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Wang Q, Liu M, Zhao K, Xu X, Zhang J, Xu B. Hyperhomocysteinemia increases the risk of vertebrobasilar dissecting aneurysm among the male Han Chinese population: a retrospective case-control study. Int J Neurosci 2024; 134:951-957. [PMID: 36714920 DOI: 10.1080/00207454.2023.2174024] [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: 09/12/2022] [Revised: 10/31/2022] [Accepted: 01/24/2023] [Indexed: 01/31/2023]
Abstract
OBJECT Vertebrobasilar dissecting aneurysms (VBDAs) are known to have a poor natural history with high rates of re-bleeding and mortality. There is a strong relation between hyperhomocysteinemia (HHcy) and cerebrovascular disease; we perform a retrospective study within the male of Chinese Han population to explore the association between HHcy and VBDAs. METHODS Eighty-eight male patients with VBDA and Eighty-one male control subjects were evaluated for their serum total homocysteine levels. With multiple logistic regression analysis, the association between HHcy and the risk of VBDAs was estimated. Interaction and stratified analyses were conducted according to age, BMI, smoking status, drinking status, and chronic disease histories. The two-piecewise linear regression model examined the threshold effect. RESULTS The multivariate logistic regression analyses revealed a significant association between HHcy and VBDAs (odds ratio (OR) = 2.62; 95% confidence interval (CI), 1.02-6.71) after adjusting for classical vascular risk factors. The relationship was stable in all subgroup analysis. The interactive role was not found in the association between HHcy and VBDAs for the potential risk factor. CONCLUSIONS In summary, our study provides evidence that HHcy can increases the risk of VBDAs in the male Han Chinese population. Further researches with appropriate study designs including sex differences and aneurysm types are needed to verify this association.
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Affiliation(s)
- Qun Wang
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Minghang Liu
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Kai Zhao
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - Xinghua Xu
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - JiaShu Zhang
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
| | - BaiNan Xu
- Department of Neurosurgery, The First Medical Center, Chinese PLA General Hospital, Haidian District, Beijing, China
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Salih M, Taussky P, Ogilvy CS. Association between cervicocerebral artery dissection and tortuosity - a review on quantitative and qualitative assessment. Acta Neurochir (Wien) 2024; 166:285. [PMID: 38977512 DOI: 10.1007/s00701-024-06171-2] [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: 04/22/2024] [Accepted: 06/17/2024] [Indexed: 07/10/2024]
Abstract
Cervicocerebral artery dissection stands out as a significant contributor to ischemic stroke in young adults. Several studies have shown that arterial tortuosity is associated with dissection. We searched Pubmed and Embase to identify studies on the association between arterial tortuosity and cervicocerebral artery dissection, and to perform a review on the epidemiology of cervicocerebral artery tortuosity and dissection, pathophysiology, measurement of vessels tortuosity, strength of association between tortuosity and dissection, clinical manifestation and management strategies. The prevalence of tortuosity in dissected cervical arteries was reported to be around 22%-65% while it is only around 8%-22% in non-dissected arteries. In tortuous cervical arteries elastin and tunica media degradation, increased wall stiffness, changes in hemodynamics as well as arterial wall inflammation might be associated with dissection. Arterial tortuosity index and vertebrobasilar artery deviation is used to measure the level of vessel tortuosity. Studies have shown an independent association between these two measurements and cervicocerebral artery dissection. Different anatomical variants of tortuosity such as loops, coils and kinks may have a different level of association with cervicocerebral artery dissection. Symptomatic patients with extracranial cervical artery dissection are often treated with anticoagulant or antiplatelet agents, while patients with intracranial arterial dissection were often treated with antiplatelets only due to concerns of developing subarachnoid hemorrhage. Patients with recurrent ischemia, compromised cerebral blood flow or contraindications for antithrombotic agents are usually treated with open surgery or endovascular technique. Those with subarachnoid hemorrhage and intracranial artery dissection are often managed with surgical intervention due to high risk of re-hemorrhage.
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Affiliation(s)
- Mira Salih
- Neurosurgery Department, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, United States
| | - Philipp Taussky
- Neurosurgery Department, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, United States
| | - Christopher S Ogilvy
- Neurosurgery Department, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, 110 Francis Street, Boston, MA, 02215, United States.
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Eun C, Kim H, Cho S, Yang K. Various treatment modalities for isolated intracranial middle cerebral arterial dissection with progressive ischemic symptoms: 2 case reports of endovascular stent and bypass surgery. J Cerebrovasc Endovasc Neurosurg 2024; 26:196-203. [PMID: 37839806 PMCID: PMC11220303 DOI: 10.7461/jcen.2023.e2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/26/2023] [Accepted: 09/24/2023] [Indexed: 10/17/2023] Open
Abstract
Isolated middle cerebral artery dissection (MCAD) is rare but increasingly recognized as a significant clinical entity, particularly in younger adults. Ischemic stroke is the most common manifestation in symptomatic cases but symptoms can vary in severity from headaches to severe neurologic deficits. Due to its rarity and unpredictable clinical course, there is no established treatment strategy for isolated MCAD. Through two case reports, we reviewed the post-operative clinical course of MCAD under different treatment modalities. Case 1 was a 21-year-old woman who presented to the emergency department with headaches and left-side hemiparesis. Isolated MCAD was diagnosed and she was successfully treated with the placement of a self-expandable stent and subsequent chemical angioplasty for post-stent vasospasm. Case 2 was a 35-year-old woman who presented to the emergency department with left-side hemiparesis and dysarthria. Isolated MCAD was diagnosed and she was successfully treated with superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis.
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Affiliation(s)
- Chanbo Eun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hongbum Kim
- Department of Neurological Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Suhee Cho
- Department of Neurological Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Kuhyun Yang
- Department of Neurological Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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Węgiel A, Zielinska N, Głowacka M, Olewnik Ł. Hypoglossal Nerve Neuropathies-Analysis of Causes and Anatomical Background. Biomedicines 2024; 12:864. [PMID: 38672218 PMCID: PMC11048189 DOI: 10.3390/biomedicines12040864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
The hypoglossal nerve is the last, and often neglected, cranial nerve. It is mainly responsible for motor innervation of the tongue and therefore the process of chewing and articulation. However, tumors, aneurysms, dissections, trauma, and various iatrogenic factors such as complications after surgeries, radiotherapy, or airway management can result in dysfunction. Correct differential diagnosis and suitable treatment require a thorough knowledge of the anatomical background of the region. This review presents the broad spectrum of hypoglossal neuropathies, paying particular attention to these with a compressive background. As many of these etiologies are not common and can be easily overlooked without prior preparation, it is important to have a comprehensive understanding of the special relations and characteristic traits of these medical conditions, as well as the most common concomitant disorders and morphological traits, influencing the clinical image. Due to the diverse etiology of hypoglossal neuropathies, specialists from many different medical branches might expect to encounter patients presenting such symptoms.
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Affiliation(s)
- Andrzej Węgiel
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-647 Lodz, Poland; (A.W.); (N.Z.)
| | - Nicol Zielinska
- Department of Anatomical Dissection and Donation, Medical University of Lodz, 90-647 Lodz, Poland; (A.W.); (N.Z.)
| | - Mariola Głowacka
- Nursing Department, Masovian Academy in Płock, 09-402 Płock, Poland;
| | - Łukasz Olewnik
- Department of Clinical Anatomy, Masovian Academy in Płock, 09-402 Płock, Poland
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Jiang W, Jia Q, Ma H, Han S, Bi S, Zhu K, Chen L, Liang G. MicroRNA-124 conducts neuroprotective effect via inhibiting AK4/ATF3 after subarachnoid hemorrhage. Exp Brain Res 2024; 242:33-45. [PMID: 37932484 DOI: 10.1007/s00221-023-06682-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/02/2023] [Indexed: 11/08/2023]
Abstract
Spontaneous subarachnoid hemorrhage (SAH) accounts for approximately 5% of all cases of stroke. SAH is correlated with elevated rates of mortality and disability. Despite significant advancements in comprehending the pathogenesis and surgical management, efficacious clinical interventions remain restricted, and the prognosis is yet to be enhanced. MicroRNAs play a crucial role in various pathological processes in organisms. Revealing these regulatory processes is conducive to the development of new treatment methods. MicroRNA-124 is highly expressed in the nervous system and has significant research value for SAH. This study aims to explore the role of miR-124 in the early post-SAH period on neural function and verify whether it is involved in the pathological and physiological processes of SAH. In this study, we used methods such as comparing the expression levels of miR-124 in cerebrospinal fluid, establishing a rat SAH model, and a mouse embryonic primary neuron hemoglobin stimulation model to verify the downstream proteins of miR-124 in SAH. Through transfection techniques, we adjusted the expression of this small RNA in Vitro and in Vivo models using miR-124 inhibitor and mimic in the primary neuron hemoglobin stimulation model and rat SAH model, and observed the phenotype. Finally, by consulting the literature and verifying in Vivo and in Vitro methods, AK4 and downstream molecule ATF3 were identified as downstream targets of miR-124.
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Affiliation(s)
- Wei Jiang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Wenhua Rd. No.83, Shenyang, 110000, Liaoning, China
| | - Qingge Jia
- Department of Reproductive Endocrinology, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Hongxin Ma
- Department of Neurosurgery, General Hospital of Northern Theater Command, Wenhua Rd. No.83, Shenyang, 110000, Liaoning, China
| | - Song Han
- Department of Neurosurgery, General Hospital of Northern Theater Command, Wenhua Rd. No.83, Shenyang, 110000, Liaoning, China
| | - Shijun Bi
- Department of Neurosurgery, General Hospital of Northern Theater Command, Wenhua Rd. No.83, Shenyang, 110000, Liaoning, China
| | - Kunyuan Zhu
- Department of Neurosurgery, General Hospital of Northern Theater Command, Wenhua Rd. No.83, Shenyang, 110000, Liaoning, China
| | - Ligang Chen
- Department of Neurosurgery, General Hospital of Northern Theater Command, Wenhua Rd. No.83, Shenyang, 110000, Liaoning, China.
| | - Guobiao Liang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Wenhua Rd. No.83, Shenyang, 110000, Liaoning, China.
