Dissecção espontânea cervical carotídea e verbal: estudo de 48 pacientes

Antiplatelets or anticoagulants? Secondary prevention in cervical artery dissection: an updated meta-analysis

BACKGROUND

Extracranial artery dissection involving either internal carotid artery or vertebral artery is a major cause of stroke in adults under 50 years of age. There is no conclusive evidence whether antiplatelets or anticoagulants are better suited in the treatment of extracranial artery dissection.

OBJECTIVES

To determine whether antiplatelets or anticoagulants have advantage over the other in the treatment of extracranial artery dissection for secondary prevention of recurrent ischemic events or death.

METHODS

Present meta-analysis followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement. Database search was done in Medline, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov from inception to May 2021 using pre-defined search strategy. Additional studies were identified from reference lists from included studies, reviews and previous meta-analyses. Outcome measures were ischaemic stroke, ischaemic stroke or transient ischaemic attack (TIA), and death.

RESULTS

Two RCTs and 64 observational studies were included in the meta-analysis. While the outcome measures of stroke, stroke or TIA and death were numerically higher with antiplatelet use, there were no statistically significant differences between antiplatelets and anticoagulants.

CONCLUSION

We found no significant difference between antiplatelet and anticoagulation treatment after extracranial artery dissection. The choice of treatment should be tailored to individual cases.

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.

Case Report: De novo Vertebral Artery Dissection After Intravascular Stenting of the Contralateral Unruptured Vertebral Artery Aneurysm

Spontaneous vertebral artery dissecting aneurysm has been increasingly attributed as a major cause of focal neurological deficits due to vertebrobasilar artery ischemia or subarachnoid hemorrhage (SAH). Although the development of spontaneous vertebral artery dissecting aneurysm (VADA) is rare, de novo VADA after treatment of contralateral vertebral artery (VA) is more less frequently observed. There are only a few reports related to de novo VADA after treatment of the contralateral VA in the medical literature. The mechanisms responsible for de novo dissection after treatment of unilateral VADA are still not clearly understood. In this manuscript, we report an unusual case of a patient with a de novo VADA after placement of a pipeline embolization device (PED) stent on the contralateral VA along with a thorough review of the literature. A 42-years old male patient was referred to the hospital with sudden onset of dizziness, nausea, and vomiting. Initial digital subtraction angiography (DSA) images demonstrated a VADA in the fourth segment of the left VA without the involvement of the posterior inferior cerebellar artery (PICA). There were no significant abnormalities found in the right vertebral artery. He underwent an endovascular pipeline embolization to treat the dissecting aneurysm (DA). Surprisingly, follow-up DSA imaging 14 months after the initial treatment showed a segmental dilatation and narrowing of the right VA, which suggested a de novo VADA on the right side that had occurred postoperatively. This was followed by a tent-assisted coil embolization therapy for occluding this de novo VADA. This patient showed an uneventful postoperative course with no neurological abnormalities. In addition to hemodynamic stress changes, the unique clinicopathological features of dissecting aneurysms may contribute significantly to the pathogenesis of de novo VA dissection. Given that VA in VADA patients may be vulnerable on both sides, it is important to consider the risk of de novo dissection after initial aneurysm treatment. The bilateral vertebral artery has to be carefully observed when treating any VADA patient to prevent any complications.

Cortex-sparing infarction in triple cervical artery dissection following chiropractic neck manipulation

Background: Multivessel cervical dissection with cortical sparing is exceptional in clinical practice. Case presentation: A 55-year-old man presented with acute-onset neck pain with associated sudden onset right-sided hemiparesis and dysphasia after chiropractic manipulation for chronic neck pain. Results and Discussion: Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. This suggests the presence of functionally patent and interconnecting leptomeningeal anastomoses between cerebral arteries, which may provide sufficient blood flow to salvage penumbral regions when a supplying artery is occluded. Conclusion: Chiropractic cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.

Antithrombotic treatment for acute extracranial carotid artery dissections: a meta-analysis

INTRODUCTION

Carotid artery dissection is a leading cause of stroke in younger patients, with an associated prevalence of 2.6-3.0 per 100,000 population. This meta-analysis aims to determine whether in patients managed medically, treatment with anticoagulants or antiplatelet agents was associated with a better outcome with respect to mortality, ischaemic stroke, and major bleeding episodes.

