2 of 7 patients with repeated US examinations, complete vessel occlusion was found on follow-up, while in 5 patients again normal results were found. In four patients, there were changing findings in two alternative confirming imaging methods (MRI/DSA, CT/MRI) and in one patient conflicting findings (CT/MRI). Brain infarctions had occurred in 7 of the initially sonographically normal patients while the other 4 had suffered from transient (n = 2) or local (n = 2) symptoms only.

CONCLUSION

Approximately 1 out of 8 patients with subsequently proven CAD has negative initial neurovascular US findings despite comprehensive examination. In patients with suspected CAD and negative US examination, repeated US examinations and further diagnostic imaging, especially MRI is necessary.

An Analysis of the Etiology of Cervical Artery Dissections: 1994 to 2003

OBJECTIVE

To provide a literature review of the etiologic breakdown of cervical artery dissections.

METHODS

A literature search of the MEDLINE database was conducted for English-language articles published from 1994 to 2003 using the search terms cervical artery dissection (CAD), vertebral artery dissection, and internal carotid artery dissection. Articles were selected for inclusion only if they incorporated a minimum of 5 case reports of CAD and contained sufficient information to ascertain a plausible etiology.

RESULTS

One thousand fourteen citations were identified; 20 met the selection criteria. There were 606 CAD cases reported in these studies; 321 (54%) were internal carotid artery dissection and 253 (46%) were vertebral artery dissection, not including cases with both. Three hundred seventy-one (61%) were classified as spontaneous, 178 (30%) were associated with trauma/trivial trauma, and 53 (9%) were associated with cervical spinal manipulation. If one apparently biased study is dropped from the data pool, the percentage of CADs related to cervical spinal manipulation drops to approximately 6%.

CONCLUSIONS

The case series that were reviewed in this article indicated that most CADs reported in the previous decade were spontaneous but that some were associated with trauma/trivial trauma, and a minority with cervical spine manipulation. This etiologic breakdown of CAD does not differ significantly from what has been portrayed by most other authors.

Non-Atherosclerotic Vascular Disease in the Young

There are a large variety of non-atherosclerotic causes of ischemic stroke in the young. Arterial dissection, most commonly associated with non-traumatic causes, is among the most common. Both the carotid and vertebrobasilar circulations can be affected. The vasculitidies represent a rare, but potentially treatable series of conditions that can lead to stroke through diverse mechanisms. Moyamoya is a nonatherosclerotic, noninflammatory, nonamyloid vasculopathy characterized by chronic progressive stenosis or occlusion of the distal internal carotid arteries and/or proximal portions of the middle and/or anterior cerebral arteries. Moyamoya can be idiopathic (moyamoya disease) or the result of other conditions. An appreciation of the unusual causes of stroke in the young is important when considering secondary prevention measures.

Carotid and vertebral artery dissection syndromes

Cervicocerebral arterial dissections (CAD) are an important cause of strokes in younger patients accounting for nearly 20% of strokes in patients under the age of 45 years. Extracranial internal carotid artery dissections comprise 70%-80% and extracranial vertebral dissections account for about 15% of all CAD. Aetiopathogenesis of CAD is incompletely understood, though trauma, respiratory infections, and underlying arteriopathy are considered important. A typical picture of local pain, headache, and ipsilateral Horner's syndrome followed after several hours by cerebral or retinal ischaemia is rare. Doppler ultrasound, MRI/MRA, and CT angiography are useful non-invasive diagnostic tests. The treatment of extracranial CAD is mainly medical using anticoagulants or antiplatelet agents although controlled studies to show their effectiveness are lacking. The prognosis of extracranial CAD is generally much better than that of the intracranial CAD. Recurrences are rare in CAD.

A systematic review of the risk factors for cervical artery dissection

BACKGROUND AND PURPOSE

Cervical artery dissection (CAD) is a recognized cause of ischemic stroke among young and middle-aged individuals. The pathogenesis of dissections is unknown, although numerous constitutional and environmental risk factors have been postulated. To better understand the quality and nature of the research on the pathogenesis of CAD, we performed a systematic review of its risk factors.

