Cervical artery dissection after sports - An analytical evaluation of 190 published cases

Impact of repeated sportive chokes on carotid intima media thickness and brain injury biomarkers in grappling athletes

PURPOSE

Vascular neck compression techniques, referred to as 'chokes' in combat sports, reduce cerebral perfusion, causing loss of consciousness or voluntary submission by the choked athlete. Despite these chokes happening millions of times yearly around the world, there is scant research on their long-term effects. This pilot study evaluated whether repeated choking in submission grappling impacts the carotid intima media thickness (CIMT) and brain injury biomarkers (NFL, hGFAP, t-Tau, and UCH-L1).

METHODS

Participants (n = 39, 29 male; ages 27-60 years) were assigned to one of two study arms: Grapplers (n = 20, 15 male) and 19 age/sex/body size matched controls. Grapplers had been exposed to >500 choke events while training for >5 years in a choke-inclusive sport. Exclusion criteria were recent TBI or deficits from a past TBI or stroke. Bilateral ultrasound measurement of the CIMT was performed, and blood was collected for quantitative analysis of four brain injury markers. Subgroup analyses were performed within the Grappler group to account for blunt head trauma as a possible confounder.

RESULTS

There was no overall difference in CIMT measurements between Grapplers (mean 0.55 mm, SD 0.07) and Controls (mean 0.57 mm, SD 0.10) p = 0.498 [95% CI -0.04-0.08], nor were there CIMT differences between Grappler subgroups of blunt Trauma and No-Trauma. There were no significant differences in any biomarkers comparing Grapplers and Controls or comparing Grappler subgroups of Trauma and No-Trauma.

CONCLUSION

This study found no significant difference in CIMT and serum brain injury biomarkers between controls and grapplers with extensive transient choke experience, nor between grapplers with extensive past blunt head trauma and those without.

Osteovascular Conflicts in the Neck Region and Cerebrovascular Events: Illustrative Cases and Literature Review

STUDY DESIGN

Literature Review.

OBJECTIVE

Abnormal bone structures in the neck can cause headache, neck pain, and difficulty swallowing, but also cerebrovascular events. We introduce the term "osteovascular conflicts" to describe this phenomenon. The objective of this study was to conduct a literature review of such conflicts involving the anterior and posterior cerebral circulation. Furthermore, we aimed at presenting additional illustrative cases from our institution both for increasing awareness for unusual osteovascular conflicts, and for assessing the practice and care of such patients.

METHODS

We focused on osteovascular conflicts in the neck leading to cerebrovascular events related to an abnormal bone structure causing arterial or venous compression, dissection, and/or occlusion. We excluded pure vascular forms without cerebrovascular repercussions. Our PubMed/MEDLINE search for articles published in any language and for which an English abstract was available (from 1966 to 2022) included Eagle's neurovascular, bow hunter's syndrome, and golfer's stroke, excluding trauma-induced artery dissections or compressions and those concerning systemic bone disorders. We also provided illustrative cases collected by the authors.

RESULTS

All studies were either case reports or small case series. We found 82 cases of Eagle's neurovascular, 258 of bow hunter's syndrome, and 17 golfer's stroke cases. Mean ages were 52, 48, and 47 years, respectively. Male predominance was evident: 81% for Eagle's, 74% for bow hunter's, and 93% for golfer's.

CONCLUSION

Osteovascular conflicts are rare but important causes of cerebrovascular events and often go unrecognised. A greater awareness of cerebrovascular symptoms related to these conflicts can facilitate early diagnosis and treatment.

Recurrence of cervical artery dissection: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Cervical artery dissection (CAD) involving the carotid or vertebral arteries is an important cause of stroke in younger patients. The purpose of this systematic review is to assess the risk of recurrent CAD.

METHODS

A systematic review and meta-analysis was conducted on studies in which patients experienced radiographically confirmed dissections involving an extracranial segment of the carotid or vertebral artery and in whom CAD recurrence rates were reported.