PATIENTS AND METHODS

A comprehensive search strategy was employed of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to March 2015), and EMBASE (January 1980 to March 2015) databases. Primary outcomes were death (all causes) or disability. Secondary outcomes were ischaemic stroke, symptomatic intracranial haemorrhage, and major extracranial haemorrhage during the reported follow-up period.

RESULTS

No completed randomized trials were found. Comparing antiplatelets with anticoagulants across 38 studies (1,398 patients), there were no significant differences in the odds of death (effects size, ES, -0.007, p = .871), nor in the death and disability comparison or across any secondary outcomes.

CONCLUSION

There were no randomised trials comparing either anticoagulants or antiplatelets with control, thus there is no level 1 evidence to support their routine use for the treatment of carotid artery dissection. Also, there were no randomised trials that directly compared anticoagulants with antiplatelet drugs, and the reported non-randomised studies did not show any evidence of a significant difference between the two.

De Novo Vertebral Artery Dissection after Endovascular Trapping for Ruptured Dissecting Internal Carotid Artery Aneurysm: Case Report

The authors present an extremely rare case of a 54-year-old female patient with subarachnoid hemorrhage due to a rupture of a dissecting internal carotid artery (ICA) aneurysm, who developed de novo vertebral artery dissection in the spasm period after endovascular trapping of the ICA. Interestingly, postoperative cardiopulmonary monitoring showed high global end-diastolic volume index and mean arterial pressure, which could contribute to this de novo dissection via hemodynamic stress in the cerebral circulation. Spontaneous intracranial artery dissection of more than two arteries is rare, and we believe this is the first case of de novo dissection occurring on a circulating vessel different from that of the initial dissection. The clinical implications are discussed in relation to postoperative hemodynamic stress with a review of the literature.

Antiplatelets versus anticoagulants for the treatment of cervical artery dissection: Bayesian meta-analysis

OBJECTIVE

To compare the effects of antiplatelets and anticoagulants on stroke and death in patients with acute cervical artery dissection.

DESIGN

Systematic review with Bayesian meta-analysis.

DATA SOURCES

The reviewers searched MEDLINE and EMBASE from inception to November 2012, checked reference lists, and contacted authors.

STUDY SELECTION

Studies were eligible if they were randomised, quasi-randomised or observational comparisons of antiplatelets and anticoagulants in patients with cervical artery dissection.

DATA EXTRACTION

Data were extracted by one reviewer and checked by another. Bayesian techniques were used to appropriately account for studies with scarce event data and imbalances in the size of comparison groups.

DATA SYNTHESIS

Thirty-seven studies (1991 patients) were included. We found no randomised trial. The primary analysis revealed a large treatment effect in favour of antiplatelets for preventing the primary composite outcome of ischaemic stroke, intracranial haemorrhage or death within the first 3 months after treatment initiation (relative risk 0.32, 95% credibility interval 0.12 to 0.63), while the degree of between-study heterogeneity was moderate (τ(2) = 0.18). In an analysis restricted to studies of higher methodological quality, the possible advantage of antiplatelets over anticoagulants was less obvious than in the main analysis (relative risk 0.73, 95% credibility interval 0.17 to 2.30).

CONCLUSION

In view of these results and the safety advantages, easier usage and lower cost of antiplatelets, we conclude that antiplatelets should be given precedence over anticoagulants as a first line treatment in patients with cervical artery dissection unless results of an adequately powered randomised trial suggest the opposite.

Internal carotid artery dissection in a patient with Ehlers-Danlos syndrome type IV: diagnosis and management

Ehlers-Danlos syndrome (EDS) type IV, also known as vascular EDS, is an inherited connective tissue disorder with an estimated prevalence of 1/100,000 to 1/250,000. In EDS type IV, vascular complications may affect all anatomical areas, with a preference for large- and medium-sized arteries. Dissections of the vertebral and carotid arteries in their extra- and intra-cranial segments are typical. The authors report the case of a patient with EDS type IV for whom the diagnosis was established based on clinical signs and who developed internal carotid artery dissection at the age of 44 years. In the absence of a specific treatment for EDS type IV, medical interventions should focus on symptomatic relief, prophylactic measures, and genetic counseling. Invasive imaging techniques are contraindicated, and a conservative approach to vascular complications is usually recommended.