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Roman Filip I, Morosanu V, Spinu D, Motoc C, Bajko Z, Sarmasan E, Roman C, Balasa R. Cervical Artery Dissections-A Demographical Analysis of Risk Factors, Clinical Characteristics Treatment Procedures, and Outcomes-A Single Centre Study of 54 Consecutive Cases. J Pers Med 2023; 14:48. [PMID: 38248748 PMCID: PMC10817437 DOI: 10.3390/jpm14010048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Cervical artery dissections (CAD) are a common cause of ischemic cerebrovascular events among the younger and middle-aged population. Altogether, CAD counts for up to 15% of all causes of stroke in patients aged 50 or younger. Among the known etiological causes, especially addressing the younger population with mechanical traumas and whiplash injuries are regarded as the main culprits. However, cases of spontaneous dissection are also widespread, with risk factors such as hypertension, migraine, and lifestyle factors increasing the risk of occurrence. Clinically, the symptoms associated with a cerebrovascular event caused by CADs are highly variable and can be classified as either compressive symptoms (such as Horner's syndrome and cervical pain) or stroke syndromes attributable to cerebral ischemia. Therefore, establishing an early diagnosis might be particularly challenging as it requires particular attention and quick clinical reasoning when interviewing the patient. With these certain particularities, our main focus was to conduct a prospective study involving up to 54 patients who were diagnosed with CAD in our clinical facility between January 2015 and December 2022, with the focus of assessing certain individual parameters attributable to each patient and their influence and prognosis value for their short and long term evolution. An important emphasis was placed on parameters such as topographical localization, clinical presentation, severity of the questioned cerebrovascular event, outcomes, and causative factors. Statistical validity tools were applied when possible.
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Affiliation(s)
- Iulian Roman Filip
- Department of Neurology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania; (I.R.F.); (V.M.); (D.S.); (C.M.); (E.S.); (R.B.)
| | - Valentin Morosanu
- Department of Neurology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania; (I.R.F.); (V.M.); (D.S.); (C.M.); (E.S.); (R.B.)
| | - Doina Spinu
- Department of Neurology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania; (I.R.F.); (V.M.); (D.S.); (C.M.); (E.S.); (R.B.)
| | - Claudiu Motoc
- Department of Neurology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania; (I.R.F.); (V.M.); (D.S.); (C.M.); (E.S.); (R.B.)
| | - Zoltan Bajko
- Department of Neurology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania; (I.R.F.); (V.M.); (D.S.); (C.M.); (E.S.); (R.B.)
| | - Emanuela Sarmasan
- Department of Neurology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania; (I.R.F.); (V.M.); (D.S.); (C.M.); (E.S.); (R.B.)
| | - Corina Roman
- Department of Neurology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania;
| | - Rodica Balasa
- Department of Neurology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania; (I.R.F.); (V.M.); (D.S.); (C.M.); (E.S.); (R.B.)
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Peret A, Romero-Sanchez G, Dabiri M, McNally JS, Johnson KM, Mossa-Basha M, Eisenmenger LB. MR Angiography of Extracranial Carotid Disease. Magn Reson Imaging Clin N Am 2023; 31:395-411. [PMID: 37414468 DOI: 10.1016/j.mric.2023.04.003] [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: 07/08/2023]
Abstract
Magnetic resonance angiography sequences, such as time-of-flight and contrast-enhanced angiography, provide clear depiction of vessel lumen, traditionally used to evaluate carotid pathologic conditions such as stenosis, dissection, and occlusion; however, atherosclerotic plaques with a similar degree of stenosis may vary tremendously from a histopathological standpoint. MR vessel wall imaging is a promising noninvasive method to evaluate the content of the vessel wall at high spatial resolution. This is particularly interesting in the case of atherosclerosis as vessel wall imaging can identify higher risk, vulnerable plaques as well as has potential applications in the evaluation of other carotid pathologic conditions.
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Affiliation(s)
- Anthony Peret
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53705, USA
| | - Griselda Romero-Sanchez
- Department of Radiology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Avenida Vasco de Quiroga No.15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan C.P.14080, Ciudad de México, Mexico City, Mexico
| | - Mona Dabiri
- Radiology Department, Children's Medical Center, Tehran University of Medical Science, No 63, Gharib Avenue, Keshavarz Blv, Tehran 1419733151, Iran
| | - Joseph Scott McNally
- Department of Radiology, University of Utah, 50 N Medical Dr, Salt Lake City, UT 84132, USA
| | - Kevin M Johnson
- Department of Medical Physics, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53705, USA
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Laura B Eisenmenger
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53705, USA.
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8
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Zhang T, Niu H, Liu Y, Cai L, Liu D, Zhao E, Li M, Liu W, Li J, Qiao P, Zheng W, Ren P, Wang Z. Dobutamine-induced alternations in cerebral blood flow of healthy adults: a 3D pseudocontinuous arterial spin labeling study. BMC Med 2023; 21:238. [PMID: 37400817 DOI: 10.1186/s12916-023-02928-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/08/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND It is unclear whether dobutamine, commonly used clinically in echocardiography and short-term congestive heart failure treatment for promoting increased myocardial contractility, affects brain microcirculatory behavior. Cerebral microcirculation plays an important role in ensuring adequate oxygen transport. Therefore, we investigated the effects of dobutamine on cerebral hemodynamics. METHODS Forty-eight healthy volunteers without cardiovascular or cerebrovascular disease underwent MRI to obtain cerebral blood flow (CBF) maps using 3D pseudocontinuous arterial spin labeling before and during the dobutamine stress test. Additionally, cerebrovascular morphology was obtained based on 3D-time-off-light (3D-TOF) magnetic resonance angiography (MRA). Electrocardiogram, heart rate (HR), respiration rate (RR), blood pressure, and blood oxygen were simultaneously recorded before and during dobutamine injection and during recovery (not during MRI). The anatomic features of the circle of Willis and the basilar artery (BA) diameter were assessed on MRA images by two radiologists with extensive neuroimaging experience. Binary logistic regression was used to test for the independent determinants of CBF changes. RESULTS HR, RR, systolic (SBP), and diastolic blood pressure (DBP) significantly increased after dobutamine infusion. Blood oxygen levels remained similar. Compared to the CBF in the resting state, the CBF values exhibited significantly lower CBF levels in both grey matter and white matter. Furthermore, compared with the CBF in the resting state, that in the stress state was decreased in the anterior circulation, mainly in the frontal lobe (voxel level P < 0.001, pixel level P < 0.05). Logistic regression showed that body mass index (BMI; odds ratio [OR] 5.80, 95% confidence interval [CI] 1.60-21.01, P = 0.008], resting SBP (OR 0.64, 95% CI 0.45-0.92, P = 0.014), and BA diameter (OR 11.04, 95% CI 1.05-116.53, P = 0.046) were significantly associated with frontal lobe CBF changes. CONCLUSIONS Dobutamine-induced stress significantly decreased CBF in the frontal lobe anterior circulation. Individuals with a high BMI and low SBP during the dobutamine stress test are more likely to have a stress-induced CBF decrease. Thus, attention should be paid to blood pressure, BMI, and cerebrovascular morphology of patients undergoing dobutamine stress echocardiography or those receiving intensive care or anesthesia.
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Affiliation(s)
- Tingting Zhang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Haijun Niu
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yawen Liu
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Linkun Cai
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Dong Liu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Erwei Zhao
- National Space Science Center, Chinese Academy of Sciences, Beijing, China
| | - Min Li
- Clinical Epidemiology and EBM Unit, Beijing Friendship Hospital, Capital Medical University, Beijing Clinical Research Institute, Beijing, China
| | - Wenjuan Liu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jing Li
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - PengGang Qiao
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Zheng
- National Space Science Center, Chinese Academy of Sciences, Beijing, China
| | - Pengling Ren
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Zhenchang Wang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China.
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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Arning C. Ultrasound Criteria for Diagnosing Spontaneous Cervical Artery Dissections. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:126-150. [PMID: 36746198 DOI: 10.1055/a-2004-4986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Spontaneous dissection of brain-supplying cervical arteries, which also includes findings after minor injuries, is one of the main causes of ischaemic strokes in young adults. Strokes due to dissection are usually due to arterio-arterial embolism. They are rarely the first symptom of dissection because an intraluminal thrombus must first develop. Therefore, early diagnosis of dissection can contribute to stroke prevention - through immediate therapy with anticoagulants or antiplatelet drugs. This article describes the diagnostic criteria and typical findings of spontaneous dissection, in which no dissecting membrane is to be expected as in aortic dissection. Traumatic dissections following blunt or penetrating injuries also present with different findings. Examiners should be aware of possible differential diagnoses whose ultrasound image may mimic a dissection. A frequently occurring but avoidable cause of misdiagnosis is idiopathic carotidynia. Ultrasound also enables differentiation between dissection and vasculitis or carotid web and detection of normal variants such as fenestration of the vertebral artery. Further possibilities for misdiagnosis may arise in the presence of a variant of the ascending pharyngeal artery or in extracranial vasospasm. The different imaging techniques for the detection of a dissection are complementary, as false-negative findings occur with all techniques; no method serves as the gold standard. In any case, ultrasound can make an important contribution to the detection of a dissection, and it is worth knowing the diagnostic criteria.
