Thrombolysis in Cervical Artery Dissection - Data from the Cervical Artery Dissection and Ischaemic Stroke Patients (CADISP) database

Intravenous Thrombolysis in Patients With Cervical Artery Dissection: A Secondary Analysis of the STOP-CAD Study

OBJECTIVES

Cervical artery dissection (CeAD) accounts for 25% of ischemic strokes in young adults. This study evaluated the benefits and harms of intravenous thrombolysis (IVT) in patients presenting with spontaneous CeAD and acute ischemic stroke symptoms.

METHODS

This analysis used data from the retrospective STOP-CAD study and included patients with spontaneous CeAD who presented within 1 day of acute ischemic stroke symptoms. Patients were dichotomized into those who received IVT and those managed without IVT. We assessed the association between IVT and 90-day functional independence (modified Rankin Scale scores 0-2) and the incidence of symptomatic intracranial hemorrhage (ICH, defined as ICH causing new or worsening neurologic symptoms within 72 hours after CeAD diagnosis).

RESULTS

This study included 1,653 patients from the original STOP-CAD cohort of 4,023. The median age was 49 years, and 35.1% were women; 512 (31.0%) received IVT. IVT was associated with 90-day functional independence (adjusted odds ratio [aOR] = 1.67, 95% CI 1.23-2.28, p = 0.001), but not with symptomatic ICH (aOR = 1.52, 95% CI 0.79-2.92, p = 0.215).

DISCUSSION

In patients with spontaneous CeAD and suspected ischemic stroke, IVT improved functional outcomes, without increasing symptomatic ICH risk. These findings support current guideline recommendations to consider thrombolysis for otherwise eligible patients with CeAD.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that IVT significantly increases the probability of 90-day functional independence in patients with CeAD.

Are There Differences between Traumatic and Spontaneous Cervical Artery Dissections?

(1) Background: Cervical arterial dissections (CeAD) are a common cause of stroke in young adults. CeAD can be spontaneous (sCeAD) or traumatic (tCeAD). Whether CeAD subtypes differ in clinical, radiological, and outcome characteristics remains unexplored. (2) Methods: Patients with CeAD were identified and divided between sCeAD and tCeAD. Demographics, clinical features, risk factors, imaging findings, treatments, and outcomes were compared between the groups. Logistic regressions were used to determine characteristics associated with favorable outcome. (3) Results: Overall, 154 patients were included (106 sCeAD and 48 tCeAD). Patients with sCeAD were significantly older (mean ± SD 46 ± 12 vs. 35 ± 14, p < 0.001) and were more likely to have hyperlipidemia (19% vs. 4%, p = 0.016), but other risk factors did not differ. Patients with tCeAD less often had signs of early infarction on imaging (21% vs. 49%, p = 0.001) and had lower stroke severity on admission (NIHSS, median, interquartile range [IQR] 0 (0-9) vs. 2 (0-4), p = 0.012), but more often had symptomatic intracranial hemorrhages (12.5% vs. 2%, p = 0.006). Patients with tCeAD less often had favorable outcomes at 90 days (78% vs. 97%, p < 0.001). In the regression analysis, the only variables associated with favorable outcome were age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.03-1.24), initial stroke severity (OR 0.84, 95% CI 0.73-0.97), degree of vessel stenosis (OR 0.35, 95% CI 0.14-0.83), and involvement of multiple vessels on presentation (OR 0.04, 95% CI 0.02-0.70), whereas dissection subtype was not associated (OR 0.45, 95% CI 0.03-68.80). (4) Conclusions: Dissection subtype is not an independent modifier of the chances of attaining functional independence.

Toward Individual Treatment in Cervical Artery Dissection: Subgroup Analysis of the TREAT-CAD Randomized Trial

OBJECTIVE

Uncertainty remains regarding antithrombotic treatment in cervical artery dissection. This analysis aimed to explore whether certain patient profiles influence the effects of different types of antithrombotic treatment.

METHODS

This was a post hoc exploratory analysis based on the per-protocol dataset from TREAT-CAD (NCT02046460), a randomized controlled trial comparing aspirin to anticoagulation in patients with cervical artery dissection. We explored the potential effects of distinct patient profiles on outcomes in participants treated with either aspirin or anticoagulation. Profiles included (1) presenting with ischemia (no/yes), (2) occlusion of the dissected artery (no/yes), (3) early versus delayed treatment start (median), and (4) intracranial extension of the dissection (no/yes). Outcomes included clinical (stroke, major hemorrhage, death) and magnetic resonance imaging outcomes (new ischemic or hemorrhagic brain lesions) and were assessed for each subgroup in separate logistic models without adjustment for multiple testing.

RESULTS

All 173 (100%) per-protocol participants were eligible for the analyses. Participants without occlusion had decreased odds of events when treated with anticoagulation (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.07-0.86). This effect was more pronounced in participants presenting with cerebral ischemia (n = 118; OR = 0.16, 95% CI = 0.04-0.55). In the latter, those with early treatment (OR = 0.26, 95% CI = 0.07-0.85) or without intracranial extension of the dissection (OR = 0.34, 95% CI = 0.11-0.97) had decreased odds of events when treated with anticoagulation.

INTERPRETATION

Anticoagulation might be preferable in patients with cervical artery dissection presenting with ischemia and no occlusion or no intracranial extension of the dissection. These findings need confirmation. ANN NEUROL 2024;95:886-897.

Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association

Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.

