The treatment of spontaneous carotid and vertebral artery dissections

Spontaneous internal carotid artery dissection in a child diagnosed by high resolution vessel wall MRI

Craniocervical dissection is one of the most common causes of stroke in children. Although the most common cause of dissection is trauma, spontaneous dissections in which no cause can be revealed may also occur. The diagnosis of this type of dissection in children can be challenging with the preferred non-invasive imaging methods (MRA, CTA). Intracranial vessel wall imaging is a promising novel method for identifying specific signs of dissection. We report an 11-year-old girl with spontaneous ICA dissection, whose diagnosis was confirmed by an MRI of the intracranial vessel wall. Vessel wall imaging has contributed substantially to the diagnosis and follow-up of this case.

Focal-onset seizure due to left internal carotid artery dissection in the context of confounding hyperglycaemia

A 36-year-old diabetic woman presented to hospital with a seizure that started with shaking of the right hand which sequentially progressed to the entire right side of the body with associated loss of consciousness. Capillary Blood Glucose was 29 mmol/L. HbA1c was 133 mmol/L. Non-contrast computerised tomography (CT) scan of the brain was normal suggesting that the cause of her seizure was hyperglycaemia. However, Magnetic Resonance Imaging (MRI) of the brain showed infarcts in the left paracentral lobule and caudate nucleus. It also identified loss of signal flow void in the intracranial segment of the left internal carotid artery (ICA) raising the suspicion for thrombosis secondary to dissection. This was later confirmed on CT angiogram. This case demonstrates how the initial CT Head was non-diagnostic. We stress the importance of taking a careful seizure history and subsequently obtaining an MRI scan to fully exclude structural pathology.

Endovascular repair of an acute symptomatic carotid artery dissection through the false dissecting carotid lumen

A 48-year-old woman presented with an acute ischemic stroke (National Institutes of Health Stroke Scale (NIHSS) 21) six hours after symptom onset. Workup revealed a left cervical internal carotid artery (ICA) occlusive dissection, which was emergently reconstructed with a flow-diverting stent. A routine Duplex scan one hour later suggested reocclusion of the ICA, confirmed by angiography. The true lumen of the ICA could not be accessed and therefore the "false lumen" of the ICA dissection was entered proximally. The true lumen and ultimately the flow-diverting stent were accessed via the false lumen. In analogy to the subintimal arterial flossing with antegrade-retrograde intervention technique described for peripheral vascular disease, several stents were placed in telescoping fashion from the true common carotid lumen through the "false dissecting" lumen of the proximal ICA into the distal true lumen. The stent construct remained patent, and the patient recovered clinically to an NIHSS of 1.

Internal carotid artery dissection without intracranial infarct following a minor shoulder trauma: The second pediatric case and review of the literature

INTRODUCTION

Carotid artery dissections may occur in severe trauma such as motor vehicle accidents or may also develop due to minor trauma. We aimed to present a case with internal carotid artery dissection that referred to the pediatric neurology department due to speech impairment after minor shoulder trauma.

CASE

A previously healthy 10-year-old male patient was admitted to the pediatric emergency clinic due to headache, vomiting and speech impairment. In his story, we learned that he had bumped shoulder to shoulder with his friend about 6 h ago. He did not fall or hit his head. On his admission he could not speak and had right central facial paralysis. There was no infarct or diffusion limitation in MRI but MR angiography showed thinning in left internal carotid artery calibration. Fat-suppressed, non-contrast T1-weighted MRI showed that the left carotid artery had ring-shaped pathological signal changes. Low-molecular-weight heparin therapy was initiated with the diagnosis of carotid artery dissection (CAD). No hemiparesis or hemiplejia occurred in the follow-up of the patient. Within a few days, his speech improved. At the end of the first month, facial paralysis completely recovered.