RESULTS

Data were extracted from 29 eligible studies (n = 5898 patients). Analysis of outcomes was performed by pooling incidence rates with random effects models weighting by inverse of variance. The incidence of recurrent CAD was 4% overall (95% confidence interval (CI) = 3-7%), 2% at 1 month (95% CI = 1-5%), and 7% at 1 year in studies with sufficient follow-up (95% CI = 4-13%). The incidence of recurrence associated with ischemic events was 2% (95% CI = 1-3%).

CONCLUSIONS

We found low rates of recurrent CAD and even lower rates of recurrence associated with ischemia. Further patient-level data and clinical subgroup analyses would improve the ability to provide patient-level risk stratification.

Common carotid artery dissection from sportive choking

Tandem occlusions of the anterior circulation refer to the simultaneous presence of a cervical carotid artery occlusion or high-grade stenosis and an ipsilateral large vessel occlusion involving the intracranial internal carotid artery, M1 or proximal M2 middle cerebral artery. Whilst carotid occlusion usually results from progressive atherosclerotic disease, in younger individuals it may arise secondary to a dissection for which there are multiple aetiologies, with trauma being an important cause in patients having a relevant history. We present a rare case of traumatic left common carotid artery dissection in a young professional Jiu-Jitsu fighter presenting with delayed stroke symptoms and angiographic findings of a tandem occlusion. This case was successfully managed with endovascular clot retrieval and antiplatelet medication.

Top of basilar syndrome due to vertebral artery dissection: How high-resolution MRI and CD31 analysis of thrombus could help

INTRODUCTION AND IMPORTANCE

Vertebral artery dissection is a rare but serious condition that can lead to neurological deficits and even death. It is commonly associated with trauma or underlying vascular diseases. Top of basilar syndrome (TOBS) is a neurological condition that can result from vertebral artery dissection, either by direct ischemia or secondary occlusion due to distal embolization of injured inner vascular tissue. We here present a patient who was initially suffering from seizure then had TOBS due to a progressive vertebral artery dissection, with emphasis of high-resolution MRI imaging and immunohistochemistry study of the thrombus.

CASE PRESENTATION

A young male presented to the emergency department with sudden onset of seizure. A history of recent neck exercise was reported. The patient had gaze palsy, adduction disability, and dysarthria. High-resolution MRI showed a vertebral artery dissection with evidence of occlusion of the top of basilar artery. After the thrombectomy, a pathologic study revealed CD31[+] tissue in the thrombus, indicating an origin from dissected vertebral artery.

CLINICAL DISCUSSION AND CONCLUSION

It's important to recognize and treat vertebral artery dissection promptly due to its varying symptoms. Using high-resolution MRI at early stage and conducting pathologic analysis of CD31 on the thrombus can assist in the diagnosis, potentially leading to more precise treatment plans and better outcomes for patients.

Diagnostic potential of routine brain MRI and high-resolution, multi-contrast vessel wall imaging in the detection of internal carotid artery dissection

Objective

Cervical artery dissection (CAD) is one of the major causes of stroke and most commonly occurs at the site of the extracranial internal carotid artery (ICA). This study aimed to assess the value of routine brain MRI, clinical information, and high-resolution, multi-contrast vessel wall MR imaging (hrVWI) for the timely detection of ICA dissection.

Methods

A total of 105 patients with CAD and 105 without CAD were recruited for this study. The lesion type in the patients was determined based on images from different modalities, including brain MRI, magnetic resonance angiography (MRA), computed tomography angiography (CTA), digital subtraction angiography (DSA), ultrasonography, and hrVWI and clinical information. Each lesion was reviewed to determine the type following a stepwise procedure by referring to (1) brain MRI only; (2) brain MRI and clinical information; (3) hrVWI only; and (4) hrVWI, CTA, DSA, and clinical information.