High risk and low prevalence diseases: Spontaneous cervical artery dissection

INTRODUCTION

Spontaneous cervical artery dissection (sCAD) is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of sCAD, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

sCAD is a condition affecting the carotid or vertebral arteries and occurs as a result of injury and compromise to the arterial wall layers. The dissection most commonly affects the extracranial vessels but may extend intracranially, resulting in subarachnoid hemorrhage. Patients typically present with symptoms due to compression of local structures, and the presentation depends on the vessel affected. The most common symptom is headache and/or neck pain. Signs and symptoms of ischemia may occur, including transient ischemic attack and stroke. There are a variety of risk factors for sCAD, including underlying connective tissue or vascular disorders, and there may be an inciting event involving minimal trauma to the head or neck. Diagnosis includes imaging, most commonly computed tomography angiography of the head and neck. Ultrasound can diagnose sCAD but should not be used to exclude the condition. Treatment includes specialist consultation (neurology and vascular specialist), consideration of thrombolysis in appropriate patients, symptomatic management, and administration of antithrombotic medications.

CONCLUSIONS

An understanding of sCAD can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Cervical Artery Dissections: Etiopathogenesis and Management

Cervical Artery Dissection (CeAD) is a frequent stroke etiology for patients younger than 50 years old. The most common immediate complications related to CeAD are headache and neck pain (65-95%), TIA/ischemic stroke (>50%), and partial Horner's syndrome (25%). The prevailing hypothesis regarding the pathogenesis of sCeAD is that the underlying constitutional vessel wall weakness of patients with sCeAD is genetically determined and that environmental factors could act as triggers. The stroke prevention treatment of CeAD remains controversial, involving anticoagulation or antiplatelet therapy and potentially emergent stenting and/or thrombectomy or angioplasty for selected cases of carotid artery dissection with occlusion. The treatment of headache associated with CeAD depends on the headache phenotype and comorbidities. Radiographically, more than 75% of CeAD cases present with occlusion or non-occlusive stenosis. Many patients demonstrate partial and complete healing, more commonly in the carotid arteries. One-fifth of the patients develop dissecting pseudoaneurysm, but this is a benign clinical entity with an extremely low rupture and stroke recurrence risk. Good recovery is achieved in many CeAD cases, and mortality remains low. Family history of CeAD, connective tissue disorders like Ehlers-Danlos syndrome type IV, and fibromuscular dysplasia are risk factors for recurrent CeAD, which can occur in 3-9% of the cases. This review serves as a comprehensive, updated overview of CeAD, emphasizing etiopathogenesis and management.

Predictors of ischemic events in patients with unilateral extracranial vertebral artery dissection: A single-center exploratory study

Objective

Extracranial vertebral artery dissection (EVAD) is one of the main causes of stroke in young and middle-aged patients. However, the diagnosis is challenging. This study aimed to identify the characteristics of EVAD on color duplex ultrasonography (CDU) and high-resolution magnetic resonance imaging (hrMRI), hoping to improve the accuracy and determine the relative contribution of vessel findings and clinical factors to acute ischemic events.

Methods

Patients with unilateral EVAD were recruited and divided into ischemia and non-ischemia groups. Clinical features of patients and the lesion location; a variety of signs which indicate dissection, including the presence of an intimal flap, double lumen, intramural hematoma, dissecting aneurysm, intraluminal thrombus, and irregular lumen; and other quantitative parameters of each dissected segment on CDU and hrMRI were reviewed, respectively. Multiple logistic regression was performed to explore the association between clinical, imaging characteristics, and ischemic events in patients with unilateral EVAD.

Results

Ninety-six patients with unilateral EVAD who met the inclusion criteria were enrolled during a six-year period. Overall, 41 cases (42.7%) were confirmed as ischemic stroke (n = 40) or transient ischemic attack (n = 1) during the 48 h after the onset of symptoms. Men, infections during the last week, and smoking were more common in the ischemia group. Intraluminal thrombus and occlusion on CDU were more prevalent in patients with cerebral ischemia than in those without (36.6 vs. 5.5%; p < 0.001, and 39.0 vs. 9.1%; p = 0.001, respectively). On hrMRI, intraluminal thrombus and occlusion were also more frequent in the ischemia group than in the non-ischemia group (34.1 vs. 5.5%; p < 0.001, and 34.1 vs. 9.1%; p = 0.003, respectively). In addition, lesion length on hrMRI was significantly longer for patients with ischemia (81.5 ± 41.7 vs. 64.7 ± 30.8 mm; p = 0.025). In multivariable logistic regression analysis, male gender, infections during the last week, and the presence of intraluminal thrombus on CDU and hrMRI were independently associated with acute ischemic events.

Conclusion

Male sex, infections during the last week, and the presence of intraluminal thrombus due to dissection are associated with an increased risk of ischemic events in patients with unilateral EVAD.

Reperfusion therapy in acute ischaemic stroke due to cervical and cerebral artery dissection: Results from a Spanish multicentre study

INTRODUCTION

Ischaemic stroke (IS) due to cervical and cerebral artery dissection (CAD) is a rare entity, and few data are available on the use of such reperfusion therapies as intravenous fibrinolysis and mechanical thrombectomy in these patients. We analysed the use of these treatments in patients with IS due to CAD and compared them against patients receiving reperfusion treatment for IS of other aetiologies.

METHODS

We conducted an observational, retrospective, multicentre study of patients with IS due to CAD recorded in the National Stroke Registry of the Spanish Society of Neurology during the period 2011-2019. Comparative analyses were performed between: a) patients with CAD treated and not treated with reperfusion therapies and b) patients treated with reperfusion for IS due to CAD and patients treated with reperfusion for IS due to other causes. Epidemiological data, stroke variables, and outcomes at discharge and at 3 months were included in the analysis.