CONCLUSION

In carotid artery dissections, prodromal symptoms such as transient ischemic attack, like in our patient, are rarely present in children. For good long term outcomes, it is very important to suspect, diagnose and initiate appropriate treatment in a rapid manner in carotid artery dissection before severe neurological findings such as acute ischemic stroke develops.

Spontaneous intracranial vertebral artery dissection with acute ischemic stroke: High-resolution magnetic resonance imaging findings

Background Acute ischemic stroke (AIS) more frequently develops in patients with intracranial vertebral artery dissection (VAD) than extracranial VAD, and is associated with possible poor clinical outcomes. The aim of this study is to compare high-resolution magnetic resonance imaging (HR-MRI) findings and clinical features of VAD with and without AIS. Methods Twenty-nine lesions from 27 patients (15 male and 12 female patients; age range = 28-73 years) who underwent diffusion MRI and 3T HR-MRI within seven days were included. We classified VAD according to the presence of AIS lesions on diffusion MRI. Clinical features and HR-MRI findings (angiographic patterns, presence of double lumen sign, dissecting flap, posterior inferior cerebellar artery involvement, remodeling index, length of affected vessels, T1-signal intensity, area of intramural hematoma, and grades and patterns of vessel wall enhancement) were evaluated. Results Thirteen VADs with AIS and 16 without AIS were included. There were no significant differences in the clinical parameters (sex, age, risk factors, symptoms). More VADs with AIS presented as a steno-occlusive pattern than VADs without AIS. More VADs without AIS presented with aneurysmal dilation, larger mean remodeling index and longer mean length than VADs with AIS. Presence of intramural hematoma, T1-iso-signal intensity of intramural hematoma and contrast enhancement were significantly more common in VADs with AIS than without AIS. Conclusions Our study showed some differences in HR-MRI comparing intracranial VAD patients with and without AIS. Differing findings may facilitate a better understanding of intracranial VAD and risk assessment of AIS in these patients.

The endovascular emergency treatment of an acute carotid artery dissection after Krav Maga training—a case report

Carotid artery dissection accounts for 20%–30% of all ischemic strokes in young patients aged <50 years. Recent guidelines on carotid disease management do not differentiate between traumatic and spontaneous dissection. We present a case of a 36-year-old male patient with the right internal carotid artery dissection treated with two XACT Abbot 6–8 mm × 40 mm stents placement after he was strangled during Krav Maga training. It is the most effective way to prevent the imminent stroke in the penumbral region. The safety and outcome of stent placement in internal carotid artery dissection remains unclear and further randomized trials are needed.

Anticoagulation vs Antiplatelet Treatment in Patients with Carotid and Vertebral Artery Dissection: A Study of 370 Patients and Literature Review

Background

Dissection of the carotid and vertebral arteries is an important cause of stroke in young patients.

Objective

The objective of this study is to compare antithrombotic treatments in patients with carotid and vertebral dissections.

Methods

Three hundred seventy patients with carotid and vertebral artery dissections were included. Univariate and multivariate analyses were conducted to analyze the association between treatment and new or recurrent events and clinical outcome.

Results

Mean follow-up was 24.3 months. In patients with spontaneous dissection, 55% received antiplatelets, 29.4% anticoagulation, and 12.6% combined treatment. New or recurrent ischemic and hemorrhagic events occurred in 9.6% of patients on antiplatelets, 10.4% on anticoagulation, and 13.3% on combined treatment. For traumatic dissection, 58.3% received antiplatelets, 26.9% anticoagulation, and 10.2% combined treatment. New or recurrent ischemic and hemorrhagic events occurred in 6.9% on antiplatelets, 11.1% on anticoagulation, and 20% on combined treatment. In patients with intracranial dissection, 63.1% were started on antiplatelets, 19.7% on anticoagulation, and 14.5% on combined treatment. Ischemic and hemorrhagic events occurred in 8.5% on antiplatelet treatment, 15.4% on anticoagulation, and 18.2% on combined treatment. In patients with extracranial dissection, 54.4% were on antiplatelets, 28.9% on anticoagulation, and 11.2% on combined treatment. Ischemic and hemorrhagic events occurred in 10.1% on antiplatelet treatment, 9.3% on anticoagulation, and 13.8% on combined treatment. The association between antithrombotic treatment and ischemic/hemorrhagic events and clinical outcome was not significant for all subtypes of dissection.