METHODS

PubMed [MEDLINE (1966 to February 22, 2005)] and Embase (1980 to February 22, 2005) were searched to identify studies fulfilling the inclusion criteria. Two reviewers independently assessed methodological quality of the primary studies. Relevant data were extracted, including the risk factor(s) investigated, characteristics of the study population, and strength of the association(s).

RESULTS

Thirty-one case-control studies were included for analysis. Selection bias, lack of control for confounding, and inadequate method of data analysis were the most common identified methodological shortcomings. Strong associations were reported from individual studies for the following risk factors: aortic root diameter >34 mm (odds ratio [OR=14.2; 95% confidence interval [CI], 3.2 to 63.6), migraine (ORadj, 3.6; 95% CI, 1.5 to 8.6), relative diameter change (>11.8%) during the cardiac cycle of the common carotid artery (ORadj, 10.0; 95% CI, 1.8 to 54.2), and trivial trauma (in the form of manipulative therapy of the neck) (ORadj, 3.8; 95% CI, 1.3 to 11). A weak association was found for homocysteine (2 studies: ORcrude, unknown; 95% CI, 1.05 to 1.52; ORcrude, 1.3; 95% CI, 1.0 to 1.7), and recent infection (ORadj, 1.60; 95% CI, 0.67 to 3.80). Two studies had conflicting findings for low levels of alpha1-antitrypsin, with the methodologically stronger study suggesting no association with CAD.

CONCLUSIONS

CAD is a multi-factorial disease. Many of the reviewed studies contained 2 or more major sources of bias commonly found in case-control studies. Only one study (of homocysteine) used healthy controls, a robust sample size, and had a low risk of biased results. The relationship between atherosclerosis and CAD has been insufficiently examined.

Isolated intracranial fibromuscular dysplasia presents as stroke in a 19-year-old female

Isolated intracranial fibromuscular dysplasia is rare and may present with cerebrovascular events. It should be considered as etiology of stroke in otherwise healthy young patients. Though diagnosis is often challenging, characteristic morphologies may be revealed on magnetic resonance and catheter angiography. Cephalocervical fibromuscular dysplasia typically involves the extracranial portion of the internal carotid artery (nearly 95%). This rare case demonstrates isolated intracranial fibromuscular dysplasia in a 19-year-old female with left caudate and genu of internal capsule stroke.

Protease Inhibitors in Spontaneous Cervical Artery Dissections

Background and Purpose— Observations in patients with arterial aneurysms, fibromuscular dysplasia, and spontaneous cervical artery dissection (sCAD) indicate that protease inhibitor deficiency might boost the enzymatic destruction of arterial tissue and increase the risk of these arterial wall diseases. Here we present the first large investigation of the protease inhibitor hypothesis in patients with sCAD.

Methods— Eighty patients with sCAD were compared with 80 age- and sex-matched healthy individuals. α 1 -antitrypsin (α 1 -AT) and α 2 -macroglobulin (α 2 -MG) levels, and α 1 -AT genotypes were assessed and compared between groups.

Results— α 1 -AT and α 2 -MG levels as well as α 1 -AT genotypes did not differ significantly between patients and controls. The frequency of Z alleles in the patient group was higher than in the control group and than in other cohorts from Europe; however, the difference remained nonsignificant. All patients with Z alleles had internal carotid artery dissections.

Conclusions— Overall, this data does not support the hypothesis that protease inhibitor levels or α 1 -AT genotypes play an important role in the etiology of sCAD. The present data does not exclude that the Pi-Z allele might have an influence on subgroups of sCAD, such as internal carotid artery dissections.

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.

Spontaneous multiple cervical artery dissection: two case reports and a review of the literature

Although spontaneous cervical artery dissection (CAD) is an uncommon cause of stroke in the general population, it accounts for 10-25% of cerebrovascular events in young to middle-aged patients. Two or more vessels are involved in fewer than 15% of dissections, but multiple spontaneous CADs are likely to be underestimated owing to frequent spontaneous recanalization and the possible oligo-symptomatic presentation. An extensive review of the literature shows that in the last 30 years only 28 cases of multiple CADs have been reported, and that in half of these patients symptoms were minor and transient. We describe two cases of multiple spontaneous CADs presenting as transient ischemic attack (TIA), in which only a specific diagnostic flow-chart allowed us to recognize multiple vessel involvement and start the appropriate therapy.