RESULTS

The study included 21,037 patients with IS: 223 (1%) had IS due to CAD, of whom 68 (30%) received reperfusion treatment. Reperfusion treatments were used less frequently in cases of vertebral artery dissection and more frequently in patients with carotid artery occlusion. Compared to patients with IS due to other causes, patients with CAD were younger, more frequently underwent mechanical thrombectomy, and less frequently received intravenous fibrinolysis. Rates of haemorrhagic complications, mortality, and independence at 3 months were similar in both groups.

CONCLUSIONS

Reperfusion therapy is frequently used in patients with IS due to CAD. The outcomes of these patients demonstrate the efficacy and safety of reperfusion treatments, and are comparable to the outcomes of patients with IS due to other aetiologies.

A review of carotid and vertebral artery dissection

Cervical artery dissection is a major cause of ischaemic stroke in young adults. The diagnosis can be challenging as some patients may present with seemingly benign symptoms such as a headache, neck pain or dizziness. However, the neurological sequelae of a transient ischaemic attack, vision loss or ischaemic stroke are potentially devastating. All hospital clinicians must be able to recognise this diagnosis and organise timely and appropriate investigations as antithrombotic treatment reduces the risk of stroke recurrence. This article reviews the literature to provide practical information for clinicians to recognise key risk factors and features of history and examination which should raise suspicion of cervical artery dissection. Diagnosis can now be made using the non-invasive, commonly available modalities of computed tomography angiography or magnetic resonance angiography. Timely treatment with antithrombotic agents is recommended to reduce the rate of an ischaemic stroke.

Stroke Prevention in Cervical Artery Dissection

PURPOSE OF REVIEW

Cervical artery dissection (CAD) is rare, yet it is a common cause of stroke in young and middle-aged adults. Historically, some senior clinicians favored anticoagulation in the prevention of stroke due to CAD. Choosing the optimal antithrombotic treatment with either antiplatelet (AP) or anticoagulant (AC) medications remains a challenge. This paper will review the clinical features and imaging of CAD, and the acute treatment and prevention of stroke due to CAD.

RECENT FINDINGS

Until 2015, there were no prospective randomized trials in the optimal antithrombotic management of CAD. The Cervical Artery Dissection in Stroke Study (CADISS) trial found that treatment with AC did not lower the risk of subsequent stroke or death at 3 months when compared to AP agents. This led to a paradigm shift in national guidelines. In 2021, The Biomarkers and Antithrombotic Treatment in of Cervical Artery Dissection (TREAT-CAD) trial however did not confirm the non-inferiority of AP therapy in stroke prevention due to CAD. The optimal antithrombotic management for stroke prevention in CAD remains uncertain, while the superiority of anticoagulation has not been established, nor has the non-inferiority of AP agents. The future direction of research should consider early preventative treatment, dual treatment with AP agents, direct oral AC medications, and aggregation of data from existing randomized trials.

Thrombolysis Improves Reperfusion and the Clinical Outcome in Tandem Occlusion Stroke Related to Cervical Dissection: TITAN and ETIS Pooled Analysis

Background and Purpose

Despite the widespread adoption of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke (LVOS) in the anterior circulation, the optimal strategy for the treatment tandem occlusion related to cervical internal carotid artery (ICA) dissection is still debated. This individual patient pooled analysis investigated the safety and efficacy of prior intravenous thrombolysis (IVT) in anterior circulation tandem occlusion related to cervical ICA dissection treated with MT.

Methods

We performed a retrospective analysis of two merged prospective multicenter international real-world observational registries: Endovascular Treatment in Ischemic Stroke (ETIS) and Thrombectomy In TANdem occlusions (TITAN) registries. Data from MT performed in the treatment of tandem LVOS related to cervical ICA dissection between January 2012 and December 2019 at 24 comprehensive stroke centers were analyzed. The primary endpoint was a favorable outcome defined as 90-day modified Rankin Scale (mRS) score of 0–2.

Results

The study included 144 patients with tandem occlusion LVOS due to cervical ICA dissection, of whom 94 (65.3%) received IVT before MT. Prior IVT was significantly associated with a better clinical outcome considering the mRS shift analysis (common odds ratio, 2.59; 95% confidence interval [CI], 1.35 to 4.93; P=0.004 for a 1-point improvement) and excellent outcome (90-day mRS 0–1) (adjusted odds ratio [aOR], 4.23; 95% CI, 1.60 to 11.18). IVT was also associated with a higher rate of intracranial successful reperfusion (83.0% vs. 64.0%; aOR, 2.70; 95% CI, 1.21 to 6.03) and a lower rate of symptomatic intracranial hemorrhage (4.3% vs. 14.8%; aOR, 0.21; 95% CI, 0.05 to 0.80).

Conclusions

Prior IVT before MT for the treatment of tandem occlusion related to cervical ICA dissection was safe and associated with an improved 90-day functional outcome.

ESO guideline for the management of extracranial and intracranial artery dissection

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.

Epidemiology and risk factors for stroke in young individuals: implications for prevention

PURPOSE OF REVIEW

Summarize and examine the epidemiology, etiologies, risk factors, and treatment of stroke among young adults and highlight the importance of early recognition, treatment, and primordial prevention of risk factors that lead to stroke.

