Angiographic frequency of saccular intracranial aneurysms in patients with spontaneous cervical artery dissection

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.

Cervical Artery Dissection and Patent Foramen Ovale in Juvenile Stroke: Causality or Casuality? A Familiar Case Report

Cervical artery dissection (CAD) and Patent Foramen Ovale (PFO) are important causes of stroke in young patients. Although PFO is considered an independent risk factor for cerebral infarction in young adults with cryptogenic stroke, other concomitant causes may be necessary to cause brain injury. PFO could be a predisposing factor of stroke through several mechanisms including paradoxical embolism from a venous source, thrombus formation in atrial septum, or atrial arrhythmias causing cerebral thromboembolism. The pathophysiology of CAD is poorly understood and includes both constitutional and environmental factors. A causal association is often difficult to establish, as other predisposing factors may also play a role in CAD etiopathogenesis. We present a family with ischemic stroke (a father and his three daughters), in which the two different stroke causes are present. We hypothesized that a paradoxical embolism caused by PFO, associated with arterial wall disease, in the presence of a procoagulant state, could produce arterial dissection and then stroke.

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.

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.

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: A Review of the Epidemiology, Pathophysiology, Treatment, and Outcome

CONTEXT

Cervical artery dissection (CAD) is a common cause of stroke in young adults. There is controversy over whether anticoagulation is superior to antiplatelet therapy in preventing stroke in patients with CAD, although meta-analyses to date have not shown any difference between the two treatments.

EVIDENCE ACQUISITION

We performed a PubMed search using each of the keywords: "Cervical artery dissection", "Dissection", "Carotid dissection", and "Vertebral dissection" between January 1^st, 1990 and July 1^st 2015. We identified evidence-based peer-reviewed articles, including randomized trials, case series and reports, and retrospective reviews that encompass the epidemiology, clinical manifestations, pathophysiology, treatment, and outcome of cervical artery dissection.

RESULTS

This paper highlights the mechanisms of cervical artery dissection and stroke in patients with dissection as well as the natural history and treatment.

CONCLUSION

Given the relatively rare incidence of this disease, multicenter studies with collaborative effort among stroke centers worldwide should be considered to enroll patients with cervical artery dissection in a randomized trial comparing the two treatments.

Visual field findings after a ruptured intracranial aneurysm

BACKGROUND

Visual field defects (VFDs) negatively affect activities of daily living and rehabilitation following aneurysmal subarachnoid haemorrhage (aSAH). The aim here was to assess VFDs in patients with aSAH and their associations with age, gender, aSAH severity, and clinical outcome.

METHODS

Patients admitted to Helsinki University Central Hospital and treated during 2011 were participants in this prospective study. Findings obtained with the Octopus 900 perimeter (Haag-Streit Inc, Koenic, Switzerland), the Goldmann perimeter (Haag-Streit Inc, Bern, Switzerland), or the confrontation visual field test on admission and 3 days, 14 days, 2 to 4 months, and 6 months postoperatively were assigned to 16 classes. Associations between post-chiasmal VFDs and relevant clinical, radiological, and demographic data were analysed with uni- and multivariate logistic regression.

RESULTS

Of 105 survivors at 6 months, 20 (19 %) had VFDs occurring for aneurysm- or operation-related reasons; homonymous hemianopias or quadrantanopias were the most common finding, occurring in 16 patients (15 %). Posterior ischaemic optic neuropathy presented in two patients (2 %). Ten survivors (10 %) no longer fulfilled visual field requirements for driving licences. Significant associations emerged between VFDs at 6 months and the Hunt and Hess (H&H), World Federation of Neurosurgical Societies (WFNS), and Fisher grades on admission, presence of intracerebral haemorrhage (ICH), hydrocephalus, or postoperative infarction, and higher modified Rankin Scale scores at 6 months. Multivariate logistic regression showed the H&H grade and presence of ICH to independently predict VFDs.

CONCLUSIONS

Assessing VFDs is advisable, especially among patients with poor-grade aSAH (H&H grade IV or V) and ICH.

Carotid artery dissection-related intracranial aneurysm development: case report

BACKGROUND AND IMPORTANCE

We analyzed the physiopathology of the association between cervical artery dissections (CADs), intracranial aneurysms (IAs), and aneurysmal subarachnoid hemorrhage.