Conclusion

The rate of new or recurrent events is similar with antiplatelet and anticoagulation treatment in treating intracranial and extracranial carotid and vertebral artery dissection.

Traumatic cervical internal carotid artery pseudoaneurysm in a child refractory to initial endovascular treatment: case report and technical considerations

PURPOSE

Optimal management of extracranial carotid artery dissections (eCAD) in pediatric patients is not well documented, and endovascular interventions are rarely reported.

METHODS

A 10-year-old girl sustained multiple systemic injuries in a motor vehicle accident, including an eCAD with pseudoaneurysm. She initially failed both aspirin and endovascular stenting with progressive enlargement of a traumatic cervical carotid pseudoaneurysm and stenosis.

RESULTS

Second-stage endovascular stent placement with coiling resulted in successful occlusion of the pseudoaneurysm. At 30-month imaging follow-up, the parent vessel remained patent with no evidence of the pseudoaneurysm.

CONCLUSION

In the setting of poly-trauma, management of eCAD can be complex especially in the pediatric population. There is little data on the endovascular treatment of eCAD in children. Failed endovascular therapies are extremely rare. Our report supports surveillance imaging as repeat endovascular treatment may be necessary.

Emergent Endovascular Management of Long-Segment and Flow-Limiting Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents

BACKGROUND AND PURPOSE

Although most cervical dissections are managed medically, emergent endovascular treatment may become necessary in the presence of intracranial large-vessel occlusions, flow-limiting and long-segment dissections with impending occlusion, and/or hypoperfusion-related ischemia at risk of infarction. We investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting.

MATERIALS AND METHODS

We retrospectively studied long-segment carotid dissections requiring stent reconstruction with multiple tandem stents (≥3 stents) and presenting with acute (<12 hours) ischemic stroke symptoms (NIHSS score, ≥4). We analyzed patient demographics, vascular risk factors, clinical presentations, imaging/angiographic findings, technical procedures/complications, and clinical outcomes.

RESULTS

Fifteen patients (mean age, 51.5 years) with acute ischemic stroke (mean NIHSS score, 15) underwent endovascular stent reconstruction for vessel and/or ischemic tissue salvage. All carotid dissections presented with >70% flow limiting stenosis and involved the distal cervical ICA with a minimum length of 3.5 cm. Carotid stent reconstruction was successful in all patients with no residual stenosis or flow limitation. Nine patients (60%) harbored intracranial occlusions, and 6 patients (40%) required intra-arterial thrombolysis/thrombectomy, achieving 100% TICI 2b-3 reperfusion. Two procedural complications were limited to thromboembolic infarcts from in-stent thrombus and asymptomatic hemorrhagic infarct transformation (7% morbidity, 0% mortality). Angiographic and ultrasound follow-up confirmed normal carotid caliber and stent patency, with 2 cases of <20% in-stent stenosis. Early clinical improvement resulted in a mean discharge NIHSS score of 6, and 9/15 (60%) patients achieved a 90-day mRS of ≤2.

CONCLUSIONS

Emergent stent reconstruction of long-segment and flow-limiting carotid dissections in acute ischemic stroke intervention is safe and effective, with favorable clinical outcomes, allowing successful thrombectomy, vessel salvage, restoration of cerebral perfusion, and/or prevention of recurrent thromboembolic stroke.

An interesting case report of vertebral artery dissection following polytrauma

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Routine/regular screening is not undertaken in polytrauma patients.

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Vertebral artery dissection can be clinically challenging to detect and diagnose due to its diverse presentation and the lack of uniform screening/guidelines.