RECENT FINDINGS

Incidence of stroke, predominantly ischemic, among young adults has increased over the past two decades. This parallels an increase in traditional risk factors such as hypertension, diabetes, and use of tobacco, and use of illicit substances among young stroke patients. Compared to older patients, there is a much higher proportion of intracerebral and subarachnoid hemorrhage in young adults. The cause of ischemic stroke in young adults is also more diverse compared to older adults with 1/3rd classified as stroke of undetermined etiology due to inadequate effort or time spent on investigating these diverse and rare etiologies. Young premature Atherosclerotic Cardiovascular Disease patients have suboptimal secondary prevention care compared to older patients with lower use of antiplatelets and statin therapy and lower adherence to statins.

SUMMARY

Among young patients, time-critical diagnosis and management remain challenging, due to atypical stroke presentations, vast etiologies, statin hesitancy, and provider clinical inertia. Early recognition and aggressive risk profile modification along with primary and secondary prevention therapy optimization are imperative to reduce the burden of stroke among young adults and save potential disability-adjusted life years.

Cervical and intracranial artery dissections

This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.

Vertebral Artery Dissection in a Woman Due to Golf: An Under Recognized Etiology

INTRODUCTION

Traditionally, spontaneous cervical artery dissections have been associated with violent, sudden neck movements. These events are a significant cause of stroke related morbidity, particularly in young people. Only a handful of cases of golf-induced vertebral artery dissection (VAD) have been described, and the discussion has primarily focused on middle-aged men. Despite the discussion focused on this demographic, women are participating in golf at higher rates than ever before, and have a higher risk for developing VAD.

CASE REPORT

A 41-year-old woman presented to our hospital with sharp neck pain, dizziness, and ptosis after swinging a driver during a morning round of golf. Imaging demonstrated a right V3/V4 VAD and subsequent ischemic infarction. After administration of tissue plasminogen activator she had abrupt change in mental status with seizure-like activity. She underwent angiogram and mechanical thrombectomy, and was started in heparin 24 hours post-tissue plasminogen activator. This was subsequently changed to low-dose aspirin following thalamic petechial hemorrhage. She was discharged from the hospital after a few days with only minor deficits. We will discuss mechanism, treatment, and outcomes of VAD in context of this case.

CONCLUSION

This patient is the first woman in the literature to suffer from VAD as a result of playing golf. The twisting motion of the head and neck in a golf swing may be a risk factor for dissection and subsequent development of stroke. As a result of increased female participation in golf, we expect to see increased incidence of women presenting with "golfer's stroke" in coming years.

Systematic review of the effectiveness of carotid surgery and endovascular carotid stenting versus best medical treatment in managing symptomatic acute carotid artery dissection

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.

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

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.

Reperfusion treatment in acute ischaemic stroke due to cervical and cerebral artery dissection: results of a Spanish national multicentre study

INTRODUCTION

Ischaemic stroke (IS) due to cervical and cerebral artery dissection (CAD) is a rare entity, and few data are available on the use of such reperfusion therapies as intravenous fibrinolysis and mechanical thrombectomy in these patients. We analysed the use of these treatments in patients with IS due to CAD and compared them against patients receiving reperfusion treatment for IS of other aetiologies.

METHOD

We conducted an observational, retrospective, multicentre study of patients with IS due to CAD recorded in the National Stroke Registry of the Spanish Society of Neurology during the period 2011-2019. Comparative analyses were performed between: a) patients with CAD treated and not treated with reperfusion therapies and b) patients treated with reperfusion for IS due to CAD and patients treated with reperfusion for IS due to other causes. Epidemiological data, stroke variables, and outcomes at discharge and at 3 months were included in the analysis.

RESULTS

The study included 21,037 patients with IS: 223 (1%) had IS due to CAD, of whom 68 (30%) received reperfusion treatment. Reperfusion treatments were used less frequently in cases of vertebral artery dissection and more frequently in patients with carotid artery occlusion. Compared to patients with IS due to other causes, patients with CAD were younger, more frequently underwent mechanical thrombectomy, and less frequently received intravenous fibrinolysis. Rates of haemorrhagic complications, mortality, and independence at 3 months were similar in both groups.

CONCLUSIONS

Reperfusion therapy is frequently used in patients with IS due to CAD. The outcomes of these patients demonstrate the efficacy and safety of reperfusion treatments, and are comparable to the outcomes of patients with IS due to other aetiologies.

Transcranial Doppler as a Predictor of Ischemic Events in Vertebral Artery Dissection

BACKGROUND AND PURPOSE

Transcranial Doppler (TCD) helps identify patients with carotid dissections at risk of ischemic events (IEs). There is paucity of data identifying independent predictors of IE in vertebral arterial dissection (VAD). We sought to investigate the clinical and ultrasound predictors of IE.

METHODS

Patients with VAD admitted between June 2017 and February 2020 were evaluated clinically and with TCD; sonographic curves, microembolic signals (MES), and the breath-holding index (BHI) test were applied. Covariates found on univariate screen (P < .25) were included in a multivariable linear regression to identify independent predictors of IEs.

RESULTS

Of 88 patients with 100 VAD, 75 (85.2%) were females with a mean age 37.9 ± 7.5 years. All patients received antiplatelet treatment. TCD monitoring lasted an average of 21 ± 2.1 minutes. TCD was abnormal in 23 cases (26.1%); 21 patients had abnormal sonographic curves in the vertebral/basilar arteries, while in 4 cases, MES were present and in 5 (4.5%), BHI was abnormal. None of the patients with a normal TCD had an IE. Six strokes occurred during follow up. On univariate analysis, male sex, diabetes, dyslipidemia, a previous myocardial infarct, migraine, time of consultation to the ER, bilateral VAD, MES, BHI abnormalities, post stenotic flow in the basilar artery (PFB), and basilar/vertebral velocities were significantly associated with the risk of IEs. In the multivariate analysis, only the presence of PFB was a significant predictor of IE (OR: 68.6, 95% CI 5-937, <.001).