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Arning C, Hanke-Arning K, Eckert B. The Clinical Features of Dissection of the Cervical Brain-Supplying Arteries. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:581-587. [PMID: 35734920 PMCID: PMC9749844 DOI: 10.3238/arztebl.m2022.0238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/04/2022] [Accepted: 05/17/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Dissections of the cervical brain-supplying arteries are a leading cause of ischemic stroke in young adults, with an annual incidence of 2.5-3 / 100 000 for carotid artery dissection and 1-1.5 / 100 000 for vertebral artery dissection. It can be assumed that many cases go unreported. We present the clinical features here to help physicians diagnose this disease entity as rapidly as possible. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed. RESULTS Spontaneous dissection of the internal carotid or vertebral artery is characterized by a hematoma in the vessel wall. It often arises in connection with minor injuries; underlying weakness of the arterial wall (possibly only temporary) may be a predisposing factor. Acute unilateral pain is the main presenting symptom. In internal carotid dissection, the site of the pain is temporal in 46% of cases, and frontal in 19%; in vertebral artery dissection, it is nuchal and occipital in 80%. Pain and local findings, such as Horner syndrome, are generally present from the beginning, while stroke may arise only after a latency of hours to days. If the diagnosis is made early with MRI, CT, or ultrasound, and anticoagulation or antiplatelet drugs can help prevent a stroke, yet none of these methods can detect all cases. Recurrent dissection is rare, except in patients with connective tissue diseases such as Ehlers-Danlos syndrome or fibromuscular dysplasia. Spontaneous dissection of the great vessels of the neck must be differentiated from aortic dissection spreading to the supra-aortic vessels and from traumatic dissection due to blunt or penetrating vascular trauma. CONCLUSION Dissection of the cervical brain-supplying vessels is not always revealed by the imaging methods that are used to detect it. Stroke prevention thus depends on the physician's being aware of the symptoms and signs of this disease entity, so that early diagnosis can be followed by appropriate treatment.
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Affiliation(s)
- Christian Arning
- Praxis Neurologie und Neuro-Ultraschall, Hamburg,*Facharzt für Neurologie und Psychiatrie Moorhof 2d, D-22399 Hamburg, Germany
| | | | - Bernd Eckert
- Department of Neuroradiology, Asklepios Klinik Altona, Hamburg
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Zhu X, Shan Y, Guo R, Zheng T, Zhang X, Liu Z, Liu K. Three-Dimensional High-Resolution Magnetic Resonance Imaging for the Assessment of Cervical Artery Dissection. Front Aging Neurosci 2022; 14:785661. [PMID: 35865747 PMCID: PMC9295408 DOI: 10.3389/fnagi.2022.785661] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background and PurposeDiagnosing cervical artery dissection (CAD) is still a challenge based on the current radiographic criteria. This study aimed to assess the value of three-dimensional high-resolution magnetic resonance imaging (3D HRMRI) in the detection of the signs of CAD and its diagnosis.Materials and MethodsPatients with CAD from January 2016 to January 2021 were recruited from our 3D HRMRI database. The signs of dissection (intramural hematomas, intimal flap, double lumen), length and location of the dissection, thickness of the intramural hematoma, intraluminal thrombus, and percentage of dilation of the outer contour of the dissection on 3D HRMRI were assessed.ResultsFourteen patients with 16 CADs, including 12 carotid CADs and 4 vertebral CADs, were finally diagnosed in this study. On 3D HRMRI, intramural hematomas were detected in 13/16 (81.3%) lesions with high sensitivity (100%) and high specificity (100%). Intimal flaps were found in 9/16 (56.3%) lesions with moderate sensitivity (64.3%) and high specificity (88.9%). Double lumen signs were observed in 4/16 (25.0%) lesions with high sensitivity (80.0%) and high specificity (100%). In addition, concomitant intraluminal thrombus were detected in 4/16 (25.0%) lesions with high sensitivity (80.0%) and high specificity (100%). The mean length of dissection was (25.1 ± 13.7) mm. The mean thickness of the intramural hematoma was (4.3 ± 2.3) mm. The mean percentage of dilation for the outer contour of the dissection was (151.3 ± 28.6)%.ConclusionThe 3D HRMRI enables detection of the dissecting signs, such as intramural hematoma, intimal flap, double lumen, and intraluminal thrombus with high sensitivity and specificity, suggesting a useful, and non-invasive tool for definitively diagnosing CAD.
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Affiliation(s)
- Xianjin Zhu
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yi Shan
- Graduate School of Peking Union Medical College, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Runcai Guo
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Tao Zheng
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Xuebin Zhang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Zunjing Liu
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Zunjing Liu,
| | - Kunpeng Liu
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
- Kunpeng Liu,
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12
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Ebrahimzadeh SA, Manzoor K, Edlow JA, Selim M, Chang YM, Bhadelia RA, Mehta P. Diagnostic yield of CT angiography performed for suspected cervical artery dissection in the emergency department. Emerg Radiol 2022; 29:825-832. [DOI: 10.1007/s10140-022-02065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/22/2022] [Indexed: 11/24/2022]
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13
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Vertebral artery dissection after-and also before-chirotherapy. J Neurol 2022; 269:3353-3354. [PMID: 35013787 DOI: 10.1007/s00415-022-10964-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
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14
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Bukhari MK, Alghamdi SA. Ischemic Stroke Secondary to Dynamic Vertebral Artery Stenosis: Case Report and Review of the Literature. Cureus 2021; 13:e20167. [PMID: 35003995 PMCID: PMC8724019 DOI: 10.7759/cureus.20167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2021] [Indexed: 11/24/2022] Open
Abstract
Ischemic stroke secondary to dynamic vertebral artery stenosis or occlusion, also known as “bow hunter's syndrome,” is a rare stroke mechanism. We report a case of a 24-year-old man with multiple hereditary exostosis (MHE) diagnosed at childhood. His first presentation to a neurologist was due to neck pain and clinical syndrome suggestive of ischemia in the vertebrobasilar territory. A therapeutic occlusion was done successfully without complication. The patient was discharged two days later on aspirin alone. In follow up one year later he continued to be symptom free. Moreover, this stroke mechanism has been reported extensively in the literature in isolation or secondary to many underlying diseases. In total, there are 168 cases reported in the published English literature, in either case reports or small series. In this review, we found that by far, vertebral artery occlusion at the atlanto-axial (C1-2) level dominated most reported cases. The most frequent presentation that led to further investigation was syncope or pre-syncope provoked by head rotation to one side. To our knowledge, there is no previous report of any stroke syndrome related to MHE before our case. In this paper, we report the first case secondary to MHE and review the literature up to date since the first reported case in 1952.
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15
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Novakovic-White R, Corona JM, White JA. Posterior Circulation Ischemia in the Endovascular Era. Neurology 2021; 97:S158-S169. [PMID: 34785614 DOI: 10.1212/wnl.0000000000012808] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/29/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To perform literature review of clinical, radiographic, and anatomical features of posterior circulation ischemia (PCI) and systematic review of the literature on the management of basilar artery occlusion (BAO) and associated outcomes. METHODS Review of literature was conducted to identify publications describing the risk factors, etiology, clinical presentation, and imaging for PCI. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed and Ovid MEDLINE were searched from 2009 to 2020 for articles relating to management of BAO. A synthesis was compiled summarizing current evidence on management of BAO. RESULTS PCI accounts for 15%-20% of strokes. Risk factors are similar to anterior circulation strokes. Dizziness (47%), unilateral limb weakness (41%), and dysarthria (31%) are the most common presenting symptoms. A noncontrast head CT will identify PCI in 21% of cases; diffusion-weighted MRI or CT perfusion increase sensitivity to 85%. Recent trials have shown endovascular therapy can achieve >80% recanalization of BAO. In select patients, 30%-60% who receive endovascular treatment can achieve favorable outcome vs without. A total of 13% achieve good outcome and there is an 86% mortality rate. DISCUSSION PCI can present with waxing and waning symptoms or clinical findings that overlap with stroke mimics and anterior circulation ischemia, making diagnosis more heavily dependent on imaging. Recanalization is an important predictor of improved functional outcome and survival. In this endovascular era, trials of BAO are fraught with deterrents to enrollment. Despite limitations, endovascular treatment has shown improved outcome in select patients.
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Affiliation(s)
- Roberta Novakovic-White
- From the Departments of Radiology (R.N.-W., J.M.C., J.A.W.), Neurology (R.N.-W.), and Neurosurgery (J.M.C., J.A.W.), The University of Texas Southwestern Medical Center, Dallas.
| | - Juan Mario Corona
- From the Departments of Radiology (R.N.-W., J.M.C., J.A.W.), Neurology (R.N.-W.), and Neurosurgery (J.M.C., J.A.W.), The University of Texas Southwestern Medical Center, Dallas
| | - Jonathan A White
- From the Departments of Radiology (R.N.-W., J.M.C., J.A.W.), Neurology (R.N.-W.), and Neurosurgery (J.M.C., J.A.W.), The University of Texas Southwestern Medical Center, Dallas.
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16
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Characteristics and Prognostic Factors of Swallowing Dysfunction in Patients with Lateral Medullary Infarction. J Stroke Cerebrovasc Dis 2021; 30:106122. [PMID: 34583216 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/30/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Lateral medullary infarction mainly impairs the pharyngeal phase of swallowing. We aimed to investigate the utility of the assessment tools of swallowing function in patients with lateral medullary infarction and to determine the factors that could predict the outcomes of swallowing function. MATERIALS AND METHODS 15 patients with lateral medullary infarction who were admitted to Suiseikai Kajikawa Hospital between August 1, 2016, and March 31, 2020 (age 62.7 ± 14.8 years, 5 women) were enrolled in this prospective study. The diagnosis was made using brain magnetic resonance imaging. We analyzed the factors associated with severe swallowing dysfunction, which was defined as the necessity for tube feeding on the 90th day from admission, with multiple logistic regression analysis. RESULTS Multivariate analyses identified the repetitive saliva swallowing test, modified water swallowing test, and vertical spread of stroke lesions as independent significant factors affecting severe swallowing dysfunction (p = 0.002, 0.016, and 0.011, respectively). The sub-scores of the pharyngeal phase of the Mann Assessment of Swallowing Ability were also significantly associated with severe swallowing dysfunction (p < 0.001). However, tongue pressure, severe passage pattern abnormality on videofluoroscopic examination, and vertebral artery dissection were not significantly associated with swallowing dysfunction. CONCLUSIONS Since lateral medullary infarction presents with swallowing dysfunction mainly in the pharyngeal phase, tools that can be used to evaluate the pharyngeal phase of swallowing, such as repetitive saliva swallowing test and modified water swallowing test, are moreuseful than tongue pressure measurement.