Current Diagnosis and Management of Blunt Internal Carotid Artery Injury

BACKGROUND

Blunt carotid artery injury (BCI) is a rare but potentially devastating injury. When undiagnosed it can result in severe disability or death.

METHODS

A Medline-based literature search was performed using key words 'blunt carotid injury' and cross-referenced with further original papers obtained from the references from this search.

RESULTS AND CONCLUSIONS

The incidence of BCI is very low. However, given the serious consequences of a missed injury, recent efforts have focussed on targeted screening for this injury in trauma patients. Conventional angiography remains the investigation of choice but may be superceded in the future by non-invasive methods such as magnetic resonance angiography or CT angiography. Operative intervention is rarely required and anti-coagulation remains the treatment of choice where dissection or pseudoaneurysm is diagnosed. The role of anti-platelet therapy is currently being investigated. Endovascular management using stents has been described but medium to long term results are not yet available.

Dissecção espontânea cervical carotídea e verbal: estudo de 48 pacientes

OBJETIVO: Dada a ausência de estudos de séries brasileiras de pacientes com dissecção arterial cervical espontânea, com o objetivo de descrever os fatores de risco, sintomas precedentes, manifestações clínicas, resultados da investigação, tratamento e evolução. MÉTODO: realizamos a análise retrospectiva dos prontuários e laudos radiológicos [angiografia digital(AD), ressonância magnética(RM) e ângio-ressonância(ARM)] dos pacientes com esse diagnóstico atendidos no Serviço de Neurologia do HC/USP entre 1997 e 2003. RESULTADOS: 48 pacientes (24 homens), média de idade 37,9 anos; 26 pacientes com dissecção carotídea (DC) unilateral, 15 com vertebral (DV) unilateral e 7 com multiarterial, todos com déficits neurológicos. Os principais fatores de risco para doença vascular foram hipertensão arterial, tabagismo e dislipidemia. Mais de 80% apresentaram pelo menos um sintoma precedente, na maioria cefaléia têmporo-parietal. Cervicalgia foi referida por 44% dos pacientes com DV e por 3,4% dos com DC. O tempo médio entre o primeiro sintoma e o déficit foi 5,4 dias para as DC e 13,5 para as DV. AD foi o principal método diagnóstico (93%), associado a RM e ARM em 42% dos casos. Em 3 pacientes a RM cervical com supressão de gordura foi isoladamente suficiente. 75% dos pacientes receberam anticoagulação. Dois pacientes fizeram trombólise endovenosa sem complicações. A evolução foi boa, exceto por dois óbitos (DC bilateral). CONCLUSÃO: Os resultados são semelhantes aos da literatura, exceto pela baixa freqüência de cervicalgia nos casos de DC e pelo predomínio de cefaléia têmporo-parietal nas dissecções arteriais cervicais. Fatores de risco para doença vascular isquêmica foram frequentes.

Headaches due to vascular disorders

The association between stroke and headache is complex, ranging from highly nonspecific, wherein headache is largely irrelevant to diagnosis and therapeutic management, to highly specific and even causative. In short, acute headache may accompany the acute stroke process, chronically complicate stroke, or, in rare instances, serve as the primary cause of stroke. With the first instance, the incidence of acute headache is highly dependent on the stroke sub-type and etiology. In this article, the headaches accompanying or causing acute stroke are addressed in some detail.

Emergent Stenting to Treat Patients With Carotid Artery Dissection

Background and Purpose— Carotid artery dissection (CAD) is a common cause of stroke in young patients. Clots formed at the low-flow zone in the false arterial lumen may give rise to distal emboli, and the mural hematoma may eventually occlude the artery. Anticoagulation is currently the accepted treatment, but it is unknown which patients will improve spontaneously, which will respond to anticoagulation, and which will have an exacerbation of ischemic symptoms despite therapy. Endovascular treatment of CAD may be an attractive alternative to anticoagulation, and methods of identifying patients who stand to benefit from such therapy need to be established.