CLINICAL PRESENTATION

A 43-year-old woman presented with diffuse subarachnoid hemorrhage (Fisher 3; Hunt-Hess 1). computed tomography angiography revealed a cervical internal carotid artery dissection and 2 IAs: right paraclinoid and right posterior communicating artery. The patient underwent surgical clipping of the 2 aneurysms. CAD was managed conservatively. Postoperative course was initially uneventful. After 24 hours, digital subtraction angiography (DSA) documented the exclusion of the aneurysms and an improvement of the CAD. After 3 days, the patient's neurological condition suddenly worsened; CT scan documented a subarachnoid rebleeding (Hunt-Hess 4) and DSA revealed the recurrence of CAD and a new right internal carotid artery aneurysm. The patient underwent clipping of the new aneurysm and decompressive craniectomy because of severe brain swelling. Postoperative neurological conditions remained poor. DSA showed the exclusion of the aneurysms and improvement of CAD. Three days later, CT scan performed after a sudden raise in intracranial pressure documented a wide intracerebral hematoma. Computed tomography angiography did not show new vascular malformations. Surgical removal of the hematoma was performed, but poor neurological conditions persisted.

CONCLUSION

CAD-related hemodynamic changes may play a role in the development of IAs. The presence of IAs must be screened carefully in case of CAD, because the dynamic behavior of CAD definitively increases the risk of IA formation, enlargement, and rupture.

[Factors predisposing to cervical artery dissection]

INTRODUCTION

Cervical artery dissection is a major cause of cerebral ischemia in young adults and can lead to various clinical symptoms, some of which are benign (e.g. headache, neck pain, Horner's syndrome, and cranial nerve palsy). However, most patients have a stroke or transient ischemic attack.

EPIDEMIOLOGY

The incidence of cervical artery dissection is low and is estimated to be around 2.6 per 100,000 inhabitants. Mortality and short-term recurrence rates are low: however; they may have been underestimated.

PATHOPHYSIOLOGY

Although the pathophysiology is still unclear constitutional and partly genetic susceptibility of the arterial wall has been proposed as a causal factor; triggered by infection or minor trauma. PREDISPOSING FACTORS: In addition to the trauma to the neck, other risk fractors have been suggested, such as infection, migraine, hyperhomocisteinamia, and the 67TT genotype of the 5,10-methylene-tetrahydrofolate reductase gene although evidence is sparse.

GENETIC FACTORS

Cervical artery dissection is now considered a multifactorial disease caused by several genetic abnormalities and environmental factors acting synergistically.

CONCLUSION

Research aimed at improving our understanding of the environmental and genetic factors predisposing to cervical artery dissection and assessment of long-term outcomes of this disease is needed. Better understanding of the underlying pathophysiology and the natural history of the disease through large prospective multicentre cohorts could also be helpful to improve therapeutic and preventive strategies. Several mutlticentre efforts are already under way to meet these needs.

Quadruple spontaneous cervical artery dissection following aneurysm embolization: a rare posttreatment complication

We present a unique case of multiple sCADs occurring after a ruptured intracranial aneurysm embolization. We discuss the impact of head extension during embolization as the prevailing factor in multiple artery dissections in this case and point out another cause of new-onset neurologic deficit in patients with aneurysmal SAH.

Cervical artery dissection

Spontaneous and traumatic cervical artery dissection is a common cause of stroke in the young. It generally carries an excellent prognosis if treatment is initiated early. Antiplatelet therapy may be as effective as or safer than warfarin, although no randomized prospective studies have addressed the issue of optimal medical therapy. Rarely, endovascular therapy may be indicated for the treatment of ruptured aneurysms or to prevent recurrent ischemia.