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Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J 2021; 6:XXXIX-LXXXVIII. [PMID: 34746432 PMCID: PMC8564160 DOI: 10.1177/23969873211046475] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/26/2021] [Indexed: 11/15/2022] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.
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Affiliation(s)
- Stephanie Debette
- Bordeaux Population Health research
center, INSERM U1219, University of Bordeaux, Bordeaux, France
- Department of Neurology and
Institute for Neurodegenerative Diseases, Bordeaux University
Hospital, France
| | - Mikael Mazighi
- Department of Neurology, Hopital Lariboisière, Paris, France
- Interventional Neuroradiology
Department, Hôpital Fondation Ophtalmologique
Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- FHU NeuroVasc, Paris, France
- Laboratory of Vascular Translational
Science, INSERM U1148, Paris, France
| | - Philippe Bijlenga
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and
Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Masatoshi Koga
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - Anna Bersano
- Fondazione IRCCS Istituto Neurologico
'Carlo Besta', Milano
| | - Janika Kõrv
- Department of Neurology and
Neurosurgery, University of Tartu, Tartu, Estonia
- Department of Neurology, Tartu University
Hospital, Tartu, Estonia
| | - Julien Haemmerli
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | | | - Piotr Tekiela
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Kaori Miwa
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - David J Seiffge
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Sabrina Schilling
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Marcel Arnold
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Hugh S Markus
- Department of Clinical
Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan T Engelter
- Department of Neurology and
Stroke Center, University Hospital 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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Haeren RHL, Jahromi BR, Niemela M. Posttraumatic subarachnoid hemorrhage related to concomitant carotid artery dissection and ruptured basilar trunk aneurysm: A case report and literature review. Surg Neurol Int 2021; 12:344. [PMID: 34345484 PMCID: PMC8326099 DOI: 10.25259/sni_193_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/16/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Carotid artery dissections (CADs) are a relatively rare disorder, whereas intracranial aneurysms (IAs) form a common cerebrovascular pathology. Since both vascular entities share similar risk factors and associations with connective tissue and vascular disorders, a common pathogenesis has been suggested. Here, we present a case of the concomitant occurrence of a CAD and a ruptured basilar trunk aneurysm (BTA). In the discussion, we elaborate on both vascular entities and have reviewed the literature on their concomitant incidence and potential shared pathogenesis. Case Description: We present a case of a 40-year-old female patient who was admitted to our hospital because of subarachnoid hemorrhage following a minor head trauma. Imaging revealed a BTA and unilateral extracranial dissection of the internal carotid artery. Despite coiling of the aneurysm, stenting of the dissection, and antithrombotic therapy, the patient died due to extensive cerebral ischemia sequelae. Conclusion: CAD and BTAs have both been associated with a vascular vulnerability but their concomitant occurrence has not been described previously. The previous studies have suggested an increased incidence of IAs in patients with a CAD and vice versa. However, the number of studies and reports on this mutual increased incidence is limited. Therefore, a shared pathogenesis seems rather speculative. In our case, we suggest that a posttraumatic CAD-induced hemodynamic alterations resulting in rupture of the saccular BTA.
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Affiliation(s)
- Roel Hubert Louis Haeren
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Limburg, Netherlands
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mika Niemela
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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19
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Sultan S, Hynes N, Acharya Y, Kavanagh E, Jordan F. Systematic review of the effectiveness of carotid surgery and endovascular carotid stenting versus best medical treatment in managing symptomatic acute carotid artery dissection. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1212. [PMID: 34430653 PMCID: PMC8350712 DOI: 10.21037/atm-20-7279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/04/2021] [Indexed: 01/08/2023]
Abstract
Cervical artery dissection (CeAD) with an intramural haematoma can lead to stroke risk, especially in young patients. We performed comprehensive searches of the Cochrane Stroke Group Trials Register, the CENTRAL, MEDLINE and EMBASE to review the effectiveness of surgical and endovascular interventions versus best medical treatment alone for symptomatic CeAD. Furthermore, we aim to elaborate on the phenotypic individual disease manifestations of spontaneous Cervical Artery Dissection (sCAD) and how they translate into stroke and risk of dissection recurrence. Primary outcomes were ipsilateral stroke and disability. Secondary outcomes were death, any stroke, or transient ischaemic attack, residual stenosis >50%, recurrence of CeAD, expanding pseudo-aneurysm or major bleeding. Our search yielded no randomised controlled trials and/or controlled clinical trials (CCTs) comparing either carotid surgery or endovascular therapy with optimal medical management; thus there was no evidence to support the use of any specific method for management of extracranial CeAD in patients who fail antithrombotic therapy. However, despite the absence of controlled studies to compare surgery or endovascular therapy in patients who fail antithrombotic therapy, carotid surgery in young patients can be justified as a personalized precision approach given the high morbidity and mortality in this age group.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland Galway, Galway, Ireland
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Teaching Hospitals, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Teaching Hospitals, Galway, Ireland
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland Galway, Galway, Ireland
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Teaching Hospitals, Galway, Ireland
| | - Edel Kavanagh
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Teaching Hospitals, Galway, Ireland
| | - Fionnuala Jordan
- College of Nursing and Midwifery, National University of Ireland, Galway, Ireland
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20
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Corcoran Ruiz KM, Rivera Perla KM, Tang OY, Toms SA, Weil RJ. Outcomes after clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage among dual-eligible beneficiaries. J Clin Neurosci 2021; 90:48-55. [PMID: 34275580 DOI: 10.1016/j.jocn.2021.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/24/2021] [Accepted: 05/02/2021] [Indexed: 11/26/2022]
Abstract
Dual-eligible beneficiaries, individuals with both Medicare and Medicaid coverage, represent a high-cost and vulnerable population; however, literature regarding outcomes is sparse. We characterized outcomes in dual-eligible beneficiaries treated for aneurysmal subarachnoid hemorrhage (aSAH) compared to Medicare only, Medicaid only, private insurance, and self-pay. A 10-year cross-sectional study of the National Inpatient Sample was conducted. Adult aSAH emergency admissions treated by neurosurgical clipping or endovascular coiling were included. Multivariable regression was used to adjust for confounders. A total of 57,666 patients met inclusion criteria. Dual-eligibles comprised 2.8% of admissions and were on average younger (62.4 years) than Medicare (70.0 years), older than all other groups, and had higher mean National Inpatient Sample-Subarachnoid Hemorrhage Severity Scores than all other groups (p ≤ 0.001). Among patients treated by clipping, dual-eligibles were less often discharged to home compared to Medicare (adjusted odds ratio (aOR) = 0.51, 95% CI = 0.30-0.87, p < 0.05) and all other insurance groups, p < 0.01. Likewise, those who received coiling were less often discharged to home compared to Medicaid (aOR = 0.41, 95% CI = 0.23-0.73), private (aOR = 0.42, 95% CI = 0.23-0.76) and self-pay patients (aOR = 0.24, 95% CI = 0.12-0.46). They also had increased odds of poor National Inpatient Sample-Subarachnoid Hemorrhage Outcome Measures compared to Medicaid, private, and self-pay patients, all p < 0.05. There were no differences in inpatient mortality or total complications. In conclusion, dual-eligible patients had higher aSAH severity scores, less often discharged home, and among patients who received coiling, dual-eligibles had increased odds of poor outcome. Dual-eligible patients with aSAH represent a vulnerable population that may benefit from targeted clinical and public policy initiatives.
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Affiliation(s)
- Kiara M Corcoran Ruiz
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Krissia M Rivera Perla
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Oliver Y Tang
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
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21
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 493] [Impact Index Per Article: 164.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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22
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Hynes N, Kavanagh EP, Sultan S, Jordan F. Surgical and radiological interventions for treating symptomatic extracranial cervical artery dissection. Cochrane Database Syst Rev 2021; 2:CD013118. [PMID: 34559418 PMCID: PMC8078186 DOI: 10.1002/14651858.cd013118.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cervical artery dissection (CeAD) is a pathological bleed or tear, or both, in the wall of the carotid or vertebral arteries as they course through the neck, and is a leading cause of stroke in young people. OBJECTIVES To assess the effectiveness of surgical and radiological interventions versus best medical treatment alone for treating symptomatic cervical artery dissection. SEARCH METHODS We performed comprehensive searches of the Cochrane Stroke Group Trials Register (last searched March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL), 2020, Issue 4, in the Cochrane Library (searched March 2020), MEDLINE (1946 to March 2020) and Embase (1974 to March 2020). We searched relevant ongoing trials and research registers (searched March 2020), checked references in all relevant papers for additional eligible studies, and contacted authors and researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of either surgical or endovascular intervention for the management of symptomatic CeAD were eligible for inclusion. Only studies with anticoagulants or antiplatelet treatment as the control group were included. Two review authors planned to independently extract data. DATA COLLECTION AND ANALYSIS Primary outcomes were ipsilateral stroke and disability. Secondary outcomes were death, any stroke, or transient ischaemic attack, residual stenosis (> 50%), recurrence of cervical dissection, expanding pseudoaneurysm, or major bleeding. We analysed the studies according to the first choice of treatment. We planned to assess for risk of bias and apply GRADE criteria for any included studies. MAIN RESULTS We did not find any completed RCTs or CCTs undertaken in this area of research. AUTHORS' CONCLUSIONS No RCTs or CCTs compared either surgery or endovascular therapy with control. Thus, there is no available evidence to support their use for the treatment of extracranial cervical artery dissection in addition to antithrombotic therapy in people who continue to have neurological symptoms when treated with antithrombotic therapy alone.
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Affiliation(s)
- Niamh Hynes
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
| | - Edel P Kavanagh
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
- Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
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Medially displaced common and internal carotid arteries presenting as a pulsatile mass: Clinicoradiologic analysis of 62 cases. EAR, NOSE & THROAT JOURNAL 2020. [DOI: 10.1177/0145561320960347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Kesserwani H. Isolated Palsy of the Cisternal Segment of the Hypoglossal Nerve Due to Arterial Dissection of the V4 Segment of the Vertebral Artery: A Case Report With a Side Note on Nerve Trunk Ischemia. Cureus 2020; 12:e9930. [PMID: 32968591 PMCID: PMC7505623 DOI: 10.7759/cureus.9930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We describe the case of a 57-year-old woman who developed severe left-sided neck pain followed by difficulty chewing, oropharyngeal dysphagia, and dysarthria. Clinically, she developed an isolated left-sided deviation of the tongue with protrusion; an isolated cisternal hypoglossal nerve palsy. A magnetic resonance angiogram imaging study revealed a left V4 cisternal vertebral artery dissection with normal diffusion-weighted imaging of the lower medulla. We outline the anatomy, histology, and pathophysiology of ischemic injury of nerve trunks and briefly review the recent trials of vertebral and carotid artery dissections.