Results

Typical clinical presentations of patients with potential CAD include headache, neck pain, and/or Horner's syndrome. Representative imaging signs in the brain MRI included a crescentic or circular iso- or hyperintensity around the lumen, a curvilinear and isointense line crossing the lumen, or aneurysmal vessel dilation. Based on brain MRI alone, 54.3% (57/105) of the patients with CAD were correctly classified, and the accuracy increased to 73.3% (77/105) when clinical information was combined (P < 0.001) with high specificity and low sensitivity. Further analysis showed that hrVWI had the superior capability in detecting CAD, with a sensitivity and a specificity of 95.1% and 97.0%, respectively.

Conclusion

The combination of brain MRI and clinical information could be used for the diagnosis of CAD; however, hrVWI should be sought for uncertain cases.

Cervical Artery Dissection

OBJECTIVE

Cervical artery dissection is a common cause of stroke in young adults. This article reviews the pathophysiology, etiology and risk factors, evaluation, management, and outcomes of spontaneous cervical artery dissection.

LATEST DEVELOPMENTS

Cervical artery dissection is believed to be a multifactorial disease, with environmental factors serving as possible triggers in patients who have a genetic predisposition to dissection formation. Cervical artery dissection can cause local symptoms or ischemic events, such as ischemic stroke or transient ischemic attack. Neuroimaging is used to confirm the diagnosis; classic findings include a long tapered arterial stenosis or occlusion, dissecting aneurysm, intimal flap, double lumen, or intramural hematoma. Patients with cervical artery dissection who present with an acute ischemic stroke should be evaluated for IV thrombolysis, endovascular therapy eligibility, or both. Antithrombotic therapy with either anticoagulation or antiplatelet treatment is used to prevent stroke from cervical artery dissection. The risk of recurrent ischemia appears low and is mostly limited to the first two weeks after symptom onset.

ESSENTIAL POINTS

Cervical artery dissection is a known cause of ischemic strokes. Current data show no difference between the benefits and risks of anticoagulation versus antiplatelet therapy in the acute phase of symptomatic extracranial cervical artery dissection, thereby supporting the recommendation that clinicians can prescribe either treatment. Further research is warranted to better understand the pathophysiology and long-term outcomes of cervical artery dissection.

Review article: Non-penetrating neck artery dissection in young adults: Not to be missed!

Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front-line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi-disciplinary team management of this condition. In general, guideline-based recommendation for the management of neck artery dissection involving an intimal flap is by anti-platelet therapy while treatment of neck artery dissection that results in a pseudo-aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.

Interplay between carotid artery dissection and thrombophilia leading to ischaemic stroke after minor head trauma in an adolescent: a case report

Stroke in children is more common than is often realised; there are numerous potential causes, including carotid artery injury resulting from minor head or neck trauma, as well as genetic conditions associated with thrombophilia. A 13-year-old boy suffered an arterial ischaemic stroke (AIS) secondary to dissection of the left internal carotid artery (ICA) after he headed the ball during a game of football. He presented with generalised tonic-clonic seizure, loss of consciousness, right-sided hemiplegia and aphasia. Neuroradiological imaging showed left caudate, putaminal and posterior insular ischaemic infarct secondary to complete occlusion of the left ICA and accompanying partial left middle cerebral artery occlusion. He was treated with anticoagulant and anti-aggregant agents. Rarely, minor head trauma can result in internal carotid artery dissection, thrombus formation and arterial occlusion, leading to arterial ischaemic stroke. Prompt diagnosis and management are crucial to achieve a good neurological outcome.Abbreviations: AIS: arterial ischaemic stroke; ANA: anti-nuclear antibody; APA: anti-phospholipid antibody; APTT: activated partial thromboplastin time; CAD: carotid artery dissection; CCAD: cranio-cervical artery dissection; CRP: C-reactive protein; CT: computed tomography; CTA: computed tomography angiography; dsDNA: double-stranded DNA; ESR: erythrocyte sedimentation rate; ICA: internal carotid artery; LA: lupus anticoagulant; MCA: middle cerebral artery; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; MTHFR: methylenetetrahydrofolate reductase; PT INR: prothrombin time international normalised ratio.