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The pathological process is more common in polytrauma and therefore there needs to be a high index of suspicion in this group of patients.

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CT angiogram and/or Doppler and duplex ultrasonography should be used as a non-invasive screening tool in patients with significant traumatic injuries.

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Early anticoagulation should ideally be the treatment, however, in traumatic injuries it is seldom used.

Introduction

The authors present an interesting case of a 19-year-old male who presented as a polytrauma patient following a fall from a height.

Presentation of case

He was initially managed on the intensive care unit with intracranial pressure bolt monitoring after being intubated and sedated and having his other traumatic injuries stabilized. Upon attempting to wean sedation and extubation a repeat CT scan of the head was undertaken and showed a new area suggested of cerebral infarction, this was a new finding. Further imaging found that he had a cervical vertebral artery dissection following this polytrauma mode of injury.

Discussion

The incidence of vertebral artery dissection following generalized or local trauma is rising but routine imaging/screening in these patients is not undertaken.

Conclusion

Our report displays select images related to this case report and emphasizes the consideration of routine imaging in head and neck traumatic injuries to diagnose internal carotid and/or vertebral artery dissections much earlier.

Management of Cervical Arterial Dissection

Background

Clinical, pathological and radiological advances in recent years have considerably advanced our understanding of the incidence and underlying mechanisms producing dissection of the cervical arteries, which should have implications for medical and, surgical therapy in the near future. This review is a summary of progress to date.

Summary of review

Numerous published studies, primarily over the last decade, have generated a rapidly evolving data base especially in the areas of etiology, neuroimaging and more recently, arterial pathology and its genetic basis.

Conclusion

Dissection of the carotid and vertebral arteries, both intracranially and extracranially, is a major and frequently underdiagnosed cause of stroke, especially in the young. These advances in clinical epidemiological observations, and new radiological and pathological data, are gradually providing an evidence-based rationale for future trials of therapeutic interventions, using both drugs and devices.

Effect of coil packing proximal to the dilated segment on postoperative medullary infarction and prognosis following internal trapping for ruptured vertebral artery dissection

INTRODUCTION

Medullary infarction is an important complication of internal trapping for vertebral artery dissection. This study investigated risk factors for medullary infarction following internal trapping of ruptured vertebral artery dissection.

METHODS

We retrospectively studied 26 patients with ruptured vertebral artery dissection who underwent endovascular treatment and postoperative magnetic resonance imaging between April 2001 and March 2013. Clinical and radiological findings were analyzed to identify factors associated with postoperative medullary infarction.

RESULTS

Ten of the 26 patients (38%) showed postoperative lateral medullary infarction on magnetic resonance imaging. Multivariate logistic regression analysis revealed that medullary infarction was independently associated with poor clinical outcome (odds ratio (OR) 17.01; 95% confidence interval (CI) 1.68-436.81; p=0.032). Univariate analysis identified vertebral artery dissection on the right side and longer length of the entire trapped area as risk factors for postoperative medullary infarction. When the trapped area was divided into three segments (dilated, distal, and proximal segments), proximal segment length, but not dilated segment length, was significantly associated with medullary infarction (OR 1.55 for a 1-mm increase in proximal segment length; 95% CI 1.15-2.63; p=0.027). Receiver operating characteristic analysis showed that proximal segment length offered a good predictor of the risk of postoperative medullary infarction, with a cut-off value of 5.8 mm (sensitivity 100%; specificity 82.3%).

CONCLUSIONS

Longer length of the trapped area, specifically the segment proximal to the dilated portion, is associated with a higher incidence of medullary infarction following internal trapping, indicating that this complication may be avoidable.