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25
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Althwanay A, Alamri A, Almuaigel MF. Spontaneous Bilateral Dissection of the Vertebral Artery: A Case Report. Cureus 2020; 12:e9310. [PMID: 32839679 PMCID: PMC7440263 DOI: 10.7759/cureus.9310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Spontaneous dissection of the vertebral artery refers to cases that do not involve significant blunt or penetrating trauma as a precipitating factor. However, cases of spontaneous dissection of the vertebral artery do have a history of trivial or minor injury involving some degree of cervical distortion such as chiropractic neck manipulation, as the extreme hyperextension and/or rotation of the neck may create areas of stretch and lead to intimal or adventitial tears in the vertebral artery causing dissection. It is a relatively rare, potentially disabling and sometimes an under-diagnosed cause of stroke. It accounts for 2% of all ischemic strokes and 7% of the cases are bilateral. Herein we present a case of bilateral vertebral artery dissection complicated by basilar artery stroke in a young male patient following chiropractic manipulation of the neck. Neuroimaging modalities upon presentation confirmed the diagnosis. Antiplatelets were administered, and a great clinical outcome after three months was achieved. This report demonstrates the potential hazards associated with neck trauma, including chiropractic manipulation, as it is under reported in Saudi Arabia.
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Tejada Meza H, Artal Roy J, Serrano Ponz M, Guelbenzu Morte S, Marta Moreno J. Pseudooclusión carotídea: un concepto a tener en cuenta en el ictus agudo. Neurologia 2020; 35:344-345. [DOI: 10.1016/j.nrl.2017.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 09/13/2017] [Accepted: 09/22/2017] [Indexed: 11/29/2022] Open
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Tejada Meza H, Artal Roy J, Serrano Ponz M, Guelbenzu Morte S, Marta Moreno J. Carotid pseudo-occlusion: a concept to consider in acute stroke. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2017.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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High-resolution compressed-sensing time-of-flight MRA in a case of acute ICA/MCA dissection. Neuroradiology 2020; 62:753-756. [PMID: 32198564 DOI: 10.1007/s00234-020-02395-y] [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: 12/29/2019] [Accepted: 03/04/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Acute, isolated intracranial dissection (ICD) represents a rare and challenging cause of acute stroke. DSA is considered to be the gold standard imaging modality in patients with ICD. The role of novel, high-resolution (HR) compressed-sensing (CS) time-of-flight (TOF) MRA techniques in ICDs is unclear. METHODS A 22-year-old male patient with an isolated right ICA/MCA intracranial dissection underwent "conventional" 3-T TOF MRA, HR CS TOF MRA and also DSA including digital rotational angiography. RESULTS Unlike the "conventional" TOF MRA, HR CS TOF MRA provided comparable image quality to rotational angiography and a dissection membrane was clearly visible in both techniques. CONCLUSION In this single case study, we demonstrated the feasibility of a novel HR CS TOF in a case of an acute isolated intracranial ICA/MCA dissection, which needs to be validated in a larger case series.
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Traumatic Neuroemergency: Imaging Patients with Traumatic Brain Injury—An Introduction. ACTA ACUST UNITED AC 2020. [DOI: 10.1007/978-3-030-38490-6_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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The structural properties of carotid arteries in carotid artery diseases - a retrospective computed tomography angiography study. Pol J Radiol 2020; 85:e82-e89. [PMID: 32467741 PMCID: PMC7247020 DOI: 10.5114/pjr.2020.93367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 01/20/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose Aim of the study was to find answers to the following questions: What haemodynamic changes may occur in patients with stenotic, aneurysmal, dissection of the carotid artery and its branches? How do these changes differ in patients with normal and carotid disease? Material and methods In order to achieve this aim, the cranio-cervical CT angiography images of patients who were referred to our clinic for any reason and received the diagnosis of carotid stenosis, carotid dissection, and extra or intracranial aneurysm were reviewed retrospectively. Results Significant differences were detected in the carotid arteries of normal patients and those with aneurysm and dissection. When normal and aneurismal patients were compared, right and left ICA diameters (p = 0.000, p = 0.002, respectively), total ICA diameters (p = 0.000), carotid left Ø diameters (p = 0.026), right and left total Ø diameters (p = 0.024), and Murray’s and our cosine values of Ø angles (p = 0.001 and p = 0.022, respectively) were found to be different. Also, in a comparison made between normal patients and patients with dissection, right CCA (p = 0.000), ICA (p = 0.001), ECA (p = 0.004) diameters, total CCA (p = 0.001), ICA (p = 0.009), and ECA (p = 0.003) diameters were also found to be different. Conclusions This study showed that the presence of aneurysm plays an important role in the remodelling of the carotid arteries. Also, it is understood that Murray’s laws are still valid for the detection of structural deterioration in carotid artery diseases. Hence, it is believed that these data can be used in artificial intelligence studies.
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Helou E, Sweid A, Tjoumakaris S, Herial N, Gooch MR, Rosenwasser RH, Jabbour P. Case Report of De Novo Cavernous Carotid Artery Aneurysm After an Acute Stroke Intervention for a Carotid Occlusion. World Neurosurg 2019; 128:336-339. [DOI: 10.1016/j.wneu.2019.05.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/10/2019] [Accepted: 05/11/2019] [Indexed: 12/18/2022]
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Ducène C, Coolen T, Horoi M, Thill MP. Two cases of pulsatile tinnitus: Key points for the clinician. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 136:S53-S55. [PMID: 30872004 DOI: 10.1016/j.anorl.2018.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/29/2018] [Accepted: 09/21/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Pulsatile tinnitus is a sound generated by an acoustic source from within the body, which is perceived by the auditory system of the patient. CASES SUMMARY We report two puzzling cases of pulsatile tinnitus with normal ENT examinations: the first was due to a cervical internal carotid artery dissection, and the second to the compression of the foramina of Monro by a craniopharyngioma, leading to hydrocephalus. DISCUSSION We review the systematic management and emphasize the decisive role of the ENT clinician regarding this pulsatile tinnitus complaint, because of the potentially severe complications of its underlying pathology.
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Affiliation(s)
- C Ducène
- ENT department, CHU Saint-Pierre, 322, rue Haute, 1000 Bruxelles, Belgium.
| | - T Coolen
- CUB Erasme, Radiology department, 808 route de Lennik, 1070 Bruxelles, Belgium
| | - M Horoi
- ENT department, CHU Saint-Pierre, 322, rue Haute, 1000 Bruxelles, Belgium
| | - M-P Thill
- ENT department, CHU Saint-Pierre, 322, rue Haute, 1000 Bruxelles, Belgium
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Updates in the Management of Cerebral Infarctions and Subarachnoid Hemorrhage Secondary to Intracranial Arterial Dissection: A Systematic Review. World Neurosurg 2019; 121:51-58. [DOI: 10.1016/j.wneu.2018.09.153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 01/10/2023]
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"Crick" in Neck Followed by Massage Led to Stroke: Uncommon Case of Vertebral Artery Dissection. World Neurosurg 2018; 115:41-43. [PMID: 29653277 DOI: 10.1016/j.wneu.2018.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/31/2018] [Accepted: 04/02/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Vertebral artery dissection (VAD) is an important cause of stroke in young and a known complication of spinal manipulation procedures, although dissection following neck massage has rarely been reported in literature. Head and neck massage by improperly trained salon employees is very popular and widely practiced in developing countries like India. In the present report we present a case of VAD following neck massage. MATERIAL AND METHODS We present an unusual case of VAD in a 30-year-old male patient following an episode of neck massage. He developed headache, nausea, vomiting, blurred vision, diplopia, dizziness, and ataxia following the procedure. Initial history and examination suggested that the patient's symptoms were vascular in origin. We also discuss a brief review of the pathology, diagnosis, symptomatology, treatment, prognosis, and occurrence of this rare entity. RESULTS Computed tomography and magnetic resonance imaging of the brain revealed acute infarction of the left cerebellar hemisphere. Digital subtraction angiography showed narrowing and dilatation of the V3 segment of the left vertebral artery with narrowing of the V4 segment consistent with dissection, along with a cavernous segment aneurysm of the contralateral internal carotid artery. CONCLUSION This report illustrates the potential hazards associated with neck massage. The vertebral arteries are at risk for dissection, which can lead to acute stroke. This case also suggests that careful history taking and awareness of the symptoms of VAD are necessary to diagnose this entity as timely diagnosis and treatment can prevent permanent disability or even death.
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Arslan IB, Arslan Y, Demirhan E, Genc S, Pekcevik Y, Altin L, Yilmaz Z, Cukurova I. Medially displaced common and internal carotid arteries presenting as a pulsatile mass: Clinicoradiologic analysis of 62 cases. EAR, NOSE & THROAT JOURNAL 2018; 96:E1-E7. [PMID: 28489237 DOI: 10.1177/014556131509404508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We conducted a prospective study to analyze the medially displaced courses of the common carotid artery (CCA) and the cervical segment of the internal carotid artery (ICA) in patients who were diagnosed with a pulsatile mass on nasopharyngolaryngoscopy and by clinicoradiologic findings. Our study group was made up of 62 patients-40 women and 22 men, aged 30 to 88 years (mean: 63.7)-who presented with a submucosal pseudomass or a bulging mass on the pharyngeal wall with obvious pulsation. For comparison purposes, we recruited a control group of 62 consecutively presenting patients who had been admitted to our Neurology Department with acute severe headache and who had undergone CT angiography based on a suspicion of an aneurysm or a vertebral or carotid artery dissection. A medially displaced carotid artery was identified in all patients in the study group. Two main course abnormalities were observed: (1) a pharyngeal superficial placement (PSP), consisting of a bulging or placement immediately adjacent to the naso-orohypopharyngeal lumen, and (2) a retropharyngeal midline placement (RMP), which entailed medialization of the carotid arteries to the midline. A PSP was observed in 11 patients, an RMP was found in 17 patients, and both were seen in 34 patients. The distance from the aberrant carotid artery to the pharyngeal wall and to the retropharyngeal midline of the retropharynx was measured at four levels: nasopharyngeal, retropalatal, retroglossal, and retroepiglottic in both groups. The mean distance was significantly shorter in the study group than in the control group at all four levels (p < 0.002). We conclude that the most likely diagnosis of a pulsatile mass detected on nasopharyngolaryngoscopy is an aberrant CCA or cervical ICA.
