Increased Internal Carotid Artery Tortuosity is a Risk Factor for Spontaneous Cervicocerebral Artery Dissection

Classification and management strategy of spontaneous carotid artery dissection

OBJECTIVE

Spontaneous carotid artery dissections (sCADs) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 patients with sCAD and proposed a new classification for sCAD with prognostic and therapeutic significance.

METHODS

This is a retrospective review of prospectively collected data from June 2018 to June 2023 of patients with sCAD treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types: type Ⅰ, intramural hematoma or dissection with <70% luminal narrowing; type Ⅱ, intramural hematoma or dissection with ≥70% luminal narrowing; type Ⅲ, dissecting aneurysm; type ⅣA, extracranial carotid artery occlusion; and type ⅣB, tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCADs.

RESULTS

A total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 patients with sCAD was 49.5 years, 78% were male, and 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 type Ⅰ (28.4%), 50 type Ⅱ (25.4%), 60 type Ⅲ (30.5%), and 31 type Ⅳ (15.7%) dissections. During a mean hospitalization length of 11.4 ± 47.0 days, there were nine recurrent strokes (4.6%) after medical treatment, two type Ⅲ dissections (1.0%), seven type Ⅳ dissections (3.6%), all ipsilateral, and one death. Overall, there were seven (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent strokes and three (1.5%, all type Ⅲ dissections) recurrent transient ischemic attacks in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (range, 3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment (EVT) or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine type I dissections (51.8%) were completely recanalized after antithrombotic therapy. A total of 19 type II dissections (38%) and 44 type III dissections (73%) received EVT for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight type IVB dissections (33%) received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all P > .05). Favorable outcome was achieved in 168 patients (93.9%).

CONCLUSIONS

This study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcomes should undergo further research.

Age and duration of hypertension are associated with carotid artery tortuosity

Objective

Tortuosity of the carotid artery is a common angiographic finding that may impact blood flow and neuronal function. However, information on its prevalence and risk factors remains limited. In this study, we determined to explore the factors affecting carotid artery tortuosity.

Methods

The head and neck computed tomography angiography (CTA) imaging and cerebral angiography data performed at the Second Affiliated Hospital of Wenzhou Medical University between January 2019 and September 2021 were collected, and a total of 356 cases were enrolled in the study after screening. Carotid artery tortuosity refers to the angle between the two adjacent segments of the carotid artery, from the opening of the aortic arch on either side to the external orifice of the carotid canal, being less than 150°. A retrospective analysis was performed to compare the general information, laboratory indicators, personal history, and medical history between the two groups. The χ2 test, t-test, and Mann-Whitney U-test were performed to compare the parameters between the two groups. If there were significant differences between the groups, multivariate logistic regression was performed to analyze the factors affecting carotid artery tortuosity.

Results

A total of 222 of the 356 cases were determined to have carotid artery tortuosity, accounting for 63.6%. There were statistically significant differences in age, body mass index (BMI), duration of diabetes and hypertension, levels of low-density lipoprotein cholesterol (LDL-C), diastolic blood pressure, history of ischemic and hemorrhagic stroke, and the usage of antihypertensive drugs between the two groups. Multivariate logistic regression analysis of the above factors showed that age (OR = 5.063, 95% CI 2.963-10.26, p < 0.001) and duration of hypertension (OR = 2.356, 95% CI 1.353-8.625, p = 0.021) were associated with a higher incidence of carotid artery tortuosity. Compared to patients who did not consume antihypertensive drugs, the incidence of carotid artery tortuosity was significantly less (OR = 0.094, 95% CI 0.002-0.713, p = 0.019) in those consuming antihypertensive drugs.

Conclusion

Carotid artery tortuosity is a relatively common carotid artery disease. The incidence of carotid artery tortuosity may increase with age and the duration of hypertension. The consumption of antihypertensive drugs may reduce the incidence of carotid artery tortuosity.