CONCLUSIONS

TCD in VAD predicts patients at high risk of IE.

Endovascular thrombectomy for tandem acute ischemic stroke associated with cervical artery dissection: a systematic review and meta-analysis

PURPOSE

Strokes associated with cervical artery dissection have been managed primarily with antithrombotics with poor outcomes. The additive role of endovascular thrombectomy remains unclear. The objective was to perform systematic review and meta-analysis to compare endovascular thrombectomy and medical therapy for acute ischemic stroke associated with cervical artery dissection.

METHODS

Studies from six electronic databases included outcomes of patient cohorts with acute ischemic stroke secondary to cervical artery dissection who underwent treatment with endovascular thrombectomy. A meta-analysis of proportions was conducted with a random effects model. Modified Rankin score at 90 days (mRS 0-2) was the primary outcome. Other outcomes included proportion of patients with thrombolysis in cerebral infarction (TICI) 2b-3 flow, 90-day mortality rate, and 90-day symptomatic intracerebral hemorrhage (sICH) rate.

RESULTS

Six studies were included, comprising 193 cases that underwent thrombectomy compared with 59 cases that were managed medically. Successful recanalization with a pooled proportion of thrombolysis in cerebral infarction (TICI) 2b-3 flow in the thrombectomy group was 74%. Favorable outcome (mRS 0-2) was superior in the pooled thrombectomy group (62.9%, 95% CI 55.8-69.5%) compared with medical management (41.5%, 95% CI 29.0-55.1%, P = 0.006). The pooled rate of 90-day mortality was similar for endovascular vs medical (8.6% vs 6.3%). The pooled rate of symptomatic intracranial haemorrhage (sICH) did not significantly differ (5.9% vs 4.2%, P = 0.60).

CONCLUSIONS

Current data suggest that endovascular thrombectomy may be an option in patients with acute ischemic stroke due to cervical artery dissection. This requires further confirmation in higher quality prospective studies.

Endovascular therapy versus intravenous thrombolysis in cervical artery dissection-related ischemic stroke: a meta-analysis

BACKGROUND

The purpose of our meta-analysis is to evaluate the endovascular therapy (EVT) in patients with cervical artery dissection (CAD)-related acute ischemic stroke (AIS) by comparing its efficacy and safety with the ones of intravenous thrombolysis (IVT).

METHODS

A systematic search on EVT to CAD-related ischemic stroke is performed. The meta-analysis models are applied to calculate either the risk ratio (RR) with 95% confidence interval (CI) or pooled proportions with 95% CI of favorable functional outcome (mRS = 0-2), excellent functional outcome (mRS = 0-1), symptomatic intracranial hemorrhage (SICH), mortality and recurrent stroke between EVT and IVT in CAD-related stroke. The differences between the two treatment groups are analyzed by the pooled odds ratio value and Chi-squared test.

RESULTS

A total of 190 patients given EVT and 139 IVT-alone patients are included. By comparing EVT alone and IVT alone, patients treated with EVT alone are more likely to experience favorable outcomes than those treated with IVT alone (71.2% vs 53.4%). Besides, there is no significant difference in excellent functional outcome, SICH, mortality and recurrent stroke between the EVT-alone and IVT-alone groups (all P > 0.05). Towards general EVT (EVT with or without IVT), the outcomes are not significantly different from those of IVT alone except for a higher mortality rate (10.2% vs 3.2%).

CONCLUSION

Based on our findings, EVT is considered to be more efficacious than IVT for CAD-related AIS patients. Although EVT alone tends to be safe and promising, its safety needs to be further evaluated, particularly for EVT separating from IVT therapy.

Epidemiology, aetiology, and management of ischaemic stroke in young adults

Epidemiological evidence suggests that the incidence of ischaemic stroke in young adults (18-50 years) has increased substantially. These patients have a long life expectancy after stroke, and the costs of long-term care pose huge challenges to health-care systems. Although the current recommendations for treatment of young and old (>50 years) patients with stroke are similar, the optimal management of young adult patients with stroke is unknown. They are usually not included in trials, and specific subanalyses limited to young adult patients with stroke are usually not done, owing to lower incidence of stroke and lower prevalence of vascular risk factors in young adults. Progress has been made in identifying patients with a considerable risk of stroke occurrence, such as those with patent foramen ovale. Future prevention studies might result in a decrease in the incidence of stroke and its sequelae in young adults. The development of guidelines specifically devoted to the management of stroke in young adults will be an important step in achieving this aim.

Efficacy and safety of endovascular treatment in acute ischemic stroke due to cervical artery dissection: A 15-year consecutive case series

Background

Limited observational data are available on endovascular treatment in acute ischemic stroke due to cervical artery dissection. Three studies comparing endovascular treatment with standard medical therapy or intravenous thrombolysis in cervical artery dissection-related acute ischemic stroke did not demonstrate superiority of endovascular treatment. Efficacy and the choice of endovascular treatment technique in this setting remain to be established.

Aims

To assess the potential efficacy and safety of endovascular treatment compared to intravenous thrombolysis alone or to no revascularization treatment in our center.