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Affiliation(s)
- Ilker Burak Arslan
- Head and Neck Surgery Clinic, Izmir Tepecik Egitim ve Arastirma Hastanesi KBB Klinigi, Gaziler cad. No: 468, 35170 Yenisehir Izmir, Turkey.
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Mehdi E, Aralasmak A, Toprak H, Yıldız S, Kurtcan S, Kolukisa M, Asıl T, Alkan A. Craniocervical Dissections: Radiologic Findings, Pitfalls, Mimicking Diseases: A Pictorial Review. Curr Med Imaging 2018; 14:207-222. [PMID: 29853818 PMCID: PMC5902863 DOI: 10.2174/1573405613666170403102235] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Craniocervical Dissections (CCD) are a crucial emergency state causing 20% of strokes in patients under the age of 45. Although DSA (digital substraction angiography) is regarded as the gold standard, noninvasive methods of CT, CTA and MRI, MRA are widely used for diagnosis. Aim: Our aim is to illustrate noninvasive imaging findings in CCD. Conclusion: Emphasizing on diagnostic pitfalls, limitations and mimicking diseases.
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Affiliation(s)
- Elnur Mehdi
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Ayse Aralasmak
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Huseyin Toprak
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Seyma Yıldız
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Serpil Kurtcan
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
| | - Mehmet Kolukisa
- Bezmialem Vakif University, Department of Neurology, Istanbul, Turkey
| | - Talip Asıl
- Bezmialem Vakif University, Department of Neurology, Istanbul, Turkey
| | - Alpay Alkan
- Bezmialem Vakif University, Department of Radiology, Istanbul, Turkey
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Tan HW, Chen X, Maingard J, Barras CD, Logan C, Thijs V, Kok HK, Lee MJ, Chandra RV, Brooks M, Asadi H. Intracranial Vessel Wall Imaging with Magnetic Resonance Imaging: Current Techniques and Applications. World Neurosurg 2018; 112:186-198. [PMID: 29360586 DOI: 10.1016/j.wneu.2018.01.083] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 11/19/2022]
Abstract
Vessel wall magnetic resonance imaging (VW-MRI) is a modern imaging technique with expanding applications in the characterization of intracranial vessel wall pathology. VW-MRI provides added diagnostic capacity compared with conventional luminal imaging methods. This review explores the principles of VW-MRI and typical imaging features of various vessel wall pathologies, such as atherosclerosis, dissection, and vasculitis. Radiologists should be familiar with this important imaging technique, given its increasing use and future relevance to everyday practice.
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Affiliation(s)
- Haur Wey Tan
- Department of Radiology, Austin Hospital, Melbourne, Australia.
| | - Xiao Chen
- Department of Radiology, Austin Hospital, Melbourne, Australia
| | - Julian Maingard
- Department of Radiology, Austin Hospital, Melbourne, Australia; Department of Interventional Neuroradiology Service, Austin Hospital, Melbourne, Australia; Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia
| | - Christen D Barras
- Lysholm Department of Neuroradiology, The National Hospital for Neurology and Neurosurgery, London, United Kingdom; The South Australian Health and Medical Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | | | - Vincent Thijs
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Hong Kuan Kok
- Department of Interventional Radiology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael J Lee
- Department of Radiology, Beaumont Hospital, Dublin, Ireland; Interventional Radiology Service, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons Ireland, Dublin, Ireland
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia; Department of Imaging, Monash University, Melbourne, Victoria, Australia
| | - Mark Brooks
- Department of Interventional Neuroradiology Service, Austin Hospital, Melbourne, Australia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia; Department of Radiology, Interventional Neuroradiology Service, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Hamed Asadi
- Department of Interventional Neuroradiology Service, Austin Hospital, Melbourne, Australia; Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia; Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia
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Sporns PB, Niederstadt T, Heindel W, Raschke MJ, Hartensuer R, Dittrich R, Hanning U. Imaging of Spontaneous and Traumatic Cervical Artery Dissection : Comparison of Typical CT Angiographic Features. Clin Neuroradiol 2018; 29:269-275. [PMID: 29374294 DOI: 10.1007/s00062-018-0666-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 01/12/2018] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Cervical artery dissection (CAD) is an important etiology of ischemic stroke and early recognition is vital to protect patients from the major complication of cerebral embolization by administration of anticoagulants. The etiology of arterial dissections differ and can be either spontaneous or traumatic. Even though the historical gold standard is still catheter angiography, recent studies suggest a good performance of computed tomography angiography (CTA) for detection of CAD. We conducted this research to evaluate the variety and frequency of possible imaging signs of spontaneous and traumatic CAD and to guide neuroradiologists' decision making. METHODS Retrospective review of the database of our multiple injured patients admitted to the Department of Trauma, Hand, and Reconstructive Surgery of the University Hospital Münster in Germany (a level 1 trauma center) for patients with traumatic CAD (tCAD) and of our stroke database (2008-2015) for patients with spontaneous CAD (sCAD) and CT/CTA on initial clinical work-up. All images were evaluated concerning specific and sensitive radiological features for dissection by two experienced neuroradiologists. Imaging features were compared between the two etiologies. RESULTS This study included 145 patients (99 male, 46 female; 45 ± 18.8 years of age), consisting of 126 dissected arteries with a traumatic and 43 with spontaneous etiology. Intimal flaps were more frequently observed after traumatic etiology (58.1% tCADs, 6.9% sCADs; p < 0.001); additionally, multivessel dissections were much more frequent in trauma patients (3 sCADs, 21 tCADs) and only less than half (42%) of the patients with traumatic dissections showed cervical spine fractures. CONCLUSION Neuroradiologists should be aware that intimal flaps and multivessel dissections are more common after a traumatic etiology. In addition, it seems important to conduct a CTA in a trauma setting, even if no cervical spine fracture is detected.
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Affiliation(s)
- Peter B Sporns
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Thomas Niederstadt
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Walter Heindel
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany
| | - René Hartensuer
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany
| | - Ralf Dittrich
- Department of Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Uta Hanning
- Department of Clinical Radiology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Do KH, Leggit JC, Galifianakis A. Extracranial Vertebral Artery Dissecting Aneurysm with Snowboarding: A Case Report. Curr Sports Med Rep 2018; 17:16-19. [PMID: 29315103 DOI: 10.1249/jsr.0000000000000441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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40
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Chandra A, Stone CR, Li WA, Geng X, Ding Y. The cerebral circulation and cerebrovascular disease II: Pathogenesis of cerebrovascular disease. Brain Circ 2017; 3:57-65. [PMID: 30276306 PMCID: PMC6126265 DOI: 10.4103/bc.bc_11_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/20/2017] [Accepted: 06/01/2017] [Indexed: 12/12/2022] Open
Abstract
In this paper, we review the cerebral circulation and cerebrovascular disease (CVD) with an overview of the major types of CVD pathogenesis. These, as categorized here, are as follows: occlusive injury intrinsic to blood vessels, occlusive injury extrinsic to blood vessels, cerebral hypoperfusion, and cerebral hemorrhage. Following an overview of each of these categories, we conclude with a discussion of cerebral edema to illustrate how the pathological origins we covered can progress clinically. The content of this paper sets the stage for the detailed, clinically oriented discussion of stroke with which our series culminates in its subsequent Part III.
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Affiliation(s)
- Ankush Chandra
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Christopher R Stone
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - William A Li
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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Traenka C, Dougoud D, Simonetti BG, Metso TM, Debette S, Pezzini A, Kloss M, Grond-Ginsbach C, Majersik JJ, Worrall BB, Leys D, Baumgartner R, Caso V, Béjot Y, Compter A, Reiner P, Thijs V, Southerland AM, Bersano A, Brandt T, Gensicke H, Touzé E, Martin JJ, Chabriat H, Tatlisumak T, Lyrer P, Arnold M, Engelter ST. Cervical artery dissection in patients ≥60 years. Neurology 2017; 88:1313-1320. [DOI: 10.1212/wnl.0000000000003788] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 01/12/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:In a cohort of patients diagnosed with cervical artery dissection (CeAD), to determine the proportion of patients aged ≥60 years and compare the frequency of characteristics (presenting symptoms, risk factors, and outcome) in patients aged <60 vs ≥60 years.Methods:We combined data from 3 large cohorts of consecutive patients diagnosed with CeAD (i.e., Cervical Artery Dissection and Ischemic Stroke Patients–Plus consortium). We dichotomized cases into 2 groups, age ≥60 and <60 years, and compared clinical characteristics, risk factors, vascular features, and 3-month outcome between the groups. First, we performed a combined analysis of pooled individual patient data. Secondary analyses were done within each cohort and across cohorts. Crude and adjusted odds ratios (OR [95% confidence interval]) were calculated.Results:Among 2,391 patients diagnosed with CeAD, we identified 177 patients (7.4%) aged ≥60 years. In this age group, cervical pain (ORadjusted 0.47 [0.33–0.66]), headache (ORadjusted 0.58 [0.42–0.79]), mechanical trigger events (ORadjusted 0.53 [0.36–0.77]), and migraine (ORadjusted 0.58 [0.39–0.85]) were less frequent than in younger patients. In turn, hypercholesterolemia (ORadjusted 1.52 [1.1–2.10]) and hypertension (ORadjusted 3.08 [2.25–4.22]) were more frequent in older patients. Key differences between age groups were confirmed in secondary analyses. In multivariable, adjusted analyses, favorable outcome (i.e., modified Rankin Scale score 0–2) was less frequent in the older age group (ORadjusted 0.45 [0.25, 0.83]).Conclusion:In our study population of patients diagnosed with CeAD, 1 in 14 was aged ≥60 years. In these patients, pain and mechanical triggers might be missing, rendering the diagnosis more challenging and increasing the risk of missed CeAD diagnosis in older patients.