Cervical-artery dissections: predisposing factors, diagnosis, and outcome

Cervical-artery dissection (CAD) is a major cause of cerebral ischaemia in young adults and can lead to various clinical symptoms, some of which are benign (eg, headache, neck pain, Horner's syndrome, and cranial-nerve palsy), but most patients have a stroke or transient ischaemic attack. In addition to trauma to the neck, other risk factors have been suggested, such as infection, migraine, hyperhomocysteinaemia, and the 677TT genotype of the 5,10-methylenetetrahydrofolate reductase gene (MTHFR 677TT), although evidence is sparse. An underlying arteriopathy, which could in part be genetically determined, is believed to have a role in the development of CAD. Importantly, both research on and optimum management of CAD strongly rely on diagnostic accuracy. Although the functional outcome of CAD is good in most patients, socioprofessional effects can be important. Incidence of the disorder in the general population is underestimated. Mortality and short-term recurrence rates are low but possibly also underestimated. Further research is warranted to improve our understanding of the underlying pathophysiology, to assess the long-term outcome, and ultimately to provide treatment and prevention strategies.

CADISP-Genetics: An International Project Searching for Genetic Risk Factors of Cervical Artery Dissections

Background

Cervical artery dissection (CAD) is a frequent cause of ischemic stroke, and occasionally death, in young adults. Several lines of evidence suggest a genetic predisposition to CAD. However, previous genetic studies have been inconclusive mainly due to insufficient numbers of patients. Our hypothesis is that CAD is a multifactorial disease caused by yet largely unidentified genetic variants and environmental factors, which may interact. Our aim is to identify genetic variants associated with an increased risk of CAD and possibly gene-environment interactions.

Methods

We organized a multinational European network, Cervical Artery Dissection and Ischemic Stroke Patients (CADISP), which aims at increasing our knowledge of the pathophysiological mechanisms of this disease in a large group of patients. Within this network, we are aiming to perform a de novo genetic association analysis using both a genome-wide and a candidate gene approach. For this purpose, DNA from approximately 1100 patients with CAD, and 2000 healthy controls is being collected. In addition, detailed clinical, laboratory, diagnostic, therapeutic, and outcome data are being collected from all participants applying predefined criteria and definitions in a standardized way. We are expecting to reach the above numbers of subjects by early 2009. Conclusions We present the strategy of a collaborative project searching for the genetic risk factors of CAD. The CADISP network will provide detailed and novel data on environmental risk factors and genetic susceptibility to CAD.

The genetics of cervical artery dissection: a systematic review

BACKGROUND AND PURPOSE

The pathophysiology of cervical artery dissections (CAD), a major cause of ischemic stroke in young adults, is poorly understood. Several arguments suggest a genetic predisposition.

METHODS

We systematically reviewed all published data on genetic risk factors for CAD and performed a meta-analysis of association studies with the MTHFR C677T polymorphism.

RESULTS

Rarely, CAD is associated with a known monogenic connective tissue disease, mainly vascular Ehlers-Danlos syndrome. However, in the large majority of CAD cases, there is no evidence for a known monogenic disease. Several arguments, including the association of CAD with dermal connective tissue abnormalities that are inherited, suggest that genetic factors also play a role in "sporadic" CAD as part of a multifactorial predisposition. We identified 15 genetic association studies: 10 were negative and 5 reported associations of 3 genetic variants in 3 different candidate genes. Two studies reported associations with polymorphisms in ICAM-1 and COL3A1, but neither has been replicated. Three studies reported an association with the MTHFR 677TT genotype, but 3 other studies did not replicate this. A meta-analysis of these data identified an overall significant association of the MTHFR 677TT genotype with CAD (OR, 1.67; 95% CI, 1.21 to 2.31). We also identified 9 studies screening candidate genes for mutations and 4 linkage studies, yielding mostly negative results.

CONCLUSIONS

Although several interesting hypotheses were generated, the majority of genetic studies in CAD have been negative until now, but they were markedly underpowered. Progress in unraveling the genetics of CAD will require the collection of DNA samples from large multicenter series.

Sports-related internal carotid artery dissection: pathogenesis and therapeutic point of view

BACKGROUND

Extracranial and intracranial internal carotid artery (ICA) dissections following sports-related activities have been reported as a result of blunt traumatic injuries. The incidence of carotid artery dissection in sports is not known. Failure of physicians to suspect a dissection in the context of a minor injury or to obtain a history from the patient can lead to permanent neurologic deficits.

REVIEW SUMMARY

The presentation of this entity is variable. We present 2 cases of ICA dissection with differences in causative mechanism and management in order to emphasize the importance of a physician's awareness, and we review the literature on this subject.