Initial and follow-up high-resolution vessel wall MRI study of spontaneous cervicocranial artery dissection

OBJECTIVES

To explore the factors associated with ischemic stroke secondary to spontaneous cervicocranial artery dissection (sCCAD) and evaluate the initial imaging markers related to outcomes.

METHODS

Initial and follow-up high-resolution vessel wall MRI (VW-MRI) in consecutive patients with sCCAD were retrospectively analyzed. The associations of clinical and imaging factors and variants of the circle of Willis (COW) with ischemic stroke were evaluated using binary logistic regression analyses. The anatomical outcomes were categorized as complete, partial, and no remodeling based on changes of the vessel wall and lumen. Ordinal logistic regression analysis was used to assess associations between initial features and outcomes.

RESULTS

A total of 115 dissected arteries (79 strokes, 36 non-strokes) were detected in 103 patients. Follow-up VW-MRI was available in 46 patients (44.7%, with 51 vessels), with a median interval of 8.5 months. Pseudoaneurysm (odd ratio [OR], 0.178; 95% confidence interval [CI], 0.039-0.810; p = 0.026) tended to rarely cause ischemic stroke, while intraluminal thrombus (OR, 5.558; 95% CI, 1.739-17.765; p = 0.004), incomplete COW (OR, 9.309; 95% CI, 2.122-40.840; p = 0.003), and partial complete COW (OR, 4.463; 95% CI, 1.211-16.453; p = 0.025) were independently associated with stroke occurrence. Furthermore, the presence of double lumen (OR, 5.749; 95% CI, 1.358-24.361; p = 0.018) and occlusion (OR, 12.975; 95% CI, 3.022-55.645; p = 0.001) were associated with no remodeling of sCCAD.

CONCLUSIONS

Multiple initial factors were found to be related to stroke occurrence and anatomical outcomes of sCCAD. High-resolution VW-MRI may provide valuable insights into the pathophysiology and evolution of sCCAD.

CLINICAL RELEVANCE STATEMENT

Initial and follow-up high-resolution vessel wall MRI may help elucidate the pathophysiology of spontaneous cervicocranial artery dissection and provide important insights into the evolution and further facilitate the optimal management of patients with spontaneous cervicocranial artery dissection.

KEY POINTS

• Clinical and imaging factors, as well as the status of primary collateral circulation, are associated with ischemic stroke secondary to spontaneous cervicocranial artery dissection. • The follow-up high-resolution vessel wall MRI provides valuable insights into the long-term evolution and anatomical outcomes of spontaneous cervicocranial artery dissection. • The high-resolution vessel wall MRI features related to ischemic stroke and anatomical outcomes may further facilitate the optimal management of patients with spontaneous cervicocranial artery dissection.

Carotid Artery Tortuosity and Internal Carotid Artery Plaque Composition

BACKGROUND

Little is known about the association between carotid artery tortuosity and internal carotid artery atherosclerosis. This study sought to evaluate the associations between various types of arterial tortuosity and vulnerable plaque components on magnetic resonance angiography (MRA).

MATERIAL AND METHODS

A retrospective review was completed of 102 patients who had undergone MRA neck imaging, with intraplaque hemorrhage (IPH) present in one or both cervical internal carotid arteries (ICA). Each ICA was assessed for two categories of tortuosity: variant arterial pathway(s) (retrojugular and/or retropharyngeal) and abnormal curvature (kinks, loops, and/or coils). All ICA plaques were assessed for the presence or absence of intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), ulceration, and enhancement, as well as the volume of IPH and degree of luminal stenosis.

RESULTS

The mean age of included patients was 73.5 years (SD = 9.0 years) and 88 (86.3%) subjects were male. The left carotid plaque was significantly more likely to have IPH (68.6% vs. 47.1%; p = 0.02). The left ICA was more likely to have a retrojugular course (22% vs. 9.9%; p = 0.002) and any variant arterial course (26.5% versus 14.67%, p = 0.01). On the right there was an association between the presence of a LRNC and retropharyngeal and/or retrojugular arterial pathway (p = 0.03). On the left there was an association between the presence of any abnormal arterial curvature and IPH volume (p = 0.03). Neither association met the adjusted statistical threshold after Bonferroni correction, with alpha set at 0.0028.

