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Maclean MA, Touchette CJ, Duda T, Almojuela A, Bergeron D, Kameda-Smith M, Persad ARL, Sader N, Alant J, Christie SD. Work-up and Management of Asymptomatic Extracranial Traumatic Vertebral Artery Injury. Can J Neurol Sci 2023; 50:662-672. [PMID: 36017734 DOI: 10.1017/cjn.2022.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Non-penetrating head and neck trauma is associated with extracranial traumatic vertebral artery injury (eTVAI) in approximately 1-2% of cases. Most patients are initially asymptomatic but have an increased risk for delayed stroke and mortality. Limited evidence is available to guide the management of asymptomatic eTVAI. As such, we sought to investigate national practice patterns regarding screening, treatment, and follow-up domains. METHODS A cross-sectional, electronic survey was distributed to members of the Canadian Neurosurgical Society and Canadian Spine Society. We presented two cases of asymptomatic eTVAI, stratified by injury mechanism, fracture type, and angiographic findings. Screening questions were answered prior to presentation of angiographic findings. Survey responses were analyzed using descriptive statistics. RESULTS One hundred-eight of 232 (46%) participants, representing 20 academic institutions, completed the survey. Case 1: 78% of respondents would screen for eTVAI with computed topography angiography (CTA) (97%), immediately (88%). The majority of respondents (97%) would treat with aspirin (89%) for 3-6 months (46%). Respondents would follow up clinically (89%) or radiographically (75%), every 1-3 months. Case 2: 73% of respondents would screen with CTA (96%), immediately (88%). Most respondents (94%) would treat with aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy. Respondents would follow up clinically (97%) or radiographically (89%), every 1-3 months. CONCLUSION This survey of Canadian practice patterns highlights consistency in the approach to screening, treatment, and follow-up of asymptomatic eTVAI. These findings are relevant to neurosurgeons, spinal surgeons, stroke neurologists, and neuro-interventionalists.
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Affiliation(s)
- Mark A Maclean
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Taylor Duda
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Alysa Almojuela
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Bergeron
- Division of Neurosurgery, Universite de Montreal, Montreal, Quebec, Canada
| | - Michelle Kameda-Smith
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Amit R L Persad
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nicholas Sader
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Jacob Alant
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sean D Christie
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Janquli M, Selvarajah L, Moloney MA, Kavanagh E, O'Neill DC, Medani M. Long-term outcome of cervical artery dissection. J Vasc Surg 2023; 78:158-165. [PMID: 36918105 DOI: 10.1016/j.jvs.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/17/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE The aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches. METHODS A retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022. RESULTS Thirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner's syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days. CONCLUSIONS The majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.
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Affiliation(s)
- Mohammed Janquli
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland.
| | - Logeswaran Selvarajah
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
| | - Michael Anthony Moloney
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
| | - Eamon Kavanagh
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
| | - Damien Christopher O'Neill
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
| | - Mekki Medani
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick, Limerick, Ireland; Department of Radiology, University Hospital Limerick, University of Limerick, Limerick, Ireland
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Liu S, Zhang X, Bai X, Yang Y, Wang T, Xu X, Xu R, Li L, Feng Y, Yang K, Wang X, Guo X, Chen J, Ma Y, Jiao L. Antiplatelet vs. Anticoagulation in Cervical Artery Dissection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Neurol 2021; 12:745106. [PMID: 34899569 PMCID: PMC8651981 DOI: 10.3389/fneur.2021.745106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The optimal management for cervical artery dissection (CAD) is uncertain. This study aimed to summarize the current randomized controlled trials (RCTs) to compare the efficacy and safety of antiplatelet and anticoagulation therapies for CAD. Methods: A literature search was conducted in the major databases, such as MEDLINE, Embase, and the Cochrane Library. Only the RCTs comparing the antiplatelet and anticoagulation therapies for the patients with CAD were included. Combined estimates of the relative risk (RR) of antiplatelet vs. anticoagulation were analyzed. Heterogeneity was measured using the I 2 statistical analysis. The analyses were performed in the intention-to-treat (ITT) and per-protocol (PP) population, respectively. Results: Two RCTs involving 444 patients in the ITT population and 370 patients in the PP population were included. The quality of studies was high overall. In the ITT population, compared with the patients in the anticoagulation group, the patients in the antiplatelet group showed a higher rate of ischemic stroke within 3 months (RR = 6.73 [95% CI, 1.22-37.15], I 2 = 0%, P = 0.029). No difference between these two treatment groups was found for the outcomes of transient ischemic attack (RR = 0.37 [95% CI, 0.09-1.58], I 2 = 0%, P = 0.181), intracranial hemorrhage (RR = 0.33 [95% CI, 0.01-7.98], I 2 = 0%, P = 0.494), major extracranial bleeding (RR = 0.31 [95% CI, 0.01-7.60], I 2 = 0%, P = 0.476), or the composite of these outcomes within 3 months. For the PP population, the results of the meta-analysis of outcomes between the antiplatelet and anticoagulation groups were consistent with the ITT population. Conclusions: Compared with the antiplatelet group, the anticoagulation group has a lower risk of ischemic stroke without increasing bleeding risk when treating CAD. Anticoagulation seems to be superior over the antiplatelet in treating CAD but needs to be further tested by specifying several issues, such as location, initial symptom types, and treatment protocols.