Predictors of Delayed Stroke in Patients with Cervical Artery Dissection

Background

Stroke in patients with acute cervical artery dissection may be anticipated by initial transient ischemic or nonischemic symptoms.

Aim

Identifying risk factors for delayed stroke upon cervical artery dissection.

Methods

Cervical artery dissection patients from the multicenter Cervical Artery Dissection and Ischemic Stroke Patients study were classified as patients without stroke ( n = 339), with stroke preceded by nonstroke symptoms (delayed stroke, n = 244), and with stroke at onset ( n = 382). Demographics, clinical, and vascular findings were compared between the three groups.

Results

Patients with delayed stroke were more likely to present with occlusive cervical artery dissection ( P < 0·001), multiple cervical artery dissection ( P = 0·031), and vertebral artery dissection ( P < 0·001) than patients without stroke. No differences were observed in age, smoking, arterial hypertension, hypercholesterolemia, migraine, body mass index, infections during the last week, and trauma during the last month, but patients with delayed stroke had less often transient ischemic attack ( P < 0·001) and local signs (Horner syndrome and cranial nerve palsy; P < 0·001).

Conclusions

Occlusive cervical artery dissection, multiple cervical artery dissection, and vertebral artery dissection were associated with an increased risk for delayed stroke. No other risk factors for delayed stroke were identified. Immediate cervical imaging of cervical artery dissection patients without ischemic stroke is needed to identify patients at increased risk for delayed ischemia.

A replication of the study 'Adverse effects of spinal manipulation: a systematic review'

Objective

To assess the significance of adverse events after spinal manipulation therapy (SMT) by replicating and critically reviewing a paper commonly cited when reviewing adverse events of SMT as reported by Ernst (J Roy Soc Med 100:330–338, 2007).

Method

Replication of a 2007 Ernst paper to compare the details recorded in this paper to the original source material. Specific items that were assessed included the time lapse between treatment and the adverse event, and the recording of other significant risk factors such as diabetes, hyperhomocysteinemia, use of oral contraceptive pill, any history of hypertension, atherosclerosis and migraine.

Results

The review of the 32 papers discussed by Ernst found numerous errors or inconsistencies from the original case reports and case series. These errors included alteration of the age or sex of the patient, and omission or misrepresentation of the long term response of the patient to the adverse event. Other errors included incorrectly assigning spinal manipulation therapy (SMT) as chiropractic treatment when it had been reported in the original paper as delivered by a non-chiropractic provider (e.g. Physician).

The original case reports often omitted to record the time lapse between treatment and the adverse event, and other significant clinical or risk factors. The country of origin of the original paper was also overlooked, which is significant as chiropractic is not legislated in many countries. In 21 of the cases reported by Ernst to be chiropractic treatment, 11 were from countries where chiropractic is not legislated.

Conclusion

The number of errors or omissions in the 2007 Ernst paper, reduce the validity of the study and the reported conclusions. The omissions of potential risk factors and the timeline between the adverse event and SMT could be significant confounding factors. Greater care is also needed to distinguish between chiropractors and other health practitioners when reviewing the application of SMT and related adverse effects.

Comparison of single versus multiple spontaneous extra- and/or intracranial arterial dissection

BACKGROUND

Anecdotal data suggest that approximately 20% of patients with a spontaneous extra- and/or intracranial arterial dissection have multiple arterial involvement. Limited data exist regarding the clinical and angiographic characteristics of patients with multiple arterial dissections. We compared the clinical and angiographic features of patients with spontaneous multiple extra- and/or intracranial arterial dissections with those who have a single arterial dissection.

METHODS

A retrospective chart review of the consecutive ischemic stroke database over a 7-year period, maintained at 2 institutions, was conducted to identify patients with spontaneous extra- and/or intracranial arterial dissection. The patients' clinical characteristics and angiographic features (including the artery affected, presence of pseudoaneurysm, fibromuscular dysplasia, and degree of stenosis) were analyzed.