CONCLUSIONS

Pathogenesis of sports-related ICA dissections may be multifactorial. Structural aberrations in the arterial walls and defective connective tissue components are assumed in some patients. Several genes have been shown to be candidates for the connective tissue aberrations. Since sports-related ICA dissection can occur extracranially or intracranially, the combined use of proper diagnostic techniques that provides information on the extracranial and intracranial vessels is recommended. Although the mechanisms and treatment modalities for intracranial and extracranial dissections might be different, the initial steps of evaluation and stabilization should be standardized for both. There is no randomized controlled study for the best treatment or management of ICA dissection.

Vasomotion in Multiple Spontaneous Cervical Artery Dissections

Background and Purpose— The etiology of spontaneous cervical artery dissection (sCAD) is still unknown, even though an underlying arteriopathy impairing vasomotion has often been suspected. This study was undertaken to investigate: (1) spontaneous, (2) endothelial-dependent, and (3) endothelial-independent vasodilation in patients with multiple sCAD.

Methods— In 19 consecutive patients with multiple carotid or vertebral artery dissections high-resolution ultrasound was used to assess spontaneous and endothelial-independent dilations (isosorbide dinitrate-mediated) in the common carotid, vertebral and brachial arteries, and endothelial-dependent dilation (flow-mediated arterial dilation) in the brachial arteries alone. The same parameters were measured in 19 healthy subjects matched for age, sex, and height (controls). Ultrasound studies were performed by one investigator, and off-line analysis by another investigator who was blinded to the clinical data and study status (patient or control).

Results— Spontaneous and endothelial-independent dilations were significantly impaired in the carotid ( P =0.0006 and P <0.0001, respectively) and vertebral arteries ( P =0.0121 and P =0.0047, respectively) of patients as compared with controls, whereas no statistically significant differences were found in the brachial arteries; conversely, endothelial-dependent dilation of the brachial arteries was significantly lower in patients as compared with controls ( P <0.0001).

Conclusions— Patients with multiple sCADs have a significantly impaired vasomotion, which may predispose to dissection.

Association of cervical internal carotid artery aneurysm with ipsilateral vertebrobasilar aneurysm in two children: a segmental entity?

INTRODUCTION

A combination of cervical and intradural aneurysm in children in the absence of systemic disorders has previously not been reported.

CASE REPORT

We report two boys with an identical combination of fusiform cervical internal carotid aneurysm and ipsilaterally located vertebrobasilar aneurysm. They had no history of trauma, they did not display any personal or familial signs of systemic disease, and the testing for collagen disease was negative. The location and appearance of the aneurysms and the identical anatomical disposition in the patients indicated a non-randomly distributed segmental vulnerability.

CONCLUSION

The cases demonstrate primary morphological signs of a developmental error being expressed in two seemingly separate segments but linked by the hypoglossal artery. It suggests a segmental error related to this embryonic vessel. They also show that few phenotypes are specific for a genotypic disorder and highlight the importance of analysing different etiologies for aneurysm formation and anatomical disposition when taking treatment strategy decisions.

Do Extracellular-Matrix-Regulating Enzymes Play a Role in Cervical Artery Dissection?

BACKGROUND

An underlying extracellular matrix defect is suspected in patients with spontaneous cervical artery dissection (SCAD). We test the hypothesis that levels of matrix metalloproteinase (MMP) 2 and 9, and elastase, extracellular-matrix-regulating enzymes involved in the vascular wall remodeling process, are modified in SCAD.

METHODS

The authors prospectively and consecutively recruited 47 patients with SCAD and 52 patients with an ischemic stroke from another cause in 2 centers, and measured their plasmatic level of MMP-2, MMP-9 and elastase 3 months after the vascular event.

RESULTS

Patients with SCAD had a higher mean MMP-2 level compared with controls [379.2 (SD = 76.6) vs. 355.9 (75.1) ng/ml; p = 0.11] and had more frequently a high level of MMP-2 (>326 ng/ml) than controls (77.8 vs. 54.5%, p = 0.019). This association was stronger in patients with multiple dissection than single artery dissection or controls (84.6, 75.0 and 54.5%, respectively, p = 0.018). The levels of MMP-9 and elastase were similar in cases and controls, but more patients had a high level of these enzymes in the group with multiple dissections than in the group with single artery dissection or controls.