Headache in pregnancy: an approach to emergency department evaluation and management

Headache is a common presenting complaint in the emergency department. The differential diagnosis is broad and includes benign primary causes as well as ominous secondary causes. The diagnosis and management of headache in the pregnant patient presents several challenges. There are important unique considerations regarding the differential diagnosis, imaging options, and medical management. Physiologic changes induced by pregnancy increase the risk of cerebral venous thrombosis, dissection, and pituitary apoplexy. Preeclampsia, a serious condition unique to pregnancy, must also be considered. A high index of suspicion for carbon monoxide toxicity should be maintained. Primary headaches should be a diagnosis of exclusion. When advanced imaging is indicated, magnetic resonance imaging (MRI) should be used, if available, to reduce radiation exposure. Contrast agents should be avoided unless absolutely necessary. Medical therapy should be selected with careful consideration of adverse fetal effects. Herein, we present a review of the literature and discuss an approach to the evaluation and management of headache in pregnancy

Management of pediatric craniocervical arterial dissections

PURPOSE

Craniocervical arterial dissections (CCADs) represent a preventable cause of acute ischemic stroke (AIS). Our objective was to describe clinical presentation, imaging features, treatment strategies, and report clinical and imaging outcomes of CCADs at a large pediatric tertiary referral center.

METHODS

Electronic medical records were queried using variations of the word dissection for patients under 25 years of age with neuroimaging over a 13-year period. Medical and imaging records were reviewed to identify carotid, vertebral, or intracranial dissections. Demographics, presenting symptoms, presence of AIS, mechanism of injury, dissection location, dissection treatment, and complications stemming from treatment were collected. Clinical outcome was classified according to modified Rankin Scale (mRS) score. Imaging follow-up was obtained until the dissection healed or stabilized.

RESULTS

A total 6,289 patients met initial search criteria. Of the 42 (0.7%) patients with CCADs, 23 (54.8%) had internal carotid artery (ICA) dissections, and 17 (40.5%) had vertebrobasilar (VB) dissections. More females had ICA dissections (p = 0.002), and more males had VB dissections (p = 0.01). CCADs associated with traumatic presentation occurred in 34 patients (81.0%), while 8 (19.0%) were spontaneous. Good outcomes (mRS 0-3) were noted for 36 patients, and 5 had poor outcomes (mRS 4-6). In the 17 patients with vessel occlusion, 50.0% had partial or complete recanalization at a mean follow-up of 23.9 months.

CONCLUSIONS

CCAD is commonly related to trauma and presents with AIS. The majority of patients experience good clinical outcome. Recanalization of initial vessel occlusion occurs in half of cases at 2 years.

Endovascular treatment of acute intracranial vertebral artery dissection: long-term follow-up results of internal trapping and reconstructive treatment using coils and stents

BACKGROUND

Endovascular internal trapping is an effective procedure for the treatment of acute vertebral artery dissection (VAD). However, the outcomes of reconstructive treatment have not been well established. The aim of our study is to evaluate the long-term clinical and angiographic results of endovascular internal trapping or reconstructive treatment of acute VAD.

METHODS

Between 2005 and 2013, 26 patients with acute VAD were managed with internal coil trapping (n=10), stent-assisted coiling (n=14), stent only (n=1), and proximal occlusion (n=1). Stent-assisted coiling included the modified stent-assisted semi-jailing technique (n=10), balloon-in-stent technique (n=2), and coiling followed by balloon mounted stent (n=2). Digital subtraction angiography (DSA) was performed in all patients except for three who died during the acute stage.

RESULTS

Of 26 patients with VAD, 14 and 12 presented with hemorrhagic and non-hemorrhagic types, respectively. The dominancy of the relevant artery was defined as dominant (n=9), even (n=12), and non-dominant (n=5). Reconstructive treatment was performed in six patients with ruptured VADs which failed balloon test occlusion and nine with non-hemorrhagic VADs. Clinical outcomes were favorable in 22 (84.6%), severe disability occurred in one, and there were three deaths (11.5%). All patients except the three who died had angiographic follow-up at 6-32 months (mean 10.4 months). The angiographic results of nine cases of internal trapping and one of proximal occlusion all showed a stable occlusion state. Among the 15 cases of reconstructive treatment, follow-up DSAs were available for the 13 surviving patients, 10 of which demonstrated stable occlusion of aneurysmal dilation and patent parent artery.