Methods

We selected all consecutive patients with cervical artery dissection-related acute ischemic stroke and intracranial occlusion from the Acute STroke Registry and Analysis of Lausanne between 2003 and 2017. We compared clinical and neuroimaging data of patients treated by endovascular treatment versus patients receiving intravenous thrombolysis or patients without revascularization treatment. Safety analysis included symptomatic intracranial hemorrhage, major radiological hemorrhages (parenchymal hematoma 1, parenchymal hematoma 2, and subarachnoid hemorrhage) and mortality within seven days. We assessed favorable clinical outcome (modified Rankin Scale 0-2) at three months using a binary logistic regression model.

Results

Of the 109 patients included, 24 had endovascular treatment, 38 received intravenous thrombolysis alone, and 47 had no revascularization treatment. Endovascular treatment patients had a higher rate of recanalization at 24 h. Major radiological hemorrhages occurred more often in endovascular treatment patients (all with bridging therapy) than in patients without revascularization treatment (p = 0.026), with no differences in symptomatic intracranial hemorrhage or mortality within seven days. Favorable clinical outcome at three months did not differ between groups (endovascular treatment versus intravenous thrombolysis p = 0.407; endovascular treatment versus no revascularization treatment p = 0.580).

Conclusions

In this single-center cohort of cervical artery dissection-related acute ischemic stroke with intracranial occlusion, endovascular treatment with prior intravenous thrombolysis may increase the risk of major radiological but not symptomatic intracranial hemorrhage. Despite the lack of clear superiority in our cohort, endovascular treatment should currently not be withheld in these patients.

Multicentric Experience in Distal-to-Proximal Revascularization of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection

BACKGROUND AND PURPOSE

Internal carotid dissection is a frequent cause of ischemic stroke in young adults. It may cause tandem occlusions in which cervical carotid obstruction is associated with intracranial proximal vessel occlusion. To date, no consensus has emerged concerning endovascular treatment strategy. Our aim was to evaluate our endovascular "distal-to-proximal" strategy in the treatment of this stroke subtype in the first large multicentric cohort.

MATERIALS AND METHODS

Prospectively managed stroke data bases from 2 separate centers were retrospectively studied between 2009 and 2014 for records of tandem occlusions related to internal carotid dissection. Atheromatous tandem occlusions were excluded. The first step in the revascularization procedure was intracranial thrombectomy. Then, cervical carotid stent placement was performed depending on the functionality of the circle of Willis and the persistence of residual cervical ICA occlusion, severe stenosis, or thrombus apposition. Efficiency, complications, and radiologic and clinical outcomes were recorded.

RESULTS

Thirty-four patients presenting with tandem occlusion stroke secondary to internal carotid dissection were treated during the study period. The mean age was 52.5 years, the mean initial NIHSS score was 17.29 ± 6.23, and the mean delay between onset and groin puncture was 3.58 ± 1.1 hours. Recanalization TICI 2b/3 was obtained in 21 cases (62%). Fifteen patients underwent cervical carotid stent placement. There was no recurrence of ipsilateral stroke in the nonstented subgroup. Twenty-one patients (67.65%) had a favorable clinical outcome after 3 months.

CONCLUSIONS

Endovascular treatment of internal carotid dissection-related tandem occlusion stroke using the distal-to-proximal recanalization strategy appears to be feasible, with low complication rates and considerable rates of successful recanalization.

Endovascular therapy versus intravenous thrombolysis in cervical artery dissection ischemic stroke - Results from the SWISS registry

INTRODUCTION

In patients with stroke attributable to cervical artery dissection, we compared endovascular therapy to intravenous thrombolysis regarding three-month outcome, recanalisation and complications.

MATERIALS AND METHODS

In a multicentre intravenous thrombolysis/endovascular therapy-register-based cohort study, all consecutive cervical artery dissection patients with intracranial artery occlusion treated within 6 h were eligible for analysis. Endovascular therapy patients (with or without prior intravenous thrombolysis) were compared to intravenous thrombolysis patients regarding (i) excellent three-month outcome (modified Rankin Scale score 0-1), (ii) symptomatic intracranial haemorrhage, (iii) recanalisation of the occluded intracranial artery and (iv) death. Upon a systematic literature review, we performed a meta-analysis comparing endovascular therapy to intravenous thrombolysis in cervical artery dissection patients regarding three-month outcome using a random-effects Mantel-Haenszel model.

RESULTS

Among 62 cervical artery dissection patients (median age 48.8 years), 24 received intravenous thrombolysis and 38 received endovascular therapy. Excellent three-month outcome occurred in 23.7% endovascular therapy and 20.8% with intravenous thrombolysis patients. Symptomatic intracranial haemorrhage occurred solely among endovascular therapy patients (5/38 patients, 13.2%) while four (80%) of these patients had bridging therapy; 6/38 endovascular therapy and 0/24 intravenous thrombolysis patients died. Four of these 6 endovascular therapy patients had bridging therapy. Recanalisation was achieved in 84.2% endovascular therapy patients and 66.7% intravenous thrombolysis patients (odds ratio 3.2, 95% confidence interval [0.9-11.38]). Sensitivity analyses in a subgroup treated within 4.5 h revealed a higher recanalisation rate among endovascular therapy patients (odds ratio 3.87, 95% confidence interval [1.00-14.95]), but no change in the key clinical findings. In a meta-analysis across eight studies (n = 212 patients), cervical artery dissection patients (110 intravenous thrombolysis and 102 endovascular therapy) showed identical odds for favourable outcome (odds ratio 0.97, 95% confidence interval [0.38-2.44]) among endovascular therapy patients and intravenous thrombolysis patients.