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Affiliation(s)
- Sihua Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China.,Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yutong Yang
- Imperial College London, National Heart & Lung Institute, London, United Kingdom
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Ran Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Long Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaofan Guo
- Department of Neurology, Loma Linda University Health, Loma Linda, CA, United States
| | - Jing Chen
- Department of Neurology, Zhumadian Central Hospital, Henan, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Engelter ST, Lyrer P, Traenka C. Cervical and intracranial artery dissections. Ther Adv Neurol Disord 2021; 14:17562864211037238. [PMID: 34408787 PMCID: PMC8366117 DOI: 10.1177/17562864211037238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/19/2021] [Indexed: 12/26/2022] Open
Abstract
This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.
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Affiliation(s)
- Stefan T Engelter
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Petersgraben 4, Basel 4031, Switzerland
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EŞKUT N, TAMER P, YILMAZ KÜSBECİ Ö, ATAÇ C, İNCİ İ. Evaluation of Time in Therapeutic Range in Patients with Cerebrovascular Disease Receiving Treatment with Warfarin. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2021. [DOI: 10.17944/mkutfd.937769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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6
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Bond KM, Krings T, Lanzino G, Brinjikji W. Intracranial dissections: A pictorial review of pathophysiology, imaging features, and natural history. J Neuroradiol 2021; 48:176-188. [DOI: 10.1016/j.neurad.2020.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 01/22/2023]
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7
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Engelter ST, Traenka C, Gensicke H, Schaedelin SA, Luft AR, Simonetti BG, Fischer U, Michel P, Sirimarco G, Kägi G, Vehoff J, Nedeltchev K, Kahles T, Kellert L, Rosenbaum S, von Rennenberg R, Sztajzel R, Leib SL, Jung S, Gralla J, Bruni N, Seiffge D, Feil K, Polymeris AA, Steiner L, Hamann J, Bonati LH, Brehm A, De Marchis GM, Peters N, Stippich C, Nolte CH, Christensen H, Wegener S, Psychogios MN, Arnold M, Lyrer P. Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial. Lancet Neurol 2021; 20:341-350. [PMID: 33765420 DOI: 10.1016/s1474-4422(21)00044-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines-based on available evidence from mostly observational studies-suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection. METHODS We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0-3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460. FINDINGS Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI -4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group. INTERPRETATION Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection. FUNDING Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.
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Affiliation(s)
- Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland.
| | - Christopher Traenka
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Sabine A Schaedelin
- Department of Clinical Research and Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas R Luft
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland; Cereneo, Centre for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Barbara Goeggel Simonetti
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland; Department of Neuropaediatrics, Institute of Paediatrics of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Centre and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Gaia Sirimarco
- Stroke Centre and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Georg Kägi
- Department of Neurology and Stroke Centre, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology and Stroke Centre, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology and Stroke Centre, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology and Stroke Centre, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany; Institute for Stroke and Dementia Research, University Hospital LMU Munich, Munich, Germany
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Regina von Rennenberg
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Roman Sztajzel
- Department of Neurology and Stroke Centre, University Hospital Geneva and Medical School, Geneva, Switzerland
| | - Stephen L Leib
- Institute for Infectious Diseases, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Nicole Bruni
- Department of Clinical Research and Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Seiffge
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Katharina Feil
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Levke Steiner
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Janne Hamann
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Christoph Stippich
- Department of Neuroradiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Susanne Wegener
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