CONCLUSIONS

This study suggests that internal trapping is a stable and effective treatment for acute VAD. Reconstructive treatment using stent and coils could also be a feasible alternative modality for hemorrhagic type VAD. However, serial DSA follow-up is essential.

Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association

PURPOSE

Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.

RESULTS

Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.

CONCLUSIONS

CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

Vocal cord paralysis secondary to spontaneous internal carotid dissection: case report and systematic review of the literature

OBJECTIVES

To present a rare case of unilateral vocal cord paralysis (VCP) secondary to spontaneous internal carotid artery dissection and to perform a literature review.

CASE REPORT

A 35-year-old male presented to the emergency department with acute onset hoarseness and dysphagia. History, physical exam and laryngoscopy revealed left sided VCP without obvious cause. Magnetic Resonance Imaging (MRI) demonstrated a left internal carotid artery dissection of unknown etiology. Neurovascular surgery was consulted and treatment with aspirin was initiated. The dysphagia and hoarseness resolved in 12 weeks with long-term neurosurgery follow-up as the management plan.

METHODS

Systematic literature review was conducted by 3 independent reviewers. Since 1988 only 9 cases of VCP due to internal carotid artery dissection have been reported. These were reviewed for: demographics, diagnostic method, treatment and vocal cord function.

RESULTS

7 patients had unilateral while 2 had bilateral VCP. MRI was used for diagnosis in 7 cases and 5 cases utilized a type of angiography. All received antithrombotic treatment with 5 out of the 9 patients experiencing vocal cord recovery in an average of 7.2 weeks.

CONCLUSION

MRI is crucial in the work-up of idiopathic VCP. If an ipsilateral internal carotid artery dissection is found, antithrombotic treatment is initiated with an expectation that vocal cord mobility is likely to return.

Clinical characteristics of symptomatic vertebral artery dissection: a systematic review

BACKGROUND

Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed with adverse consequences. We assessed the frequency of head/neck pain, other neurological symptoms, and cerebrovascular events in symptomatic VAD.

METHODS

We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality, and clinical data were abstracted. Pooled proportions were calculated.

RESULTS

Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. The most common symptoms were dizziness/vertigo (58%), headache (51%), and neck pain (46%). Stroke was common (63%), especially with extracranial dissections (66% vs. 32%, P<0.0001), whereas transient ischemic attack (14%) and subarachnoid hemorrhage (10%) were uncommon. Subarachnoid hemorrhage was seen only with intracranial dissections (57% vs. 0%, P=0.003). Fewer than half of the patients had obvious trauma, and only 7.9% had a known connective tissue disease. Outcome was good (modified Rankin scale 0 to 1) in 67% and poor (modified Rankin scale 5 to 6) in 10% of patients.

CONCLUSIONS

VAD is associated with nonspecific symptoms such as dizziness, vertigo, headache, or neck pain. Ischemic stroke is the most common reported cerebrovascular complication. VAD should be considered in the diagnostic assessment of patients presenting with dizziness or craniocervical pain, even in the absence of other risk factors. Future studies should compare clinical findings as predictors in well-defined, undifferentiated populations of clinical VAD suspects.

Long-term clinical and angiographic outcomes in patients with cervico-cranial dissections treated with stent placement: a meta-analysis of case series