DISCUSSION AND CONCLUSION

In this cohort study, there was no clear signal of superiority of endovascular therapy over intravenous thrombolysis in cervical artery dissection patients, which - given the limitation of our sample size - does not prove that endovascular therapy in these patients cannot be superior in future studies. The observation that symptomatic intracranial haemorrhage and deaths in the endovascular therapy group occurred predominantly in bridging patients requires further investigation.

Neurogenic pulmonary oedema secondary to vertebral artery dissection while playing tennis

We present a case of a patient who developed vertebral artery dissection (VAD) while playing tennis and presented with neurogenic pulmonary oedema. The case highlights two important points: acute pulmonary oedema as an unusual presenting feature of VAD and VAD, an important cause of stroke in young people, as being associated with playing low-impact sports such as tennis. These associations, independent of each other, are under-recognised and can lead to a delay in diagnosis.

Extracranial Cervical Artery Dissections

Cervical artery dissections (CeAD) include both internal carotid and vertebral artery dissections. They are rare but important causes of stroke, especially in younger patients. CeAD should be considered in patients with strokelike symptoms, a new-onset headache and/or neck pain, and/or other risk factors. Early imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is key to making the diagnosis. Treatment may vary depending on the extent of the dissection, timing of the dissection, and other comorbidities. The overall prognosis is good, but does depend on the initial severity of symptoms.

Spontaneous carotid dissection

Carotid dissection is a rare occurrence but it is the main cause of stroke in individuals aged less than 45 years, and can be the etiology in up to 25% of strokes in young adults. We report a case with classic image of ying yang on vascular ultrasound, which was treated according to the best available medical evidence, yielding a favorable outcome.

Cervical artery dissection in patients ≥60 years

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.

The Use of Tissue Plasminogen Activator in the Treatment of Wallenberg Syndrome Caused by Vertebral Artery Dissection

BACKGROUND

Acute cerebrovascular accident (CVA) is a devastating cause of patient morbidity and mortality. Up to 10% of acute CVAs in young patients are caused by dissection of the vertebral or carotid artery. Wallenberg syndrome results from a CVA in the vertebral or posterior inferior artery of the cerebellum and manifests as various degrees of cerebellar dysfunction. The administration of a thrombolytic medication has been recommended in the treatment of patients with stroke caused by cervical artery dissection. Surprisingly, there is scant literature on the use of this medication in the treatment of this condition.

CASE REPORT

We describe a 42-year-old man with the sudden onset of headache, left-sided neck pain, vomiting, nystagmus, and ataxia 1 h after completing a weightlifting routine. Computed tomography angiography revealed a grade IV left vertebral artery injury with a dissection flap extending distally and resulting in complete occlusion. Subsequent magnetic resonance imaging and angiography demonstrated acute left cerebellar and lateral medullary infarcts, consistent with Wallenberg syndrome. The patient was treated with tissue plasminogen activator, which failed to resolve his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently manage patients with acute CVAs. For select patients, the administration of tissue plasminogen activator can improve outcomes. However, the risk of major hemorrhage with this medication is significant. Cervical artery dissection is an important cause of acute stroke in young patients and is often missed on initial presentation. It is imperative for the emergency physician to consider acute cervical artery dissection as a cause of stroke and to be knowledgeable regarding the efficacy of thrombolytic medications for this condition.

Endovascular treatment of acute internal carotid artery dissections: technical considerations, clinical and angiographic outcome

INTRODUCTION

In acute internal carotid artery dissection (a-ICAD) with concomitant intracranial large vessel occlusion or haemodynamic impairment, the effectiveness of medical treatment is limited and endovascular therapy (EVT) can be considered. Feasibility, safety and outcome of EVT in a-ICAD are not well described yet.

METHODS

From an institutional database, we retrospectively selected consecutive patients treated for a-ICAD between January 2007 and July 2015. We assessed recanalization results defining <50 % residual stenosis and mTICI ≥2b as successful. Procedural adverse events and symptomatic haemorrhages were reported as well as clinical outcome at 90 days defining a mRS ≤2 as favourable. Follow-up angiographies were reviewed and retreatments reported.

RESULTS

In the defined period, 73 patients (mean age 48 years (31-73), mean NIHSS 11 (0-27)) received EVT for a-ICAD. The majority (60 %) had tandem occlusions. Cervical artery reconstruction was successful in 100 % and intracranial thrombectomy in 85 %. Thrombus formation (18 %) and thromboembolism (20 %) were the most frequent adverse events but clinically relevant only in 8 %. Symptomatic haemorrhage occurred in 5 %. Clinical outcome was favourable in 64 %, with a lower chance after tandem occlusion (55 vs. 79 %, p = 0.047). Death rate was 10 %. None of the patients developed recurrent ischaemic symptoms, but control angiography revealed abnormal findings of the reconstructed ICA in 38 % leading to retreatment in 17 %.

CONCLUSION

EVT of a-ICAD is feasible with a predominantly favourable clinical outcome. Improvement of devices and techniques is warranted to reduce the risk of thrombus formation and thromboembolism during treatment and insufficient vessel wall healing thereafter.

Endovascular treatment in the acute and non-acute phases of carotid dissection: a therapeutic approach

Background

Carotid dissection (CD) may, in certain cases, lead to significant stenosis, occlusion, or pseudoaneurysm formation, causing embolic stroke or hemodynamic failure, despite medical therapy.

Objective

To evaluate the results of endovascular treatment and clinical outcomes of patients with CD.

Methods

A four-hospital retrospective study of endovascular treatment of extracranial CD in which medical treatment had failed or patients presented with a National Institute of Health Stroke Scale (NIHSS) score ≥8.