CONCLUSION

ICA tortuosity is not associated with carotid artery plaque composition, and likely does not play a role in the development of high-risk plaques.

Association between internal carotid artery kinking and ischemic stroke: A population-based cross-sectional study

AIM

Evidence for an association between Internal carotid artery (ICA) kinking and ischemic stroke has been controversial. We aimed to examine the association between ICA tortuosity and risk of ischemic stroke and specific ischemic stroke subtypes (large artery atherosclerosis, LAA; small artery occlusion, SAO).

METHODS

A total of 419 outpatients were included in this cross-sectional study. ICA kinking was objectively assessed by head and neck computed tomography angiography (CTA). The risk of ischemic stroke for each patient was evaluated according to the Essen Stroke Risk Score (ESRS). Ischemic stroke subtypes (LAA and SAO) were measure with head magnetic resonance imaging (MRI).

RESULTS

The average age of patients was 59.1 years (SD = 13.25) and 264 (63.0 %) were males. The prevalence of ICA kinking in this sample was 31.5 % (132 out of 419). Individuals with ICA kinking was associated with 0.55-points increase in ESRS score than those without ICA kinking (95 % CI, 0.28-0.81, p < 0.001) among patients over 50 years. In addition, right ICA kinking or left ICA kinking were associated with 0.35-points (95 % CI, 0.08-0.63) and 0.49-points (95 % CI, 0.23-0.76) increase in ESRS score, respectively. For specific ischemic stroke subtypes, individuals with ICA kinking had a 10.34-fold increased risk of SAO compared to those without ICA kinking (95 % CI, 6.22-20.68). Individuals with right ICA kinking had a 4.51-fold risk of SAO than those without kinking (95 % CI, 2.64-7.71), and had an 8.86-fold risk of SAO than those without kinking in the left ICA kinking (95 % CI, 4.97-15.79).

CONCLUSION

Our findings support the role of ICA kinking on ischemic stroke. Early screening and proper treatment of carotid artery tortuosity could be a potential intervention strategy for the prevention of ischemic stroke later on.

3D-printed tortuous vessels with Photodissociable and morphology-controllable ink

Acute ischemic stroke (AIS) is a high mortality cerebrovascular disease associated with vessel curvature. However, the relevant mechanism remains unclear due to a lack of appropriate tortuous vascular models to investigate and validate. This study explores the combination of projection-based 3D bioprinting (PBP) with photo-stimulus-responsive techniques to fabricate a sodium alginate (SA)/acrylamide (AAM) hydrogel vascular scaffold capable of bending deformation. The coordination of Fe³⁺ ions with carboxylate groups in the alginate chains of the vascular scaffold acts as a molecular switch, which can be dissociated through photoreduction to enable the deformation response. Fourier Transform Infrared (FTIR) and X-ray Photoelectron Spectroscopy (XPS) results verified the deformation principle. By subjecting the scaffold to UV light exposure, Fe³⁺ is reduced to Fe²⁺ in spatially selected regions, resulting in the release of strain and subsequent deformation. Furthermore, it also controlled the degree and direction of curvature of the vessels. The cell seeding experiment verified that the vascular scaffold showed excellent biocompatibility. Overall, our approach could be used to generate an in vitro model of curved vascular pathology to investigate the pathogenesis and provide new directions for the diagnosis and treatment of vascular diseases in the future.

Diagnostic potential of routine brain MRI and high-resolution, multi-contrast vessel wall imaging in the detection of internal carotid artery dissection

Objective

Cervical artery dissection (CAD) is one of the major causes of stroke and most commonly occurs at the site of the extracranial internal carotid artery (ICA). This study aimed to assess the value of routine brain MRI, clinical information, and high-resolution, multi-contrast vessel wall MR imaging (hrVWI) for the timely detection of ICA dissection.