RESULTS

A total of 76 patients were admitted with spontaneous extra- and/or intracranial arterial dissection; 46 dissections were confirmed with 4-vessel cerebral angiography. Multiple arterial dissections were found in a total of 10 (22%) patients. Involvement of multiple arteries was more prevalent in the young, when compared to a single spontaneous arterial dissection (7 [70%] in patients <45 years of age v 11 [31%]; P = .03). Patients with multiple arterial dissections had a higher proportion of pseudoaneurysms (9 [90%] v 11 [31%]; P = .001), a higher prevalence of underlying fibromuscular dysplasia (3 [30%] v 3 [8%]; P = .11), and were more likely to involve the posterior circulation (P < .0001).

CONCLUSIONS

The presence of multiple, simultaneous spontaneous extra- and/or intracranial arterial dissections must be considered when a single spontaneous arterial dissection is identified.

Antithrombotic drugs for carotid artery dissection

BACKGROUND

Extracranial internal carotid artery dissection (eICAD) is a leading cause of stroke in younger patients.

OBJECTIVES

1. To determine whether, in patients with eICAD, treatment with anticoagulants, antiplatelet agents or control was associated with a better functional outcome. 2. To compare, among patients treated with either anticoagulants or antiplatelet agents, the risk of ischaemic strokes and major bleeding episodes.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 3 October 2009). In addition, we performed comprehensive searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to November 2009) and EMBASE (January 1980 to November 2009), checked all relevant papers for additional eligible studies and contacted authors and researchers in the field.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials and non-randomised studies (if they reported on outcome stratified by antithrombotic treatment and included at least four patients) of anticoagulants or antiplatelet agents for the treatment of extracranial internal carotid artery dissection. Two review authors independently extracted data.

DATA COLLECTION AND ANALYSIS

Primary outcomes were death (all causes) and death or disability. Secondary outcomes were ischaemic stroke, symptomatic intracranial haemorrhage, and major extracranial haemorrhage during the reported follow-up period. The first choice treatment was taken for analyses.

MAIN RESULTS

We did not find any completed randomised trials. Comparing antiplatelets with anticoagulants across 36 observational studies (1285 patients), there were no significant differences in the odds of death (Peto odds ratio (Peto OR) 2.02, 95% CI 0.62 to 6.60), or the occurrence of ischaemic stroke (OR 0.63, 95% CI 0.21 to 1.86) (34 studies, 1262 patients). For the outcome of death or disability, there was a non-significant trend in favour of anticoagulants (OR 1.77, 95% CI 0.98 to 3.22; P = 0.06) (26 studies, 463 patients). Symptomatic intracranial haemorrhages (5/627; 0.8%) and major extracranial haemorrhages (7/425; 1.6%) occurred only in the anticoagulation group; however, for both these outcomes, the estimates were imprecise and indicated no significant difference between the two treatment modalities.

AUTHORS' CONCLUSIONS

There were no randomised trials comparing either anticoagulants or antiplatelet drugs with control, thus there is no evidence to support their routine use for the treatment of extracranial internal carotid artery dissection. There were also no randomised trials that directly compared anticoagulants with antiplatelet drugs and the reported non-randomised studies did not show any evidence of a significant difference between the two.

Spontaneous cervical artery dissection: an update on clinical and diagnostic aspects

Spontaneous cervical arterial dissection (SCAD) is a non-traumatic tear or disruption in the wall of the internal carotid arteries or the vertebral arteries. It accounts for about 25% of strokes in patients aged under 45 years. Awareness of its clinical features and advances in imaging over the last two decades have contributed to earlier identification of this condition. SCAD has become the commonest form of vascular lesion identified in the cervical carotid and vertebral arteries, second only to atherosclerosis. This review is an update on the epidemiology, vulnerable arterial segments, risk factors, clinical features, diagnosis, current treatment and prognosis of SCAD.