Cervical Artery Dissections and Ischemic Strokes Associated with Vascular Neck Compression Techniques (Sportive Chokes)

BACKGROUND

Strangulation as a fight-finishing maneuver in combat sports, termed "choking" in that context, occurs worldwide millions of times yearly. This activity can be trained safely, but devastating injuries can occur.

OBJECTIVE

Our aim was to present a case series of cervical artery dissections and ischemic strokes associated with sportive choking. Sharing these cases is meant to draw awareness, to assist emergency physicians in caring for these athletes, and to provide a platform for further research.

METHODS

Institutional Review Board approval was obtained. Participants consented for medical information transfer and anonymous academic reproduction. The minimum medical record information necessary for inclusion was a report of diagnosis-confirming advanced imaging. Participants were contacted for primary information in addition to what the medical records could provide and to confirm some information in the record (e.g., pertinent medical history, demographic characteristics, choking event description, medical care, and commentary on their current health). Medical records and additional first-hand information were reviewed and participants were included if they had a diagnosed dissection or stroke likely associated with a sportive choke.

RESULTS

Ten cases met all criteria for inclusion. There were 5 cases of carotid artery dissection, 3 cases of vertebral artery dissection, and 2 cases of ischemic stroke without dissection. Nine of 10 participants survived and 3 of 10 have returned to submission grappling training.

CONCLUSIONS

Cervical artery dissections and ischemic strokes can occur in association with sportive choking. Emergency physicians must be aware of the widespread nature of this activity and must be vigilant in approaching management of patients with symptoms consistent with these injuries.

Approach considerations for the management of strangulation in the emergency department

Patients with a history of strangulation present to the emergency department with a variety of different circumstances and injury patterns. We review the terminology, pathophysiology, evaluation, management, and special considerations for strangulation injuries, including an overview of forensic considerations and legal framework for strangulation events.

Rotational Vertebrobasilar Insufficiency: Is There a Physiological Spectrum? Phase-Contrast Magnetic Resonance Imaging Quantification in Healthy Volunteers

BACKGROUND

Some cases of cerebral ischemia have been attributed to dynamic flow limitation in neck vessels. It however remains unknown whether this represents the extreme end of a physiological response.

METHODS

Eighteen healthy volunteers were recruited to this prospective study. Cervical blood flow (ml/min/m²) was assessed using phase-contrast MRI, and cerebral perfusion ratios were assessed using arterial spin labeling perfusion at neutral position, predefined head rotations, as well as flexion and extension. Inter-reader agreements were assessed using intraclass correlation coefficient.

RESULTS

The mean age was 38.6 ± 10.8 (range = 22-56) years, for five male participants and 13 females. The means for height and weight were 168 cm and 73.2 kg, respectively. There were no significant differences in individual arterial blood flow with change in head position (P > 0.05). Similarly, the repeated-measures analysis of variance test demonstrated no significant difference in perfusion ratios in relation to head position movement (P > 0.05). Inter-reader agreement was excellent (intraclass correlation coefficient = 0.97).

CONCLUSIONS

There is neither significant change in either individual cervical arterial blood flow nor cerebral perfusion within the normal physiological/anatomical range of motion in healthy individuals. It is therefore reasonable to conclude that any such hemodynamic change identified in a patient with ischemic stroke be considered causative.

Assessing Cranial Nerves in Physical Therapy Practice: Findings from a Cross-Sectional Survey and Implication for Clinical Practice

BACKGROUND AND OBJECTIVE

Serious pathologies of the neck can potentially result in cranial nerve palsy. Knowledge about cranial nerve examination (CNE) seems sparse, and its use is still unknown. We aim to investigate the knowledge, skills, and utilization of CNE of Italian physiotherapists.

MATERIALS AND METHODS

An online cross-sectional survey.

