Treatment Issues in Spontaneous Cervicocephalic Artery Dissections

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.

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.

Surgical and radiological interventions for treating symptomatic extracranial cervical artery dissection

BACKGROUND

Cervical artery dissection (CeAD) is a pathological bleed or tear, or both, in the wall of the carotid or vertebral arteries as they course through the neck, and is a leading cause of stroke in young people.

OBJECTIVES

To assess the effectiveness of surgical and radiological interventions versus best medical treatment alone for treating symptomatic cervical artery dissection.

SEARCH METHODS

We performed comprehensive searches of the Cochrane Stroke Group Trials Register (last searched March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL), 2020, Issue 4, in the Cochrane Library (searched March 2020), MEDLINE (1946 to March 2020) and Embase (1974 to March 2020). We searched relevant ongoing trials and research registers (searched March 2020), checked references in all relevant papers for additional eligible studies, and contacted authors and researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of either surgical or endovascular intervention for the management of symptomatic CeAD were eligible for inclusion. Only studies with anticoagulants or antiplatelet treatment as the control group were included. Two review authors planned to independently extract data.

DATA COLLECTION AND ANALYSIS

Primary outcomes were ipsilateral stroke and disability. Secondary outcomes were death, any stroke, or transient ischaemic attack, residual stenosis (> 50%), recurrence of cervical dissection, expanding pseudoaneurysm, or major bleeding. We analysed the studies according to the first choice of treatment. We planned to assess for risk of bias and apply GRADE criteria for any included studies.

MAIN RESULTS

We did not find any completed RCTs or CCTs undertaken in this area of research.

AUTHORS' CONCLUSIONS

No RCTs or CCTs compared either surgery or endovascular therapy with control. Thus, there is no available evidence to support their use for the treatment of extracranial cervical artery dissection in addition to antithrombotic therapy in people who continue to have neurological symptoms when treated with antithrombotic therapy alone.

Antiplatelets versus Anticoagulants in the Treatment of Extracranial Carotid and Vertebral Artery Dissection

Background

Very few studies have compared the safety and efficacy of antiplatelets and anticoagulants in the treatment of extracranial carotid and vertebral artery dissection. Our study was aimed at comparing the two types of antithrombotic treatment in extracranial dissection and to study the predictors of outcome in these patients.

Materials and Methods

Prospective data of 200 consecutive patients with a confirmed diagnosis of extracranial carotid (n = 132) or vertebral (n = 68) artery dissection (76% males; mean age, 43.5 ± 13 years) treated with antiplatelets (n = 136) or anticoagulants (n = 64) were analyzed retrospectively. The presenting symptom was stroke in 74.5%, transient ischemic attack (TIA) in 18.5%, and local symptoms in 7% of the patients. Follow-up was done at three and six months. Primary outcome measures were TIA or stroke and symptomatic intracerebral hemorrhage (SICH) at three months.

Results

At the three-month follow-up, 106 (53%) patients had an excellent outcome. Recurrent ischemic events occurred in 7 (3.5%) and SICH in 11 (5.55%) patients. Six (4.41%) patients in the antiplatelet group and 1 patient (1.56%) in the anticoagulant group had recurrent ischemic events (P = 0.434); SICH was more frequent in the anticoagulant group (9.4% vs 3.7%, P = 0.185). On multivariate analysis, significant predictors of a poor three-month outcome were stroke as the presenting event and severity of stroke at onset.

Conclusions

The risk of recurrent ischemic events in carotid and vertebral artery dissection is low and is irrespective of the type of antithrombotic treatment. Stroke as the presenting event and severity of stroke at onset were significant predictors of a poor three-month outcome.

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.

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.

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.

Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection

Spontaneous intracranial artery dissection is an uncommon and probably underdiagnosed cause of stroke that is defined by the occurrence of a haematoma in the wall of an intracranial artery. Patients can present with headache, ischaemic stroke, subarachnoid haemorrhage, or symptoms associated with mass effect, mostly on the brainstem. Although intracranial artery dissection is less common than cervical artery dissection in adults of European ethnic origin, intracranial artery dissection is reportedly more common in children and in Asian populations. Risk factors and mechanisms are poorly understood, and diagnosis is challenging because characteristic imaging features can be difficult to detect in view of the small size of intracranial arteries. Therefore, multimodal follow-up imaging is often needed to confirm the diagnosis. Treatment of intracranial artery dissections is empirical in the absence of data from randomised controlled trials. Most patients with subarachnoid haemorrhage undergo surgical or endovascular treatment to prevent rebleeding, whereas patients with intracranial artery dissection and cerebral ischaemia are treated with antithrombotics. Prognosis seems worse in patients with subarachnoid haemorrhage than in those without.

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.

Outcome of cervicocranial artery dissection with different treatments: a systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis is to compare clinical outcomes between endovascular treatment and conservative treatment for cervicocranial artery dissection.

METHODS

Medline, Embase, and Cochrane Library databases were searched for studies comparing endovascular treatment versus conservative treatment for cervicocranial artery dissection patients. The period searched was from November 1994 to March 2013. Fifteen observational studies involving 442 cervicocranial artery dissection patients were found. Evaluated outcomes included rate of mortality, disability, and good recovery. The rebleeding rate in subarachnoid hemorrhage (SAH) patients was also recorded and compared.

RESULTS

In general, patients who received endovascular treatment enjoyed a lower mortality rate than those who received conservative treatment (P = .02, odds ratio [OR]: .5, 95% confidence interval [CI]: .27-.90), especially patients having ruptured cervicocranial artery dissection (P = .002, OR: .32, 95% CI .15-.66) and dissecting aneurysms (P = .006, OR: .31, 95% CI .14-.71). Among SAH patients with a Hunt-Hess score of 3 or more, endovascular treatment decreased mortality significantly (P = .006, OR: .22, 95% CI .08-.65), whereas no significant differences between these 2 treatments occurred in patients having a Hunt-Hess score less than 3.

CONCLUSIONS

Endovascular treatment yields a better outcome, with greater benefit in patients with ruptured cervicocranial artery dissection, dissecting aneurysms, and a Hunt-Hess score of 3 or more. Randomized controlled trials comparing these 2 therapeutic strategies are needed.

Vascular profiling: should manual therapists take blood pressure?

Risk assessment of the cervical spine prior to manual therapy interventions is currently a contentious topic, highlighted by recent suggestions in the medical press (http://www.bmj.com/content/344/bmj.e3679), that manipulative therapy should be abandoned because of the perceived risk. This paper addresses the issue of manual therapists using blood pressure measurement as an aid to clinical reasoning and decision making. The authors' use a case series of three neuromusculoskeletal presentations, which support the contention that blood pressure recording can prove to be an appropriate objective test for assessment prior to manual therapy interventions. Furthermore, it is suggested that blood pressure testing may provide direction for risk assessment and/or the management of patients across all populations and age groups as part of a holistic 'vascular profiling' approach to clinical reasoning and decision making.

Antiplatelet therapy in cerebrovascular disorders

Antiplatelet treatment is a mainstay in acute and long-term secondary stroke prevention. Aspirin is still most widely used worldwide, however, there is increasing evidence from small randomised trials that dual antiplatelet therapy combining aspirin with dipyridamole or clopidogrel might be more effective in the acute and early chronic post-ischemic phase (i.e. first 90 days). Both clopidogrel and the combination of aspirin and extended-release dipyridamole are recommended by current guidelines in long-term secondary stroke prevention in patients who are at high risk for a recurrent ischemic stroke, since they are more effective compared with aspirin monotherapy. Antiplatelet agents are the therapy of choice in patients with ischemic stroke due to intracranial stenosis and patent foramen ovale. In contrast, oral anticoagulation is clearly superior to single or double antiplatelet therapy in patients with cardioembolic stroke, mainly caused by atrial fibrillation.Concerning newer antiplatelet agents, only cilostazol appears to be a promising therapeutic option in patients with ischemic stroke in the near future, but so far, only studies in Asian stroke patients have been performed.