Spontaneous bilateral carotid and vertebral artery dissections associated with multiple disparate intracranial aneurysms, subarachnoid hemorrhage and spontaneous resolution. Case report and literature review

Spontaneous bilateral carotid and vertebral artery dissections (CADs and VADs) are rare. A 29-year-old female presented with a collapse, 4 weeks after a sudden onset of severe neck and shoulder pain. CT scan revealed diffuse subarachnoid hemorrhage (SAH) and early hydrocephalus. Angiography revealed bilateral CADs and VADs, along with multiple fusiform and saccular aneurysms. Systemic vessels - including the renal arteries - were normal, and no risk factors or underlying vasculopathy were apparent. The presumed source of SAH (a posterior cerebral artery aneurysm) was successfully clipped. Each dissection, by contrast, was managed conservatively with heparin prophylaxis; and spontaneous CAD and VAD resolution occurred within 6 months. We present a unique case of four-vessel dissection associated with multiple disparate saccular and fusiform aneurysms. We suspect that underlying vasculopathy - perhaps novel - may become apparent with time.

[Spontaneous internal carotid artery dissection with paralysis of lower cranial nerves: case report]

Spontaneous internal carotid artery dissection is a rare event that strikes patients at their productive age. As early intervention frequently determines a significant improvement, it is important to broaden the knowledge of the clinical, pathogenic and pathophysiological aspects of this disease. The objective is making an early diagnosis and treatment to avoid a bad outcome. We report the case of a 46 years-old man with spontaneous carotid artery dissection that had an atypical manifestation characterized by sudden paralysis of lower cranial nerves.

Antithrombotic drugs for carotid artery dissection

BACKGROUND

Extracranial internal carotid artery dissection can lead to occlusion of the artery and hence cause an ischaemic stroke. It is the underlying stroke mechanism in approximately 2.5% of all strokes. It is the second leading cause of stroke in patients younger than 45 years of age. Anticoagulants or antiplatelets may prevent arterial thrombosis in extracranial internal carotid artery dissection, but these benefits may be offset by increased bleeding.

OBJECTIVES

To determine whether antithrombotic drugs (antiplatelet drugs, anticoagulation) are effective and safe in the treatment of patients with extracranial internal carotid artery dissection, and which is the better treatment.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 3 October 2002). In addition we performed comprehensive searches of the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 2, 2002), MEDLINE (January 1966 to May 2002) and EMBASE (January 1980 to June 2002), and checked all relevant papers for additional eligible studies.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials assessing the efficacy of anticoagulants or antiplatelets for the treatment of extracranial internal carotid artery dissection, and non-randomised trials, e.g. case series (studies), that reported on any antithrombotic treatment with at least 4 patients, were eligible for inclusion. Data from all eligible studies were extracted independently by two reviewers. Disagreements were resolved by discussion.

DATA COLLECTION AND ANALYSIS

Data on the primary outcome measures were extracted systematically. These were: death (all causes) and death or disability. Secondary outcomes were: first stroke occurrence, stroke recurrence, any stroke during reported follow-up, extracranial haemorrhage, and intracranial haemorrhage. The first choice treatment was taken for analyses.

MAIN RESULTS

No randomised trials were identified. No reliable comparisons of antiplatelet drugs or anticoagulants with control were available. Twenty-six eligible studies including 327 patients (who either received antiplatelet drugs or anticoagulants) were to be included in the comparative analysis. There was no significant difference in odds of death comparing antiplatelet drugs with anticoagulants (Peto odds ratio (Peto OR) 1.59, 95% CI 0.22-11.59). There was also no significant difference in the odds of being dead or disabled (Peto OR 1.94, 95% CI 0.76-4.91). Few intracranial haemorrhages (0.5%) were reported for patients on anticoagulants, none for patients on antiplatelets.

REVIEWER'S CONCLUSIONS

There were no randomised trials comparing either anticoagulants or antiplatelet drugs with control. There is, therefore, no evidence to support their routine use for the treatment of extracranial internal carotid artery dissection. There were also no randomised trials that directly compared anticoagulants with antiplatelet drugs, and the reported non-randomised studies did not show any evidence of a significant difference between the two. We suggest that a randomised trial including at least 1400 patients in each treatment arm with this condition is clearly needed.