Methods

A total of 105 patients with CAD and 105 without CAD were recruited for this study. The lesion type in the patients was determined based on images from different modalities, including brain MRI, magnetic resonance angiography (MRA), computed tomography angiography (CTA), digital subtraction angiography (DSA), ultrasonography, and hrVWI and clinical information. Each lesion was reviewed to determine the type following a stepwise procedure by referring to (1) brain MRI only; (2) brain MRI and clinical information; (3) hrVWI only; and (4) hrVWI, CTA, DSA, and clinical information.

Results

Typical clinical presentations of patients with potential CAD include headache, neck pain, and/or Horner's syndrome. Representative imaging signs in the brain MRI included a crescentic or circular iso- or hyperintensity around the lumen, a curvilinear and isointense line crossing the lumen, or aneurysmal vessel dilation. Based on brain MRI alone, 54.3% (57/105) of the patients with CAD were correctly classified, and the accuracy increased to 73.3% (77/105) when clinical information was combined (P < 0.001) with high specificity and low sensitivity. Further analysis showed that hrVWI had the superior capability in detecting CAD, with a sensitivity and a specificity of 95.1% and 97.0%, respectively.

Conclusion

The combination of brain MRI and clinical information could be used for the diagnosis of CAD; however, hrVWI should be sought for uncertain cases.

A Study of the Association Between Carotid Artery Curvature and Intracranial Aneurysms

BACKGROUND

Carotid artery curvature is considered a sign of a weak vessel wall, and we hypothesize that a weak vascular wall under the effect of hemodynamics may cause intracranial aneurysms.

MATERIALS AND METHODS

The general data of 534 patients with aneurysms and 473 control patients were retrospectively analyzed in a case-control study. Carotid artery curvature was characterized as none, tortuosity, kinking, and coiling by computed tomography angiography images. Univariate analysis was performed to determine the degree of carotid artery tortuosity and to analyze the general data between the aneurysm group and the control group, and then, multivariate statistical logistic regression analysis was used to analyze the statistical significance of the univariate analysis. Finally, the correlation between aneurysm-related features and carotid artery curvature was analyzed.

RESULTS

Univariate analysis showed that kinking was significantly related to the occurrence of intracranial aneurysms ( P =0.009). The results of multivariate regression analysis showed that kinking was an independent risk factor for the occurrence of aneurysms (odds ratio: 1.942; 95% confidence interval: 1.387-2.720 for model 1; odds ratio: 1.995; 95% confidence interval: 1.419-2.805 for model 2). In the analysis of the correlation between the characteristics of intracranial aneurysms and the curvature of the internal carotid artery, there was no correlation between the curvature of the internal carotid artery and the size, location or number of aneurysms, or whether the intracranial aneurysm was ruptured.

CONCLUSION

Intracranial aneurysms are associated with carotid artery curvature. Kinking of the internal carotid artery may indicate a higher risk for aneurysm formation.

Delayed Development of Aneurysmal Dilatations in Patients with Extracranial Carotid Artery Dissections

OBJECTIVE

Dissection of the carotid artery (CaAD) may result in aneurysm formation. The present study was undertaken to evaluate the time of onset of post-dissection extracranial carotid artery aneurysms (ECAA) following CaAD, and to analyse independent risk factors for the development of these aneurysms.

METHODS

From four European stroke centres, 360 patients with extracranial CaAD were included. The time between the estimated dissection onset and aneurysm formation was analysed, and the clinical risk factors increasing the probability of aneurysm were assessed.