Results

Thirty-eight patients (mean age 46.6±13.5 years, 78.9% male, 84.2% spontaneous CD, 44.7% left CD and 26.3% bilateral CD) were analyzed. In 24 patients (63.2%) treatment was undertaken in the acute-phase CD (APCD). IV recombinant tissue plasminogen activator was administered in 7 (29.2%) APCD cases. The patients with APCD exhibited a high rate of successful revascularization (Thrombolysis In Cerebral Infarction ≥2b; 19 patients (79.2%)), a low risk of symptomatic intracranial hemorrhage (n=2 (8.3%)), and good global functional outcomes (modified Rankin Scale (mRS) ≤2; n=17 (70.8%)). Good recanalization correlated (p=0.001) with good clinical evolution (mRS ≤2) in the patients with APCD. Of the 14 patients with non-acute phase CD (NAPCD), seven were treated for pseudoaneurysm with multiple stents (six patients) or covered prostheses, with stenosis being treated in the remaining seven patients.

Conclusions

Endovascular treatment of selected cases of patients with CD associated with thromboembolic events and hemodynamic failure after unsuccessful medical therapy is a safe and effective method of restoring vessel lumen integrity, with good short-term clinical evolution.

Comprehensive analysis of intra-arterial treatment for acute ischemic stroke due to cervical artery dissection

Objective

The safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this study was twofold: first, describe a large series with CeAD treated with IAT; second, analyze outcomes with CeAD receiving IAT versus (a) CeAD not treated with IAT, (b) CeAD receiving intravenous thrombolysis (IVT) alone, and (c) non-CeAD mechanism of AIS receiving IAT.

Design

Demographics, clinical characteristics, treatment, and outcomes were summarized for all CeAD patients treated with IAT from January 2010 to May 2015. Outcomes included favorable 90 day modified Rankin Scale (mRS) score of 0–2, symptomatic intracerebral hemorrhage (sICH), recanalization (Thrombolysis in Cerebral Infarction 2b-3), procedural complications, and mortality. Outcomes were analyzed with χ² tests and multivariate logistic regression.

Results

There were 161 patients with CeAD: 24 were treated with IAT and comprised our target population. Dissections were more common in the internal carotid (n=18) than in the vertebral arteries (n=6). All but one patient had intracranial embolus. IAT techniques included thrombectomy (n=19), IA thrombolysis (n=17), stent (n=14), and angioplasty (n=7). Outcomes included favorable 90 day mRS score of 0–2 in 63%, 4 deaths, 1 sICH, and 3 procedural complications. After adjustment, favorable mRS in our target population was similar to comparison populations: (a) in CeAD, IAT versus no IAT (OR 0.62, p=0.56); (b) In CeAD, IAT versus IVT alone (OR 1.32, p=0.79); and (c) IAT in CeAD versus non-CeAD mechanism of AIS (OR 0.58, p=0.34).

Conclusions

IAT is a valid alternative therapeutic option for AIS caused by CeAD due to the low complication rate and excellent outcomes observed in this study.

Safety and Efficacy of Thrombolysis in Cervical Artery Dissection-Related Ischemic Stroke: A Meta-Analysis of Observational Studies

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.

Diagnosis and treatment of cervical artery dissection

Cervical artery dissection (CAD) is a major cause of stroke in the young. A mural hematoma is detected in most CAD patients. The intramural blood accumulation should not be considered a reason to withhold intravenous thrombolysis in patients with CAD-related stroke. Because intravenous-thrombolyzed CAD patients might not recover as well as other stroke patients, acute endovascular treatment is an alternative. Regarding the choice of antithrombotic agents, this article discusses the findings of 4 meta-analyses across observational data, the current status of 3 randomized controlled trials, and arguments and counterarguments favoring anticoagulants over antiplatelets. Furthermore, the role of stenting and surgery is addressed.

Pathophysiology and risk factors of cervical artery dissection: what have we learnt from large hospital-based cohorts?

PURPOSE OF REVIEW

Cervical artery dissection (CeAD) is a major cause of ischemic stroke in young and middle-aged adults, although relatively uncommon in the community. Recent large collaborative projects have provided new insights into mechanisms and risk factors of CeAD.

RECENT FINDINGS

Pathologic changes observed at the media-adventitia border in temporal arteries of CeAD patients suggest a predisposing arterial wall weakness. In large multicenter series of CeAD patients, compared to age-matched healthy controls and patients with an ischemic stroke of another cause, hypertension and migraine, especially without aura, were confirmed as risk factors for CeAD, in addition to cervical trauma and recent infection. Hypercholesterolemia and being overweight were shown to be inversely associated with CeAD. Differences in risk factor profile and structural features between carotid and vertebral dissection suggest that their pathophysiology may partly differ. An association of CeAD with fibromuscular dysplasia and reversible cerebral vasoconstriction syndrome was described. Genetic risk factors of CeAD are still poorly understood.

SUMMARY

Large cohorts of CeAD patients have refined our understanding of the pathophysiology and risk factors of CeAD, but the molecular mechanisms are still poorly understood. Ongoing high-throughput genetic projects will hopefully provide novel insight into the biological substrate of CeAD.

Traumatic dissection of the internal carotid artery: simultaneous infarct of optic nerve and brain

KEY CLINICAL MESSAGE

Traumatic intracranial internal carotid artery dissection is a rare but significant cause of stroke in patients in their forties, leading to high morbidity and mortality. Simultaneous ischemic stroke and optic nerve infarction can occur. Clinical suspicion of dissection is determining in the acute management.