CONCLUSION

Patients with SCAD have higher plasma levels of proteases, particularly MMP-2. The association is stronger in patients with multiple dissections.

Segmental disruption of internal elastic lamina in spontaneous vertebral artery dissection combined with redundancy of multiple cervical arteries

A 49-year-old man developed a spontaneous vertebral artery dissection leading to cerebellar and brain stem infarction. Cerebral angiograph demonstrated redundancy, including kinks, loops and coils, in multiple cervicocephalic arteries, in addition to the dissecting artery. Histological examination of the superficial temporal artery revealed segmental disruptions of the internal elastic lamina and intimal abnormalities. These ultrastructural abnormalities may impair vessel wall integrity and predispose to nontraumatic arterial dissection and vascular tortuosity.

Non-Atherosclerotic Vascular Disease in the Young

There are a large variety of non-atherosclerotic causes of ischemic stroke in the young. Arterial dissection, most commonly associated with non-traumatic causes, is among the most common. Both the carotid and vertebrobasilar circulations can be affected. The vasculitidies represent a rare, but potentially treatable series of conditions that can lead to stroke through diverse mechanisms. Moyamoya is a nonatherosclerotic, noninflammatory, nonamyloid vasculopathy characterized by chronic progressive stenosis or occlusion of the distal internal carotid arteries and/or proximal portions of the middle and/or anterior cerebral arteries. Moyamoya can be idiopathic (moyamoya disease) or the result of other conditions. An appreciation of the unusual causes of stroke in the young is important when considering secondary prevention measures.

Carotid and vertebral artery dissection syndromes

Cervicocerebral arterial dissections (CAD) are an important cause of strokes in younger patients accounting for nearly 20% of strokes in patients under the age of 45 years. Extracranial internal carotid artery dissections comprise 70%-80% and extracranial vertebral dissections account for about 15% of all CAD. Aetiopathogenesis of CAD is incompletely understood, though trauma, respiratory infections, and underlying arteriopathy are considered important. A typical picture of local pain, headache, and ipsilateral Horner's syndrome followed after several hours by cerebral or retinal ischaemia is rare. Doppler ultrasound, MRI/MRA, and CT angiography are useful non-invasive diagnostic tests. The treatment of extracranial CAD is mainly medical using anticoagulants or antiplatelet agents although controlled studies to show their effectiveness are lacking. The prognosis of extracranial CAD is generally much better than that of the intracranial CAD. Recurrences are rare in CAD.

Increased Stiffness of the Carotid Wall Material in Patients With Spontaneous Cervical Artery Dissection

BACKGROUND AND PURPOSE

The cause of spontaneous cervical artery dissection (sCAD) is largely unknown. An underlying connective tissue disorder has often been postulated, but arterial mechanical properties have rarely been studied. The study aim was to determine the elastic properties of a cervical artery, the common carotid artery, and a distal muscular artery, the radial artery in sCAD patients.

METHODS

We studied 32 patients with previous sCAD (median delay: 2.2 years) and 32 control subjects with similar age and blood pressure. Internal diameter, intima-media thickness, distensibility, and Young's elastic modulus were determined at the site of the right and left common carotid arteries and the radial artery using noninvasive high-resolution echotracking systems.

RESULTS

In patients with previous sCAD, cross-sectional distensibility and compliance of the affected carotid artery did not differ from those of the contralateral carotid artery. Young's elastic modulus (ie, the stiffness of the wall material) was 58% higher (0.44+/-0.32 versus 0.28+/-0.15 kPa.10(3), P<0.001) and circumferential wall stress was 14% higher (56+/-12 versus 49+/-12 kPa, P<0.001) in sCAD patients than in controls. The highest tertile of common carotid artery Young's elastic modulus was associated with an 8-fold higher risk of sCAD. Aortic stiffness, assessed from the carotid-femoral pulse wave velocity, and radial artery parameters did not differ between sCAD and controls.

CONCLUSIONS

Carotid arteries, but not aorta and radial artery, displayed abnormal elastic properties in sCAD patients. Higher stiffness of carotid wall material and circumferential wall stress could increase the risk of dissection in these patients.