RESULTS

The median duration of follow up was 5.2 months (range 0 - 24 months). A total of 75 post-dissection ECAAs were identified in 70 patients (19.4%, 95% confidence interval [CI] 15.7 - 23.8). In 52 of 70 (74%) patients, the ECAA was diagnosed at the initial clinical work up of CaAD diagnosis, with the median estimated time of dissection onset to ECAA diagnosis being six days (interquartile range [IQR] 0 - 25). In the remaining 18 (26%) patients who had normal carotid arteries at the initial imaging, the aneurysm diagnosis was made a median of 6.2 months (189 days) from the original imaging (IQR 128 - 198). A Cox proportional hazards model showed that both multiple artery dissections (hazard ratio [HR] 2.58, 95% CI 1.54 - 4.33) and arterial tortuosity (HR 1.79, 95% CI 1.08 - 2.95) were associated with presence of ipsilateral ECAA.

CONCLUSION

This post hoc cohort analysis showed substantially delayed development of ipsilateral ECAA in patients with CaAD, months after baseline. Multiple dissections and arterial tortuosity are associated with the presence of ECAA and can be used in future prediction models of ECAA development in patients with CaAD.

Carotid artery dissection in Hutchinson-Gilford Progeria: a case report

Background

Strokes in the paediatric age group have their own epidemiology and aetiology and are frequently misdiagnosed. As in the adult population, they present some risk factors that must be identified. Cerebral arteriopathies as a cause of paediatric ischaemic stroke present a very diverse aetiology and morphology.

In this article we report a paediatric stroke in a patient who was diagnosed during his first months of life of Hutchinson-Gilford´s Progeria (HGP). This is a rare genetic condition caused by mutations in the LMNA gene, producing an aberrant lamin A protein. The disease leads to premature aging, and cardiovascular complications are the first cause of morbidity and mortality in these patients.

Case presentation

We report the case of a 5-year-old patient with HGP (missense mutation—de novo—c.1822G > A in heterozygosis, LMNA gene). The patient was diagnosed during his first year of life and presented distinct phenotypical features. No other relevant comorbidities were present.

He was admitted to the emergency department for right hemiparesis with at least 4 h of evolution, with inability to open the hand and slight decrease in the level of consciousness (pedNIHSS 5–6). Cranial-CT and angio-CT showed findings indicative of left carotid dissection. Consensus was reached on conservative medical management with anticoagulation and antiplatelet therapy. In the first few days, the patient had a favourable evolution with resolution of the right lower limb hemiparesis and, one month after discharge, of the hand paresis.

Conclusions

The clinical manifestations, the vascular phenotype of the genetic mutation and the location of the radiological signs on a specific vascular morphology are indicative of carotid dissection. Spontaneous dissections occur under a predisposing risk factor or disease and are an exceptional finding in patients with HGP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03179-4.

Association between carotid artery dissection and vascular tortuosity: a case-control study

PURPOSE

We aimed to verify if vascular tortuosity (VT) may represent a risk factor for spontaneous epiaortic vessel dissection (sEVD) in young adult patients.

METHODS

We identified 304 patients aged under 55 years consecutively admitted for acute cerebrovascular events to our Stroke Unit. After checking the possibility to perform a 3D reconstruction of epiaortic vessels on CT-angiography images, we selected and compared fifty patients with sEVD (cases) with fifty-one patients without dissection (controls). VT of carotid and vertebral arteries was measured on reconstructions evaluating the vascular tortuosity index (VTI), calculated according to a specific algorithm, and the presence of kinking and coiling. Differences between groups were analyzed by Student-t test for numeric variables and chi-square test for categoric ones. A ROC curve analysis was used to look for a VTI threshold value beyond which the risk of dissection was significantly increased.

RESULTS

VTI was significantly higher in cases than in controls only considering carotid arteries (p = 0.029); cases did not have a significantly higher rate of kinking and coiling than controls (p = 0.059 and 0.077, respectively). We have found a significant VTI threshold value of 27.9% (under curve area = 61.6%, p = 0.04) only for carotid artery dissection.

CONCLUSION

VT appears to be associated with an increased risk of dissection for the carotid district but not for the vertebral one. The different structure, embryogenesis, and pathophysiology of dissection between the two districts could explain this finding. VTI threshold as carotid artery dissection predictor deserves confirmation in larger studies.