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Traenka C, Gensicke H, Schaedelin S, Luft A, Arnold M, Michel P, Kägi G, Kahles T, Nolte CH, Kellert L, Rosenbaum S, Sztaizel R, Brehm A, Stippich C, Psychogios M, Lyrer P, Engelter ST. Biomarkers and antithrombotic treatment in cervical artery dissection - Design of the TREAT-CAD randomised trial. Eur Stroke J 2020; 5:309-319. [PMID: 33072885 DOI: 10.1177/2396987320921151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/16/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction The type of antithrombotic treatment in cervical artery dissection patients is still a matter of debate. Most physicians prefer anticoagulants over antiplatelet agents for stroke prevention. However, this approach is not evidence-based and antiplatelets might be as safe and as effective. The 'Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection' ('TREAT-CAD') trial (clinicaltrials.gov: NCT02046460) compares Aspirin to oral anticoagulants (vitamin K antagonists) with regard to efficacy and safety by using both clinical and imaging surrogate outcome measures. TREAT-CAD tests the hypothesis, that aspirin is as safe and effective as vitamin K antagonists. Patients and methods TREAD-CAD is a Prospective, Randomised controlled, Open-labelled, multicentre, non-inferiority trial with Blinded assessment of outcome Events (PROBE-design). Key eligibility criteria are (i) clinical symptoms attributable to cervical artery dissection and (ii) verification of the cervical artery dissection diagnosis by established magnetic resonance imaging criteria. Patients are randomised to receive either Aspirin 300 mg daily or vitamin K antagonists for 90 days. Results Primary outcomes are assessed at 14 ± 10 days (magnetic resonance imaging and clinical examination) and at 90 ± 30 days (clinical examinations). The primary endpoint is a composite outcome measure - labelled Cerebrovascular Ischemia, major Hemorrhagic events or Death (CIHD) - and includes (i) occurrence of any stroke (including retinal infarction), (ii) new ischaemic lesions on diffusion-weighted magnetic resonance imaging, (iii) any major extracranial haemorrhage, (iv) any symptomatic intracranial haemorrhage, (v) any new haemorrhagic lesion visible on paramagnetic-susceptible sequences and (vi) death. Discussion After database closure, (i) central verification of cervical artery dissection diagnosis will be done by two experienced raters, (ii) adjudication of outcome events will be performed by independent adjudication committees, separately for clinical and imaging outcomes. The primary analysis will be done on the per protocol data set. The targeted sample size consists of 169 evaluable patients in the per protocol data set. Conclusion TREAT-CAD is testing the non-inferiority of Aspirin versus vitamin K antagonists treatment in patients with symptomatic cervical artery dissection by combined clinical and magnetic resonance imaging outcomes.
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Affiliation(s)
- Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Department of Clinical Research, Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas Luft
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Georg Kägi
- Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Timo Kahles
- Department of Neurology and Stroke Center, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Christian H Nolte
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Klinik und Hochschulambulanz für Neurologie, Berlin, Germany.,Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Roman Sztaizel
- Departement of Neurology and Stroke Center, University Hospital Geneva and Medical School, Geneva, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Christoph Stippich
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Marios Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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9
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Papanikolaou P, Antonopoulos AS, Mastorakou I, Angelopoulos A, Kostoula E, Mystakidi XV, Simantiris S, Galiatsatos N, Oikonomou E, Tousoulis D. Antithrombotic Therapy in Carotid Artery Disease. Curr Pharm Des 2020; 26:2725-2734. [PMID: 32418521 DOI: 10.2174/1381612826666200518111359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022]
Abstract
The management of asymptomatic atherosclerotic carotid artery disease and the role of antithrombotic therapy is of increasing importance for stroke prevention. Non-invasive imaging of carotid plaques can identify high-risk plaque features that are associated with the risk of plaque rupture. Carotid plaque necrosis, hemorrhage, fibrous cap thinning, and the presence of foam cells have all been correlated with the risk of rupture and onset of neurological symptoms in patients with carotid stenosis. Antiplatelets are currently recommended for patients with a history of ischemic stroke and/or significant carotid artery stenosis, with aspirin and clopidogrel being the most widely used and studied agents. The role of dual antiplatelet therapy remains controversial. Moreover, there is scarce evidence on the role of newer anticoagulant agents in stable patients with carotid artery stenosis. In this review article, we discuss the pathophysiology of carotid atherosclerosis, the use of non-invasive imaging for detecting the vulnerable carotid plaque and summarize the existing clinical evidence on the use of antiplatelet and antithrombotic agents in carotid artery disease.