Methods— We present here 3 cases of spontaneous symptomatic CAD in which endovascular stenting procedures were performed on the basis of a paradigm aimed at identifying potentially salvageable but at-risk brain tissue by combining clinical with MRI (diffusion and perfusion) and angiographic data.

Results— Diffusion-perfusion MRI mismatches and/or evidence of cerebral ischemia on angiographic parenchymography were identified in all patients. They did not respond to anticoagulation, were therefore treated with endovascular stents, and had excellent outcomes.

Conclusions— Endovascular stent placement may be an immediate, effective, and safe method of restoring vessel lumen integrity. It may be considered for selected patients who are clinically symptomatic despite anticoagulant treatment and in whom neuroimaging methods suggest that the neurological signs originate from a viable, hypoperfused, ischemic penumbra.

A pain in the neck: dissection of the vertebral artery

A49-year-old male model developed an acute severe occipital headache and neck stiffness following a day spent striking dynamic poses for a modelling assignment, during which he had been required to hold his head in several awkward positions for protracted periods of time. In the subsequent 24 hours he developed slurred speech, poor balance and a persistent pain in the neck. On presentation to hospital he was dysarthric and ataxic of gait, and had upper limb weakness, finger nose ataxia, an upper motor neurone facial nerve palsy and an extensor plantar response.

Magnetic resonance imaging of the brain showed a 2 cm × 1 cm infarction in the left pons extending to the midbrain (Figure 1).

The patient was commenced on aspirin and by 8 weeks his neurological symptoms had completely resolved.

Cervical Arterial Dissection

Background and Purpose— Cervical arterial dissection is a major cause of stroke in young adults, yet despite standard treatment with anticoagulants or antiplatelet drugs, its management remains uncertain. The goal of this study was to assess the natural history of the disorder and to decide on the feasibility of a therapeutic trial.

Methods— Collaborating members of the Canadian Stroke Consortium prospectively enrolled consecutively referred patients with angiographically proven acute vertebral or carotid arterial dissection. Data recorded included clinical and radiological details, recurrence of ischemic cerebral events, and medical or surgical treatment.

Results— Of 116 patients, 67 had vertebral and 49 had carotid dissections, with no difference in age or sex. In 68 (59%), trauma occurred at the time of dissection. During the course of a 1-year follow-up, at least 17 patients (15%) had recurrent transient ischemic attacks, stroke, or death, mainly in the weeks immediately after the dissection. In 105 patients with complete follow-up, the event rate in those treated with anticoagulants was 8.3% and in those treated with aspirin was 12.4%, a nonsignificant difference of 4.1%. Using these data, we calculate that for a 2-arm trial (aspirin versus anticoagulants) with 80% power and 5% significance, 913 patients are needed in each group.

Conclusions— From our data indicating an initial relatively high recurrence rate, a multicenter trial of anticoagulants versus aspirin involving a total of 2000 patients is feasible.

Risk of stroke and recurrent dissection after a cervical artery dissection: A multicenter study

OBJECTIVE

To assess the risk of stroke, TIA, or dissection recurrence after a first event of cervical artery dissection (CAD).

METHODS

The authors undertook a historical cohort study of consecutive patients with a first event of CAD who were admitted in 24 departments of neurology within a period of at least 1 year. Patients were retrospectively selected from a stroke data bank or from the local administrative data bank using the 10th revision of the International Statistical Classification of Diseases. A neurologist and a radiologist reviewed all charts to validate diagnosis and collect data. In 2002, patients were interviewed by phone or during a visit by the local investigators.

RESULTS

Four hundred fifty-nine patients (mean age 44.0 +/- 9.7 years) were included in the study. Among the 457 survivors, 25 (5.5%) could not be contacted in 2002 because they had moved. After a mean follow-up of 31 months, four (0.9%) patients presented a recurrent ischemic stroke attributable to either not yet completely recovered initial CAD (n = 2) or a recurrent CAD (n = 2). Eight (1.8%) patients had a TIA without CAD recurrence. Two TIA occurred at the acute stage of CAD. Of the six remaining TIA, only one was associated with chronic arterial stenosis. In addition, two patients had recurrent CAD without stroke, giving a total of four (0.9%) CAD recurrences.