Limited clinical and angiographic data exists for patients with spontaneous or traumatic cervico-cranial dissections treated with stent placement. We reviewed clinical and angiographic data on consecutive patients admitted to our hospital with spontaneous, traumatic, and iatrogenic cervico-cranial dissections treated with stent placement to study immediate and long-term clinical and angiographic outcomes. Additional patients were identified using pertinent studies published between 1980 and 2009, using a search of the PubMed, Cochrane, and Ovid libraries. Post-procedure complications and clinical outcomes were documented. Angiographic abnormalities collected at follow-up included presence of in-stent restenosis or pseudoaneurysm. After applying our strict search criteria, four studies including our series were used in the meta-analysis, representing 46 patients (mean age [standard deviation] 47 ± 14 years; 24 [52%] male) treated with stent placement for dissection. Overall, 72 stents were placed to treat 28 spontaneous, 11 traumatic, and 7 iatrogenic dissection patients with 51 dissections, involving 51 vessels; with a mean pre-stent stenosis of 71 ± 26% and mean post-stent stenosis of 6 ± 15%. The immediate and follow-up post-procedure complication rates per stent placed was 8 (11%) and 8 (11%), respectively. Among the 36 patients who underwent follow-up angiography, in-stent restenosis or pseudoaneurysms were present in 3 (8%) and 2 (6%) patients, respectively. A high rate of sustained resolution of angiographic abnormalities during long-term follow-up was noted, with a low rate of new transient ischemic attack, ischemic stroke, or death, supporting the feasibility, safety, and effectiveness of endovascular stent reconstruction.

Traumatic tiger attack

Attacks on humans by large cats are uncommon occurrences and thus the principles of managing such injuries are not well documented. The authors here report the case of an 11-year-old boy who was mauled by a privately owned tiger. The attack resulted in multiple cranial lacerations and fractures, dissection of the internal carotid artery, and persistent neurological deficits. This case outlines the multiple sources of injury and pathology that can result from such an attack. Discussion is focused on the pattern of injury seen in large feline attacks and the treatment approach.

The etiology of cervical artery dissection

The etiology of cervical artery dissection (CAD) is unclear, although a number of risk factors have been reported to be associated with the condition. On rare occasions, patients experience CAD after cervical spine manipulation, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition of interest to chiropractors. This commentary reports on the relevant anatomy of the cervical arteries, developmental features of CAD, epidemiology of the condition, and mechanisms of dissection. The analysis of CAD risk factors is confusing, however, because many people are exposed to mechanical events and known pathophysiological associations without ever experiencing dissection. No cause-and-effect relationship has been established between cervical spine manipulation and CAD, but it seems that cervical manipulation may be capable of triggering dissection in a susceptible patient or contributing to the evolution of an already existing CAD. Despite the many risk factors that have been proposed as possible causes of CAD, it is still unknown which of them actually predispose patients to CAD after cervical spine manipulation.

Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

BACKGROUND:

Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.

OBJECTIVE:

To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.

METHODS:

We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.

RESULTS:

For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).

CONCLUSION:

Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

Endovascular treatment of ruptured dissecting vertebral artery aneurysms--long-term follow-up results, benefits of early embolization, and predictors of outcome

INTRODUCTION

The purpose of this study was to evaluate the effect of endovascular treatment of ruptured dissecting aneurysms of the vertebral artery, the benefits of early embolization, and the predictors of outcomes.

CLINICAL MATERIAL AND METHODS

Between September, 2001 and May, 2009, 25 patients with ruptured vertebral dissecting aneurysms were treated by internal coil trapping (n = 23) or stents (n = 2) in our hospital. There were 14 males and 11 females with a mean age of 45 years (age range, 22-66 years). Dissecting aneurysms were supra-posterior inferior cerebellar artery lesions (n = 16), infra-posterior inferior cerebellar artery lesions (n = 6), or involved the posterior inferior cerebellar artery (n = 3).

RESULTS

Complete occlusion of dissected arterial and aneurysm segments (internal trapping) was achieved in 21 (91.3%) of 23 patients. The two patients with posterior inferior cerebellar artery involvement underwent double stent only placement. Clinical outcomes were favorable in 17 (68%) of 25 patients, 2 (8%) had severe disability, and 6 (24%) patients died. Risk factors that varied with favorable versus unfavorable outcomes were: preoperative Hunt-Hess, World Federation of Neurological Surgeons scale, presence of hydrocephalus, presence of lateral medullary syndrome, presence of low cranial nerve palsy, rebleeding, time of endovascular procedures, and time from admission to procedure. However, univariate Cox analysis confirmed that only low preoperative Hunt-Hess grade predicted favorable clinical outcome. Early embolization did not affect clinical outcome, but reduced the risk of rebleeding and inpatient stay.