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Grossberg JA, Haussen DC, Cardoso FB, Rebello LC, Bouslama M, Anderson AM, Frankel MR, Nogueira RG. Cervical Carotid Pseudo-Occlusions and False Dissections. Stroke 2017; 48:774-777. [DOI: 10.1161/strokeaha.116.015427] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 11/07/2016] [Accepted: 11/28/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Pseudo-occlusion (PO) of the cervical internal carotid artery (ICA) refers to an isolated occlusion of the intracranial ICA that appears as an extracranial ICA occlusion on computed tomography angiography (CTA) or digital subtraction angiography because of blockage of distal contrast penetration by a stagnant column of unopacified blood. We aim to better characterize this poorly recognized entity.
Methods—
Retrospective review of an endovascular database (2010–2015; n=898). Only patients with isolated intracranial ICA occlusions as confirmed by angiographic exploration were included. CTA and digital subtraction angiography images were categorized according to their apparent site of occlusion as (1) extracranial ICA PO or (2) discernible intracranial ICA occlusion.
Results—
Cervical ICA PO occurred in 21/46 (46%) patients on CTA (17 proximal cervical; 4 midcervical). Fifteen (71%) of these patients also had PO on digital subtraction angiography. A flame-shaped PO mimicking a carotid dissection was seen in 7 (33%) patients on CTA and in 6 (29%) patients on digital subtraction angiography. Patients with and without CTA PO had similar age (64.8±17.1 versus 60.2±15.7 years;
P
=0.35), sex (male, 47% versus 52%;
P
=1.00), and intravenous tissue-type plasminogen activator use (38% versus 40%;
P
=1.00). The rates of modified Treatment In Cerebral Ischemia 2b-3 reperfusion were 71.4% in the PO versus 100% in the non-PO cohorts (
P
<0.01). The rates of parenchymal hematoma, 90-day modified Rankin Scale score 0–2, and 90-day mortality were 4.8% versus 8% (
P
=0.66), 40% versus 66.7% (
P
=0.12), and 25% versus 21% (
P
=0.77) in PO versus non-PO patients, respectively. Multivariate analysis indicated that PO patients had lower chances of modified Treatment In Cerebral Ischemia 3 reperfusion (odds ratio 0.14; 95% confidence interval 0.02–0.70;
P
=0.01).
Conclusions—
Cervical ICA PO is a relatively common entity and may be associated with decreased reperfusion rates.
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Affiliation(s)
- Jonathan A. Grossberg
- From the Department of Neurosurgery (J.A.G), and Department of Neurology (D.C.H., L.C.R., M.B., A.M.A., M.R.K., R.G.N.), Emory University/Grady Memorial Hospital, Atlanta, GA; and Department of Neurology, Universidade Estadual de Campinas, SP, Brasil (F.B.C)
| | - Diogo C. Haussen
- From the Department of Neurosurgery (J.A.G), and Department of Neurology (D.C.H., L.C.R., M.B., A.M.A., M.R.K., R.G.N.), Emory University/Grady Memorial Hospital, Atlanta, GA; and Department of Neurology, Universidade Estadual de Campinas, SP, Brasil (F.B.C)
| | - Fabricio B. Cardoso
- From the Department of Neurosurgery (J.A.G), and Department of Neurology (D.C.H., L.C.R., M.B., A.M.A., M.R.K., R.G.N.), Emory University/Grady Memorial Hospital, Atlanta, GA; and Department of Neurology, Universidade Estadual de Campinas, SP, Brasil (F.B.C)
| | - Leticia C. Rebello
- From the Department of Neurosurgery (J.A.G), and Department of Neurology (D.C.H., L.C.R., M.B., A.M.A., M.R.K., R.G.N.), Emory University/Grady Memorial Hospital, Atlanta, GA; and Department of Neurology, Universidade Estadual de Campinas, SP, Brasil (F.B.C)
| | - Mehdi Bouslama
- From the Department of Neurosurgery (J.A.G), and Department of Neurology (D.C.H., L.C.R., M.B., A.M.A., M.R.K., R.G.N.), Emory University/Grady Memorial Hospital, Atlanta, GA; and Department of Neurology, Universidade Estadual de Campinas, SP, Brasil (F.B.C)
| | - Aaron M. Anderson
- From the Department of Neurosurgery (J.A.G), and Department of Neurology (D.C.H., L.C.R., M.B., A.M.A., M.R.K., R.G.N.), Emory University/Grady Memorial Hospital, Atlanta, GA; and Department of Neurology, Universidade Estadual de Campinas, SP, Brasil (F.B.C)
| | - Michael R. Frankel
- From the Department of Neurosurgery (J.A.G), and Department of Neurology (D.C.H., L.C.R., M.B., A.M.A., M.R.K., R.G.N.), Emory University/Grady Memorial Hospital, Atlanta, GA; and Department of Neurology, Universidade Estadual de Campinas, SP, Brasil (F.B.C)
| | - Raul G. Nogueira
- From the Department of Neurosurgery (J.A.G), and Department of Neurology (D.C.H., L.C.R., M.B., A.M.A., M.R.K., R.G.N.), Emory University/Grady Memorial Hospital, Atlanta, GA; and Department of Neurology, Universidade Estadual de Campinas, SP, Brasil (F.B.C)
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Berntsen EM. Cervical artery dissection - choice of diagnostic imaging. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:166. [PMID: 28181743 DOI: 10.4045/tidsskr.16.1087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Limbucci N, Nappini S, Rosi A, Renieri L, Consoli A, Mangiafico S. Intentional subintimal carotid stenting of internal carotid dissection in a patient with acute ischaemic stroke. Interv Neuroradiol 2016; 23:69-72. [PMID: 27798324 DOI: 10.1177/1591019916673220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Carotid artery dissection is a common cause of juvenile stroke. Endovascular treatment of acute stroke due to carotid dissection can be challenging, and endoluminal crossing of the dissection is sometimes impossible. We describe a case of intentional subintimal recanalisation of a cervical carotid dissection followed by intracranial thrombectomy and stenting. We report the case of a young woman with severe acute ischaemic stroke due to carotid artery dissection and intracranial embolism. After failure of endoluminal crossing of the dissected segment, intentional subintimal crossing with re-entry distally to the dissection was achieved and a stent was deployed. Then, middle cerebral artery thrombectomy was performed achieving good recanalisation. Acute thrombus formed in the bulged segment of the carotid stent and was managed with additional stent placement. The patient had a good clinical recovery. In selected cases, after failure of conventional techniques, subintimal recanalisation of carotid dissections may be performed.
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Affiliation(s)
- Nicola Limbucci
- Interventional Neuroradiology Unit, Careggi University Hospital, Italy
| | - Sergio Nappini
- Interventional Neuroradiology Unit, Careggi University Hospital, Italy
| | - Andrea Rosi
- Interventional Neuroradiology Unit, Careggi University Hospital, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, Careggi University Hospital, Italy
| | - Arturo Consoli
- Interventional Neuroradiology Unit, Careggi University Hospital, Italy
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Posterior atlantoaxial fusion as treatment option for extracranial vertebral artery dissecting aneurysm: a case report and literature review. Acta Neurochir (Wien) 2016; 158:1741-4. [PMID: 27383200 DOI: 10.1007/s00701-016-2891-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
Abstract
Symptomatic extracranial vertebral artery (VA) dissection may need surgery. We describe such a case successfully treated with atlantoaxial fusion based on its rare dynamic angiographic findings. A 27-year-old woman suffered from repeated brainstem and cerebellar infarctions from a left extracranial VA dissecting aneurysm. Dynamic angiography showed the dissecting aneurysm of the V3 segment in the neutral head position, and deflation of the aneurysm during rightward head rotation. She underwent posterior atlantoaxial fusion, and the lesion was repaired with no subsequent ischemia. Posterior atlantoaxial fusion can be an option for some extracranial VA dissections with preserving its anterograde blood flow.
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Kim BJ, Yang E, Kim NY, Kim MJ, Kang DW, Kwon SU, Kim JS. Vascular Tortuosity May Be Associated With Cervical Artery Dissection. Stroke 2016; 47:2548-52. [PMID: 27531344 DOI: 10.1161/strokeaha.116.013736] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 07/18/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Dissection is an increasingly recognized cause of ischemic stroke, which occurs spontaneously or after trauma, in relatively young patients. We hypothesized that there might be a predisposing factor weakening the vascular wall and that arterial tortuosity might be higher in patients with dissection. METHODS We consecutively enrolled cervical artery dissection (CerAD) patients who had undergone magnetic resonance angiography. Age- and sex-matched healthy subjects who underwent magnetic resonance angiography in a routine health examination were used as controls. The tortuosity was measured semiautomatically from the carotid artery and vertebral artery (VA) arteries. Tortuosity index was defined as: [(arc/chord)-1×100] in each arteries. Independent risk factors associated with CerAD were investigated using multivariable analysis. Subgroup analysis according to the dissected artery was performed. RESULTS There were no differences in vascular risk factors between the 75 CerAD patients and the 75 controls. The tortuosity indexes of the contralesional VA (16.3±6.8 versus 12.1±4.5, respectively; P<0.001) and carotid artery (8.8±4.0 versus 7.3±2.9, respectively; P=0.01) were higher in patients with CerAD compared with those of control subjects. VA tortuosity (odds ratio, 1.175; P=0.001) was independently associated with the presence of CerAD. In subgroup analysis, VA tortuosity was significantly higher in 57 patients with VA dissection than in controls (P<0.001), and carotid artery tortuosity was marginally higher in 18 patients with carotid artery dissection (P=0.05). CONCLUSIONS CerAD is associated with tortuous cervical arteries, which may implicate weakened cervical vascular structure in these patients.