CONCLUSIONS

Patients with a first event of CAD have a very low risk of ischemic events or dissection recurrences. Ischemic events seem rarely to be in relation with chronic arterial lesions.

[Ischemic strokes in young adults]

PURPOSE

The incidence of cerebral ischemia occurring between 15 and 45 years of age is of 60 to 200 new cases per year per million inhabitants. The causes of cerebral ischemia consist of complications of atherosclerosis, cardio embolism, small-vessel occlusion, other determined causes and unknown causes. The breakdown of the causes differ from that of elderly subjects with a prominence of "unknown causes" and "other determined causes".

KEY MESSAGE

The association of a patent foramen ovale and an interatrioseptal aneurysm is a marker of an increased risk of recurrence. Cervical-artery dissections are the leading cause of cerebral ischemia in young adults and are usually associated with a good outcome in patients who survive the acute stage. Depending on the exhaustivity of the diagnostic work-up, 30 to 50% of cases have no clear cause. Mortality rate and recurrence rates in cerebral ischemia occurring in young adults are low. A negative diagnostic work-up is associated with a low risk of recurrence. Epilepsy is frequent. The incidence of cerebral ischemia occurring during pregnancies is 4,3 for 100,000 deliveries. Specific causes are led by eclampsia, and reversible angiopathies of the post partum period.

FUTURE

If the outcome is good, the causes are multiple and research should focus on the identification of new causes and the natural history in many of them.

Cerebral blood flow and oxygen metabolism in symptomatic internal carotid artery occlusion by atherosclerosis and by cervical dissection

Symptomatic internal carotid artery occlusion by atherosclerosis and by cervical dissection are distinct conditions with different long-term prognoses. The purpose of the present study is to investigate if regional cerebral blood flow and oxygen metabolism, after onset of stroke, differ between both conditions. Seventeen patients with symptomatic unilateral atherosclerotic internal carotid occlusion and 10 patients with symptomatic internal carotid occlusion due to cervical dissection were submitted to a positron emission tomographic (PET) study between 1 and 2 months after stroke onset. The steady state technique with 15O was used in order to determine regional cerebral blood flow, regional oxygen extraction fraction, and regional cerebral metabolic rate for oxygen in the infarct area, the peri-infarct zone, the remaining homolateral hemisphere, and the contralateral hemisphere. The results were compared between both patient's populations. The patients with cervical dissection were on average much younger than those with atherosclerotic occlusion, but neurological impairment on admission and disability at 3 months were comparable. Between both patient populations, no differences in rCBF, rOEF, and rCMRO2 could be demonstrated in the different regions of interest when the results were age-adjusted. Except for age-related changes, no differences in PET findings could be demonstrated between patients with symptomatic internal carotid occlusion caused by either atherosclerosis or cervical dissection.

Association of internal carotid artery dissection and chiropractic manipulation

BACKGROUND

To determine the relationship between chiropractic manipulative therapy and internal carotid artery dissection, a MEDLINE literature search was performed for the years 1966 through 2000 using the terms internal carotid dissection. Literature that included information concerning causation of ICAD, as well as all case studies and series, was selected for review.

REVIEW SUMMARY

In reviewing the cases of internal carotid dissection potentially related to CMT, there were many confounding factors, such as connective tissue aberrations, underlying arteriopathy, or coexistent infection, that obscured any obvious cause-and-effect relationship. To date there are only 13 reported cases of ICAD temporally related to CMT. Most ICADs seem to occur spontaneously and progress from local symptoms of headache and neck pain to cortical ischemic signs. Approximately one third of the reported cases were manipulated by practitioners other than chiropractic physicians, and because of the differential risk related to major differences in training and practice between practitioners who manipulate the spine, it would be inappropriate to compare adverse outcomes between practitioner groups.

CONCLUSIONS

The medical literature does not support a clear causal relationship between CMT and ICAD. Reported cases are exceedingly scarce, and none support clear cause and effect.