Spontaneous Arterial Dissection

Unraveling the Links between Chronic Inflammation, Autoimmunity, and Spontaneous Cervicocranial Arterial Dissection

Advances in imaging techniques have led to a rise in the diagnosis of spontaneous cervicocranial arterial dissection (SCCAD), which is now considered a common cause of stroke in young adults. However, our understanding of the pathophysiological mechanisms underlying SCCAD remains limited. Prior studies have proposed various factors contributing to arterial wall weakness or stress as potential causes for SCCAD. A combination of biopsies, case reports, and case-control studies suggests that inflammatory changes and autoimmunity may play roles in the cascade of events leading to SCCAD. In this review, we examine the close relationship between SCCAD, chronic inflammation, and autoimmune diseases, aiming to explore potential underlying pathophysiological mechanisms connecting these conditions. While some relevant hypotheses and studies exist, direct evidence on this topic is still relatively scarce. Further investigation of the underlying mechanisms in larger clinical cohorts is needed, and the exploration of animal models may provide novel insights.

Diagnosis and treatment of cervical artery dissection

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.

A case of carotid artery dissection after surgical repair of aortic dissection successfully treated with endovascular therapy using intravascular ultrasound

A 71-year-old woman developed the dissection from right brachiocephalic trunk (BCT) to internal carotid artery 6 days after the operation of ascending aortic dissection. Since no improvement of symptoms was observed despite conservative therapy, we performed endovascular therapy (EVT). Although a balloon-expandable stent was implanted in the BCT to seal the entry point of the dissection, the true lumen of the carotid artery was still compressed. Thus, we covered the dissected lesion completely with multiple stents, and her neurological findings improved. This case demonstrates that EVT using multiple stents is an effective strategy to manage dissection of supra-aortic branches.

Carotid artery dissection: endovascular treatment. Report of 12 patients

OBJECTIVE

The purpose of this article is to report our experience with endovascular treatment of internal carotid artery (ICA) dissection with the use of stents.

BACKGROUND

Carotid dissection is an important cause of ischemic stroke in young and middle-aged patients. There are some patients in whom invasive management is recommended.

METHODS

Twelve patients (eight females, four males), mean age of 50 years (range 35-80 years) with ICA dissection, were treated with the endovascular approach during a 24-month period. Patients included in this study underwent magnetic resonance (MR) and digital subtraction angiography (DSA) for diagnosis. Over this time period, 162 patients with ICA dissections were seen at our institution. Indications for endovascular treatment were: recurrent ischemic events despite adequate anticoagulant treatment in seven cases, contraindication to anticoagulation in four cases, and one case with significant mismatch between diffusion and perfusion weighted MR. Eleven dissections were spontaneous and one was traumatic. The follow-up was performed clinically with Doppler ultrasound (US) and MR at 6, 12, and 24 months.

RESULTS

Stent deployment was successful in all cases. Acute symptoms were resolved in 66.7% of patients. No patients deteriorated their neurological status. There were no new clinical events, stent stenosis or occlusion on 24 months follow-up.

CONCLUSION

Our results showed an excellent clinical outcome of the treated patients. This suggests promising results with the use of endovascular treatment in selected patients.

Symptomatic spontaneous intracranial carotid artery dissection treated with a self-expanding intracranial nitinol stent: a case report

BACKGROUND

Although extracranial carotid dissection with stroke is common, intracranial dissection with stroke is rare. Stenting has been used to treat extracranial carotid dissections. Intracranially, however, it is only recently that stents have become a feasible option for this disease. We present a case of a spontaneous intracranial CAD with progressive symptoms despite medical management treated with a self-expanding intracranial micronitinol stent.

CASE DESCRIPTION

A 47-year-old, right-handed woman presented to the emergency department after noticing left-sided face and arm weakness and numbness, along with slurred speech. The patient was started on aspirin 325 mg/d orally and lovenox 40 mg/d subcutaneously. On hospital day 2, the patient was noted to have repeated episodes of weakness and numbness on the left side and MRI evidence of a new stroke. A diagnostic cerebral angiogram from a selective right internal carotid injection revealed a flow-limiting stenosis secondary to a dissection of the supraclinoid internal carotid artery with severe flow limitation to the hemisphere. Endovascular management was decided on, and a Neuroform stent measuring 4.5 x 20 mm (Boston Scientific Corporation, Natick, Mass) was deployed across the dissection with significant improvement of flow to that hemisphere on the poststent angiogram.

CONCLUSIONS

This case illustrates the successful off-label use of a self-expanding intracranial nitinol stent to treat a symptomatic intracranial internal CAD in the setting of failure of traditional medical management. This is a promising application of novel endovascular technology.

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.

Magnetic Resonance Imaging of Suspected Cervicocranial Arterial Dissections

The authors propose that the optimal screening protocol for evaluation of suspected cervicocranial arterial dissections is magnetic resonance imaging (MRI) that includes three components: 1) contrast-enhanced three-dimensional time-of-flight magnetic resonance angiography (MRA) through the superior mediastinum, neck, and skull base; 2) three-dimensional multiple overlapping thin-section acquisition MRA of the skull base and Circle of Willis region; and 3) axial non-contrast, non-fat-suppressed T1-weighted, fat-suppressed T1-weighted, and T2-weighted spin-echo MRI from the level of the aortic arch through the level of the circle of Willis. MRA permits visualization of vascular luminal narrowing or obliteration, which can suggest vascular dissection but can also be caused by congenital variation, dysplasia, intraluminal thrombus, vasospasm, or extramural compression by tumor. By directly visualizing the blood vessel wall, axial T1-weighted and T2-weighted spin-echo MRI can identify the intramural hemorrhage of vascular dissection. This protocol is designed to maximize the sensitivity of a noninvasive technique and may eliminate the need for conventional endovascular angiography.

Recurrent aortic dissection in Marfan's syndrome: possible effects of anticoagulation

Recent reports support the role of a valve-sparing procedure in ascending aortic dissection in patients with Marfans syndrome. A 49-year-old woman with Marfans syndrome and prior aortic aneurysm repaired with a composite graft presented with sudden-onset chest pain. Following an initial negative computed tomographic (CT) scan, a long dissection involving the descending thoracic and abdominal aorta was discovered on a repeat CT scan a few hours later. Symptoms improved gradually with optimal medical management and the patient was discharged home on anticoagulant therapy. Although no direct cause-and-effect relationship can be established, chronic anticoagulant therapy may accelerate the progression of recurrent dissection in these patients. A valve-sparing procedure should be considered in eligible patients with Marfans syndrome who need operative correction to avoid possible future untoward effects of long-term anticoagulant therapy.