RESULTS

396 completed the survey, reaching the required sample size. Although Italian physiotherapists consider CNE relevant (mean ± SD = 7.6/10 ± 2.0), over half of all responders (n = 229 (57.8%)) were not trained in the fundamentals and around a third did not use it in their daily practice (n = 138 (34.8%)). Additionally, participants were unconfident and insecure in conducting (n = 152 (38.4%) and n = 147 (37.1%)), interpreting (n = 140 (35.4%) and n = 164 (41.4%)), and managing the CNE (n = 141 (35.6%) and n = 154 (38.9%)). Possessing a musculoskeletal specialization was associated with an increased value attributed to clinical practice guidelines and reduced the lack of confidence in conducting, interpreting, and managing the CNE (respectively, n = 35 (25.5%), p = 0.0001; n = 32 (23.4%) p = 0.0002; n = 32 (23.4%) p = 0.0002). Working in a direct access setting significantly increased the considered relevance of guidelines and the concerns about arterial (p = 0.004) and other serious pathologies (p = 0.021). Pain and visual disturbances were considered the main indicators to CNE, demonstrating limited knowledge of signs and symptoms' indicating CNE. Participants considered specific training in CNE as relevant (mean ± SD = 7.6/10 = 2.1).

CONCLUSIONS

a substantial proportion of Italian physiotherapists are not schooled in the fundamentals of cranial nerve examination. Given the number of physiotherapists who work in first contact roles, this is a professional concern.

Posttraumatic subarachnoid hemorrhage related to concomitant carotid artery dissection and ruptured basilar trunk aneurysm: A case report and literature review

Background:

Carotid artery dissections (CADs) are a relatively rare disorder, whereas intracranial aneurysms (IAs) form a common cerebrovascular pathology. Since both vascular entities share similar risk factors and associations with connective tissue and vascular disorders, a common pathogenesis has been suggested. Here, we present a case of the concomitant occurrence of a CAD and a ruptured basilar trunk aneurysm (BTA). In the discussion, we elaborate on both vascular entities and have reviewed the literature on their concomitant incidence and potential shared pathogenesis.

Case Description:

We present a case of a 40-year-old female patient who was admitted to our hospital because of subarachnoid hemorrhage following a minor head trauma. Imaging revealed a BTA and unilateral extracranial dissection of the internal carotid artery. Despite coiling of the aneurysm, stenting of the dissection, and antithrombotic therapy, the patient died due to extensive cerebral ischemia sequelae.

Conclusion:

CAD and BTAs have both been associated with a vascular vulnerability but their concomitant occurrence has not been described previously. The previous studies have suggested an increased incidence of IAs in patients with a CAD and vice versa. However, the number of studies and reports on this mutual increased incidence is limited. Therefore, a shared pathogenesis seems rather speculative. In our case, we suggest that a posttraumatic CAD-induced hemodynamic alterations resulting in rupture of the saccular BTA.

Cervical Artery Dissection and Sports

Cervical artery dissection (CeAD) occurring in the context of sports is a matter of concern for CeAD patients. They seek advice on the role of sports in CeAD and on the safety of resuming sports after CeAD. The scarcity of studies and guidelines addressing these issues poses a challenge. We aimed at summarizing the current knowledge about CeAD and sports in order to provide an informed, comprehensive opinion for counseling CeAD patients. We took into account pathophysiological considerations, observations of cases reports, series, and registries, and conclusions by analogy from aortic dissection or inherited connective tissue syndromes. In summary, practicing active sports as the cause of CeAD seems uncommon. It seems recommendable to refrain from any kind of sports activities for at least 1 month, which can be extended in case of an unfavorable clinical or neurovascular course. We recommend starting with sport activities at low intensity—preferably with types of endurance sports—and to gradually increase the pace in an individually tailored manner, taking into circumstances of the occurrences of the CeAD in the individual patient (particularly in relation to sports), the meaning of sports activities for the individual well-being, the presence or absence of comorbidities and of neurological sequela, neurovascular findings, and whether there are signs of an underlying connective tissue alteration. Major limitations and several forms of bias are acknowledged. Still, in the absence of any better data, the summarized observations and considerations might help clinicians in advising and counseling patients with CeAD in clinical practice.