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Affiliation(s)
- Bum Joon Kim
- From the Department of Neurology, Kyung Hee University Hospital, Kyung Hee University, College of Medicine, Seoul, Korea (B.J.K.); Department of Neurology, University of Ulsan (B.J.K., N.-Y.K., D.-W.K., S.U.K., J.S.K.), Health Screening and Promotion Center (M.-J.K.), and Asan Institute of Life Science (E.Y.), Asan Medical Center, Seoul, Korea
| | - Ewha Yang
- From the Department of Neurology, Kyung Hee University Hospital, Kyung Hee University, College of Medicine, Seoul, Korea (B.J.K.); Department of Neurology, University of Ulsan (B.J.K., N.-Y.K., D.-W.K., S.U.K., J.S.K.), Health Screening and Promotion Center (M.-J.K.), and Asan Institute of Life Science (E.Y.), Asan Medical Center, Seoul, Korea
| | - Na-Young Kim
- From the Department of Neurology, Kyung Hee University Hospital, Kyung Hee University, College of Medicine, Seoul, Korea (B.J.K.); Department of Neurology, University of Ulsan (B.J.K., N.-Y.K., D.-W.K., S.U.K., J.S.K.), Health Screening and Promotion Center (M.-J.K.), and Asan Institute of Life Science (E.Y.), Asan Medical Center, Seoul, Korea
| | - Mi-Jung Kim
- From the Department of Neurology, Kyung Hee University Hospital, Kyung Hee University, College of Medicine, Seoul, Korea (B.J.K.); Department of Neurology, University of Ulsan (B.J.K., N.-Y.K., D.-W.K., S.U.K., J.S.K.), Health Screening and Promotion Center (M.-J.K.), and Asan Institute of Life Science (E.Y.), Asan Medical Center, Seoul, Korea
| | - Dong-Wha Kang
- From the Department of Neurology, Kyung Hee University Hospital, Kyung Hee University, College of Medicine, Seoul, Korea (B.J.K.); Department of Neurology, University of Ulsan (B.J.K., N.-Y.K., D.-W.K., S.U.K., J.S.K.), Health Screening and Promotion Center (M.-J.K.), and Asan Institute of Life Science (E.Y.), Asan Medical Center, Seoul, Korea
| | - Sun U Kwon
- From the Department of Neurology, Kyung Hee University Hospital, Kyung Hee University, College of Medicine, Seoul, Korea (B.J.K.); Department of Neurology, University of Ulsan (B.J.K., N.-Y.K., D.-W.K., S.U.K., J.S.K.), Health Screening and Promotion Center (M.-J.K.), and Asan Institute of Life Science (E.Y.), Asan Medical Center, Seoul, Korea
| | - Jong S Kim
- From the Department of Neurology, Kyung Hee University Hospital, Kyung Hee University, College of Medicine, Seoul, Korea (B.J.K.); Department of Neurology, University of Ulsan (B.J.K., N.-Y.K., D.-W.K., S.U.K., J.S.K.), Health Screening and Promotion Center (M.-J.K.), and Asan Institute of Life Science (E.Y.), Asan Medical Center, Seoul, Korea.
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47
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Alexander MD, Yuan C, Rutman A, Tirschwell DL, Palagallo G, Gandhi D, Sekhar LN, Mossa-Basha M. High-resolution intracranial vessel wall imaging: imaging beyond the lumen. J Neurol Neurosurg Psychiatry 2016; 87:589-97. [PMID: 26746187 PMCID: PMC5504758 DOI: 10.1136/jnnp-2015-312020] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/23/2015] [Indexed: 01/21/2023]
Abstract
Accurate and timely diagnosis of intracranial vasculopathies is important due to significant risk of morbidity with delayed and/or incorrect diagnosis both from the disease process as well as inappropriate therapies. Conventional vascular imaging techniques for analysis of intracranial vascular disease provide limited information since they only identify changes to the vessel lumen. New advanced MR intracranial vessel wall imaging (IVW) techniques can allow direct characterisation of the vessel wall. These techniques can advance diagnostic accuracy and may potentially improve patient outcomes by better guided treatment decisions in comparison to previously available invasive and non-invasive techniques. While neuroradiological expertise is invaluable in accurate examination interpretation, clinician familiarity with the application and findings of the various vasculopathies on IVW can help guide diagnostic and therapeutic decision-making. This review article provides a brief overview of the technical aspects of IVW and discusses the IVW findings of various intracranial vasculopathies, differentiating characteristics and indications for when this technique can be beneficial in patient management.
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Affiliation(s)
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Aaron Rutman
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - David L Tirschwell
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Gerald Palagallo
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Dheeraj Gandhi
- Department of Radiology, Neurology and Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington, Seattle, Washington, USA
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State-of-art in surgical treatment of dissecting posterior circulation intracranial aneurysms. Neurosurg Rev 2016; 41:31-45. [PMID: 27215913 DOI: 10.1007/s10143-016-0749-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/17/2016] [Accepted: 04/09/2016] [Indexed: 11/27/2022]
Abstract
Vertebrobasilar (VB) intracranial dissecting aneurysms (IDAs) pose difficult therapeutic issues and are especially among the most difficult to manage surgically. There are, however, some cases where selective aneurysm obliteration by endovascular approach is impossible or is associated with an unacceptable risk of morbidity. This is particularly true when the aneurysm is dissecting, giant, or has a large neck. In such cases, surgical treatment may be the only alternative. Optimal management of these lesions is therefore challenging and treatment decisions have to be made on a case-by-case basis. Ideal treatment should be a complete surgical excision of the lesion; however, this procedure might only be possible after distal and proximal vessel wall occlusion which might not be tolerated by the patient depending on the location of the aneurysm. Therefore, formulation of recommendations concerning the surgical strategy remains still difficult due to inconsistency of surgical outcomes. The literature describing surgical strategy of VB IDAs is varying in quality and content, and many studies deal with only a few patients. In the presented review, the authors summarize the current knowledge on the incidence, pathogenesis, clinical presentation, and diagnostic procedures with special emphasis on surgical treatment of IDAs in posterior circulation.
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Lin J, Sun Y, Zhao S, Xu J, Zhao C. Safety and Efficacy of Thrombolysis in Cervical Artery Dissection-Related Ischemic Stroke: A Meta-Analysis of Observational Studies. Cerebrovasc Dis 2016; 42:272-9. [DOI: 10.1159/000446004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 04/06/2016] [Indexed: 11/19/2022] Open
Abstract
Background: Although thrombolysis is considered to be the first-line treatment for ischemic stroke, there remains an ongoing controversy on the safety and efficacy of thrombolysis in cervical artery dissection (CAD). The aim of this meta-analysis was to assess observational data related to the safety and efficacy of thrombolysis in CAD-related ischemic stroke. Methods: We performed a systematic search of the efficacy of thrombolysis treatment in CAD-related ischemic stroke with appropriate observational studies identified for the study. The meta-analysis models in Comprehensive Meta-Analysis V2 software were applied to calculate the merged rates of favorable outcome (modified Rankin Scale, mRS 0-2), excellent outcome (mRS 0-1), intracranial hemorrhage (ICH), symptomatic ICH (SICH), mortality and recurrent stroke between thrombolysis and non-thrombolysis in CAD-related stroke. The difference of outcomes and adverse events between the 2 groups was compared by analyzing the pooled OR value and chi-square test using the software SPSS. Results: A total of 846 patients were identified from 10 studies (174 with thrombolysis; 672 with non-thrombolysis). The meta-analysis detected no significant statistical difference in the proportion of CAD-related stroke patients enjoying a favorable outcome at the 3 months' follow-up between the thrombolysis and non-thrombolysis groups (53.7 vs. 58.2%, OR 0.782, χ2 = 0.594, p > 0.05); non-thrombolysis was slightly superior than thrombolysis in terms of excellent outcome (52.4 vs. 34.4%, OR 0.489, χ2 = 9.143, p = 0.002). There was no significant difference in SICH, mortality and recurrent stroke rates between the 2 groups (all p > 0.05). ICH rate was higher in the thrombolysis group of CAD-related stroke patients compared to that in the non-thrombolysis group (12.3 vs. 7.4%, OR 2.647, χ2 = 4.127, p = 0.042). Conclusion: Thrombolysis seems to be equally safe and will achieve an efficacy similar to the efficacy of non-thrombolysis in patients with acute ischemic stroke due to CAD. It is also as effective as thrombolysis in stroke from miscellaneous causes. Therefore, CAD patients experiencing a stroke should not be denied thrombolysis therapy. However, this will need to be confirmed in large-scale randomized studies, especially involving intravenous thrombolysis treatment.
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Nouh A, Hussain M, Mehta T, Yaghi S. Embolic Strokes of Unknown Source and Cryptogenic Stroke: Implications in Clinical Practice. Front Neurol 2016; 7:37. [PMID: 27047443 PMCID: PMC4800279 DOI: 10.3389/fneur.2016.00037] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/07/2016] [Indexed: 12/31/2022] Open
Abstract
Up to a third of strokes are rendered cryptogenic or of undetermined etiology. This number is specifically higher in younger patients. At times, inadequate diagnostic workups, multiple causes, or an under-recognized etiology contributes to this statistic. Embolic stroke of undetermined source, a new clinical entity particularly refers to patients with embolic stroke for whom the etiology of embolism remains unidentified despite through investigations ruling out established cardiac and vascular sources. In this article, we review current classification and discuss important clinical considerations in these patients; highlighting cardiac arrhythmias and structural abnormalities, patent foramen ovale, paradoxical sources, and potentially under-recognized, vascular, inflammatory, autoimmune, and hematologic sources in relation to clinical practice.
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Affiliation(s)
- Amre Nouh
- Hartford Hospital, University of Connecticut , Hartford, CT , USA
| | - Mohammed Hussain
- Hartford Hospital, University of Connecticut , Hartford, CT , USA
| | - Tapan Mehta
- Hartford Hospital, University of Connecticut , Hartford, CT , USA
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