CONCLUSION

In our experience, internal trapping of the dissected segment with a coil was straightforward, applicable to most patients, prevented rebleeding safely and effectively without significant procedural complications, and had a good follow-up outcome. The low Hunt-Hess grade remained predictors of favorable clinical outcomes. The timing of embolization did not significantly affect clinical outcome but early embolization reduces inpatient stay.

Endovascular strategies for vertebrobasilar dissecting aneurysms

BACKGROUND AND PURPOSE

Dissecting vertebrobasilar aneurysms are challenging to treat, and standard treatment modalities remain controversial. We retrospectively evaluated our experience using endovascular techniques to treat these aneurysms.

MATERIALS AND METHODS

From February 1997 to December 2007, 42 patients with intradural vertebrobasilar dissecting aneurysms underwent endovascular treatment. Twenty-nine patients had ruptured aneurysms, and 13 patients had unruptured dissecting aneurysms. The endovascular modalities for vertebrobasilar dissecting aneurysms were the following: 1) trapping (n = 30), 2) proximal occlusion (n = 3), 3) stent with coil (n = 6), and 4) stent alone (n = 3).

RESULTS

Seventeen of the 29 patients with ruptured vertebrobasilar dissecting aneurysms had successful outcomes without procedural complications following endovascular treatment. Procedure-related complications were the following: 1) rebleeding (n = 3), 2) posterior inferior cerebellar artery (PICA) territory infarction (n = 6), 3) brain stem infarction (n = 2), and 4) thromboembolism-related multiple infarctions (n = 1). Clinical outcomes were favorable in 32 patients (76.1%). There were 3 (7.1%) procedure-related mortalities due to rebleeding, and 1 (2.4%) non-procedure-related mortality due to pneumonia sepsis. All 13 patients with unruptured vertebrobasilar dissecting aneurysms had favorable clinical and radiologic outcomes without procedure-related complications.

CONCLUSIONS

Endovascular procedures for treatment of unruptured symptomatic dissecting aneurysms resulted in favorable outcomes. Ruptured vertebrobasilar dissecting aneurysms are associated with a high risk of periprocedural complications. Risks can be managed by using appropriate endovascular techniques according to aneurysm location, configuration, and relationship with the PICA.

Cervical artery dissection: pathology, epidemiology and management

BACKGROUND

Cervical artery dissection is often treated with anticoagulants to prevent ischemic stroke. The risk-benefit ratio of anticoagulation versus antiplatelet therapy is unclear.

OBJECTIVES

To provide an educational review of current data on the disease to explain the rationale for the treatment options and to explore the results of management studies in order to determine if anticoagulation is justified.

METHODS

We searched the databases MEDLINE and EMBASE as well as bibliographies for information on anticoagulants and antiplatelet agents in cervical, i.e. carotid and/or vertebral artery, dissection.

RESULTS

There are no randomized controlled trials on the treatment. One systematic review from 2003 identified 20 case series or cohort studies. We identified 9 additional studies with a total of 1,033 patients. Of those, 731 received anticoagulation sometimes followed by platelet inhibition vs. 282 patients treated with antiplatelet agents alone. The rate of ischemic stroke was 2.3% vs. 6.9% and bleeding complications were reported in 0.7% vs. 0%.

CONCLUSION

It cannot be excluded that there is a net benefit from anticoagulant therapy in cervical dissection, but the studies are flawed by considerable bias. Very ill patients at a high risk of ischemic stroke may have been given aspirin due to fear of hemorrhagic complications. A randomized controlled trial is planned and will be crucial to resolve this issue.