Mechanical thrombectomy in patients with cervical artery dissection and stroke in the anterior or posterior circulation - a multicenter analysis from the German Stroke Registry

Background

Cervical artery dissection (CAD) is a rare cause of acute ischemic stroke (AIS) with large vessel occlusion (LVO) and may constitute a challenge for mechanical thrombectomy (MT). We compared procedural characteristics, reperfusion rates, and clinical outcome in AIS patients undergoing MT with and without CAD.

Methods

We performed a pre-specified analysis of patients registered within the German Stroke Registry, a prospectively maintained multicenter registry of consecutive patients with AIS patients treated by MT. Procedural characteristics included time periods and additional application of medication.

Results

Of 2589 patients, 62 (2.4%) were diagnosed with CAD. CAD patients were younger, had lower rates of known vascular risk factors and larger baseline stroke volumes. MT in CAD patients took significantly longer (median [IQR] groin-puncture-to-flow restoration time: 98 [67–136] versus 70 [45–100] minutes; p < 0.001) and more often required use of intra-arterial medication (34.4% versus 15.6%; p < 0.001). Reperfusion success (modified Treatment in Cerebral Infarction score 2b-3: 85.2% versus 83.3%, p = 0.690) and favorable functional outcome after 3 months (modified Rankin Scale score ≤ 2: 70.9% versus 36.4%, adjusted p = 0.086) did not differ significantly between patients with and without CAD. The latter findings held true for both CAD in the anterior and posterior circulation.

Conclusion

CAD in AIS requiring MT is rare. MT in patients with CAD constitutes a particular procedural challenge, but still achieves favorable radiological and functional outcomes in most patients. Our data provide indirect evidence that MT is of clinical benefit in patients with AIS due to LVO and CAD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00119-y.

The safety of sportive chokes: a cross-sectional survey-based study

Objectives: Sportive choking or strangling, known as a 'choke' in the combat sports community, is the practice of compressing the jugular veins and carotid arteries to threaten unconsciousness by lowering cerebral perfusion pressure. This is commonly practiced within combat sports and police/military combatives. The safety profile of sportive choking is underrepresented in the literature. The authors sought to explore the safety of sportive chokes. Methods: A convenience sample of visitors to two combat sports internet forums completed an anonymous web-based survey on choking experience and related symptoms. Descriptive statistics were used to describe the obtained data. Bivariate analysis was performed to elaborate on relationships between grappling experience and the number of times choked, between the number of times choked with pre-syncope/syncope, and between the duration of symptoms and the number of times choked with pre-syncope/syncope. Results: Overall, 4421 individuals completed the survey. One hundred and fourteen were excluded, leaving 4307 analyzed respondents. Ninety-four percent were male, 89.2% were ages 18-44 years. Seventy-nine percent had >1 year of grappling experience and 30% had >5 years. Of the 4307, 1443 (33.5%) reported being choked >500 times, 3257 (75.7%) have been choked to near-syncope, and 1198 (27.8%) have been choked unconscious. Two of the 4307 (0.05%) reported ongoing symptoms from chokes. Of the respondents, 94.3% felt applying a choke would be a safe and effective way to control a street fight; 83.6% felt that vascular neck restraint, the police combative equivalent of sportive choking, would be appropriate as an alternative escalation of force option. Conclusion: Based on a convenience sample of 4307 respondents' self-reported data, sportive choking appears to be safe. Only 0.05% experienced ongoing symptoms, which were likely not related to brain ischemia.

Recurrence of cervical artery dissection: protocol for a systematic review

INTRODUCTION

Cervical artery dissection, including carotid and vertebral artery dissection, is an important cause of stroke in the young. Risk of developing cervical artery dissection has been associated with physical activity in various forms and has been presumed to be related to minor trauma and mechanical stretching of the cervical arteries. This systematic review will aim to synthesise data on the risk of recurrent cervical artery dissection after an initial dissection. This information may be applied to further understand the natural history of this disease, and potentially to help direct evidence-based discussions on safe return to activity after dissection.