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Affiliation(s)
- Paraskevi Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Irene Mastorakou
- Imaging Department - Onassis Cardiac Surgery Centre, Athens, Greece
| | - Andreas Angelopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | | | - Xara-Vasiliki Mystakidi
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Spyros Simantiris
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Nikolaos Galiatsatos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Evangelos Oikonomou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
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10
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Nash M, Rafay MF. Craniocervical Arterial Dissection in Children: Pathophysiology and Management. Pediatr Neurol 2019; 95:9-18. [PMID: 30955992 DOI: 10.1016/j.pediatrneurol.2019.01.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/24/2019] [Accepted: 01/26/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Craniocervical arterial dissection is a commonly reported arteriopathy associated with stroke in children. It is characterized by a high stroke recurrence rate and variable outcomes. Here we review the pathophysiology, clinical presentation, and diagnostic neuroimaging approaches that are helpful in accurate diagnosis and follow-up of children with arterial dissection. METHODS MEDLINE searches (2000 to 2018) for articles that contained patients aged less than 18 years with craniocervical arterial dissection was performed, with the goal of analyzing their presenting features, pathophysiological mechanisms, and imaging characteristics and interventions. RESULTS Sixteen articles met the study criteria and reported 182 cases of craniocervical arterial dissection, 68% male, average age 8.6 years. Dissection was associated with head and neck trauma in 56% of the cases and frequently involved the posterior (61%) and extracranial locations (64%); the vertebral artery was the most commonly involved artery (60%). The most common clinical presentation was hemiparesis (80/160, 50%), followed by headache (64/164, 39%). Magnetic resonance imaging was the preferred neuroimaging method, followed by cerebral catheter angiography as a gold standard definitive neurovascular imaging modality when the initial vascular imaging revealed nondiagnostic findings. CONCLUSIONS The diagnosis of arterial dissection requires a high index of suspicion and consideration for detailed neurovascular imaging, including both the cranial and cervical regions. Neurovascular imaging challenges, especially visualization of arterial abnormalities, highlight the importance of appropriate and timely use of specific neurovascular imaging techniques. Magnetic resonance imaging appears to be the preferred neurovascular imaging modality in children with arterial dissection and may obviate the need for invasive cerebral catheter angiography.
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Affiliation(s)
- Monica Nash
- Department of Nursing, Red River College, Winnipeg, Manitoba, Canada
| | - Mubeen F Rafay
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, University of Manitoba, Manitoba, Canada; Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.
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11
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Losseff N, Adams M, Brown MM, Grieve J, Simister R. Stroke and Cerebrovascular Diseases. Neurology 2016. [DOI: 10.1002/9781118486160.ch5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | | | - Joan Grieve
- National Hospital for Neurology & Neurosurgery
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12
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Case Studies of Uncommon and Rare Headache Disorders. Neurol Clin 2016; 34:631-50. [PMID: 27445245 DOI: 10.1016/j.ncl.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The following 6 case studies are presented: a 12-day migraine with recurring aura?; a migraineur with a new constant headache for 1 month; an orthostatic headache; a unilateral headache; migraine with aura and limb pain without headache; and nocturnal headaches. These cases illustrate the fascinating diversity and challenges of primary and secondary headaches that neurologists commonly encounter.
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13
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Bae HJ, Debette S. Commentary on the Cervical Artery Dissection in Stroke Study Trial. Stroke 2016; 47:1413-5. [PMID: 27048699 DOI: 10.1161/strokeaha.115.011516] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/08/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Hee-Joon Bae
- From the Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (H.-J.B.); and Department of Neurology, Bordeaux University Hospital, and Inserm U897, Bordeaux University, Bordeaux, France (S.D.).
| | - Stéphanie Debette
- From the Department of Neurology, Cerebrovascular Disease Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (H.-J.B.); and Department of Neurology, Bordeaux University Hospital, and Inserm U897, Bordeaux University, Bordeaux, France (S.D.)
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14
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Conforto AB. Challenges in diagnosis and treatment of cervico-cephalic arterial dissections. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:273-4. [DOI: 10.1590/0004-282x20160039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 01/15/2016] [Indexed: 11/22/2022]
Affiliation(s)
- Adriana Bastos Conforto
- Universidade de São Paulo, Brazil; Instituto Israelita de Ensino e Pesquisa Albert Einstein, Brazil
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15
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Minor trauma causing stroke in a young athlete. Case Rep Neurol Med 2015; 2015:182875. [PMID: 25883815 PMCID: PMC4391316 DOI: 10.1155/2015/182875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/18/2015] [Accepted: 03/20/2015] [Indexed: 11/17/2022] Open
Abstract
A 17-year-old Caucasian male presented with sudden dizziness, ataxia, vertigo, and clumsiness lasting for a couple of hours. He had a subtle trauma during a wrestling match 2 days prior to the presentation. A CT Angiogram (CTA) and MRI showed left vertebral artery dissection (VAD). The patient was treated with anticoagulation with heparin drip in the ICU. The patient was discharged home on the third day on Lovenox-warfarin bridging. This case underscores the importance of considering VAD as a differential diagnosis in patients with sports-related symptoms especially in activities entailing hyperextension or hyperrotation of neck. Due to a varied latent period, often minor underlying trauma, and subtle presentation, a low index of suspicion is warranted in timely diagnosis and treatment of VAD. Considering recent evidence in treatment modality, either antiplatelet therapy or anticoagulation may be used for treatment of VAD.
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