METHODS AND ANALYSIS

A broad search of multiple electronic databases (Medline, Embase, Cochrane Central Register of Controlled Trials and Web of Science) will be conducted to identify studies published as of 13 November 2019, examining all-comers with cervical artery dissection observed over time. Studies will be screened by two independent reviewers in a two-level process to determine eligibility for inclusion. Data will be pooled from eligible articles and the main outcome of recurrent cervical artery dissection at 5 years will be determined using quantitative analysis.

ETHICS AND DISSEMINATION

Ethics approval is not necessary as no primary data are being collected. The information will be disseminated in the form of a systematic review article which will be submitted to a peer-reviewed medical journal.

PROSPERO REGISTRATION NUMBER

CRD42020166105.

Changes in internal carotid and vertebral arterial wall stiffness with head movement can be detected with shear wave elastography

Background: Safe practice is important for patients with neck pain, with the potential for injury to cervical arteries. Cervical manipulation or end range techniques/positions may place considerable strain on the arteries. Altered integrity of the arterial wall may render them more susceptible to minor trauma, particularly in the upper cervical region. Screening of blood flow velocity is limited for predicting those at risk. Examining properties of the cervical arterial wall (stiffness characteristics) and their response to head movement may provide an alternate measure of arterial susceptibility.Objectives: To investigate whether shear wave ultrasound elastography can detect any changes in internal carotid (ICA) and vertebral (VA) arterial wall stiffness in neutral compared with contralateral head rotation.Design: Observational studyMethods: Shear wave ultrasound elastography was used to measure the stiffness of the ICA and VA. Shear wave velocity (m/s), indicative of arterial stiffness, was measured in both arteries proximally (C3-4) and distally (C1-2) in neutral and contralateral head rotation as were intimal thickness (mm) and flow velocity (cm/s).Results: Thirty participants (20-62 years) were successfully imaged. The VA was stiffer than ICA and it became significantly stiffer in contralateral rotation (p = 0.05). The ICA became significantly less stiff (p = 0.01). Effects were more apparent at C1-2 but significant in the ICA only (p = 0.03). Flow velocity and intimal thickness were unchanged in rotation.Conclusions: Changes in VA and ICA arterial wall stiffness can be measured with shear wave ultrasound elastography. This measure may ultimately help identify arteries with greater vulnerability to rotational stresses.

Shear wave elastography of the cervical arteries: A novel approach to the assessment of cervical arterial wall stiffness. An investigation of psychometric properties and intra-rater reliability

BACKGROUND

Cervical arterial dissection, can occur spontaneously and is a rare but catastrophic adverse event associated with neck manipulation. Pathophysiology involves altered integrity of the arterial wall increasing its vulnerability to minor trauma. Those at risk are difficult to detect. Previous screening investigated blood flow but altered mechanical properties as stiffness of cervical arterial wall could provide a more valid indication of arterial integrity or even early dissection.

OBJECTIVES

To investigate suitability and intra-rater reliability of shear wave ultrasound elastography to measure mechanical properties of the cervical arterial wall. Suitability was assessed by ability to track arteries along their length and measurement accuracy.

DESIGN

Observational and intra-rater reliability study.

METHODS

Internal carotid (ICA) and vertebral arteries (VA) of healthy participants were examined with shear wave elastography. Shear wave velocity (m/s) indicative of wall stiffness was measured with the head in the neutral position: proximally (C3-4) and distally (C1-2) where injuries have been more commonly reported. Proximal measures were repeated to assess intra-rater reliability.

RESULTS

Thirty healthy participants (13 female), mean age of 29 (±12.8) years were imaged. Mean VA wall stiffness (3.4 m/s) was greater than ICA (2.3 m/s) (p < 0.000). Intra-rater reliability for ICA was ICC 0.81 (CI 0.52 to 0.92) and for VA ICC 0.76 (CI 0.38 to 0.9). Standard error of measurement was 0.16 for ICA and 0.34 for VA.

CONCLUSIONS

Shear wave ultrasound elastography appears a suitable and reliable method to measure cervical arterial wall stiffness, justifying further research into its use for screening arterial integrity.