Spontaneous multiple cervical artery dissection: two case reports and a review of the literature

Although spontaneous cervical artery dissection (CAD) is an uncommon cause of stroke in the general population, it accounts for 10-25% of cerebrovascular events in young to middle-aged patients. Two or more vessels are involved in fewer than 15% of dissections, but multiple spontaneous CADs are likely to be underestimated owing to frequent spontaneous recanalization and the possible oligo-symptomatic presentation. An extensive review of the literature shows that in the last 30 years only 28 cases of multiple CADs have been reported, and that in half of these patients symptoms were minor and transient. We describe two cases of multiple spontaneous CADs presenting as transient ischemic attack (TIA), in which only a specific diagnostic flow-chart allowed us to recognize multiple vessel involvement and start the appropriate therapy.

A syndrome of spontaneous cerebral and cervical artery dissections with angiolipomatosis. Report of two cases

A primary or systemic arteriopathy is frequently suspected in patients with spontaneous cerebral or cervical artery dissections. The authors report on two patients with such dissections accompanied by angiolipomatosis, a previously unreported association, and propose a common developmental defect in these patients. A 50-year-old man with subcutaneous angiolipomatosis developed painful monocular blindness. Angiography studies revealed a spontaneous extracranial internal carotid artery (ICA) dissection and an ipsilateral fusiform intracranial ICA aneurysm. The ICA dissection was treated with aspirin, and after 6 months a craniotomy was performed. The aneurysm was found to be fusiform; it involved the entire supraclinoid portion of the ICA, and was wrapped with cotton. A 49-year-old man with a congenitally bicuspid aortic valve and subcutaneous angiolipomatosis developed posterior neck pain. Magnetic resonance imaging and angiography demonstrated a fusiform distal vertebral artery aneurysm. A craniotomy was performed and the aneurysm was found to incorporate the posterior inferior cerebellar artery as well as a perforating artery: the lesion was wrapped cotton. The tunica media of the arteries of the head and neck as well as the aortic valvular cusps are derived from neural crest cells, and angiolipomatosis has been associated with tumors of neural crest derivation. These associations indicate that a neural crest disorder may be the underlying abnormality in these patients.

Outcome of extracranial cervicocephalic arterial dissections: a follow-up study

Cervicocephalic arterial dissections (CCAD) are an increasingly recognized cause of ischemic stroke in young adults. Various treatments have been suggested but no controlled trial has ever been performed. Medical treatment has included anticoagulant or platelet antiaggregant therapy. Surgical correction has been proposed for selected patients who have failed medical therapy. Percutaneous balloon angioplasty and stenting have been increasingly used in some patients, although long-term results are unknown. The objective of the study was to review our recent experience with the management and outcome of extracranial CCAD. We identified 27 patients with extracranial CCAD who were evaluated, treated and/or followed by our Stroke Service from September 1995 to August 2001. Clinical presentation, diagnostic evaluation, management, and outcome were reviewed. There were 15 men (56%) and 12 women (44%) with mean ages of 38 and 43 years respectively. Diagnosis was made by cerebral angiography in 15 (56%) patients and by MRI/MRA only in 12 (44%) patients. Twenty-two patients had spontaneous and five had traumatic extracranial CCAD. Most common associated disorders were arterial hypertension (37%) and migraine (26%). One patient presented only with a painful post-ganglionic Horner syndrome, another patient with neck pain and post-ganglionic Horner syndrome, another patient solely with protracted unilateral headaches, three with transient ischemic attacks (TIA), and 21 with ischemic strokes. The internal carotid artery (ICA) was the most frequently involved vessel (63%), followed by the vertebral artery (30%, and multivessel involvement in two patients (7%). Eighteen patients received anticoagulant therapy and nine platelet anti-aggregants. Follow-up extended from 2 to 115 months, with a mean of 58 months. At the end of follow-up, 23 (85%) patients had either no disability or only minor sequelae (modified Rankin score: 0 to 1), and four (15%) patients had moderate limitations (modified Rankin score: 2 to 3). Two patients had a recurrent ischemic stroke, one unrelated to recurrent CCAD, and the other following percutaneous balloon angioplasty/stenting for treatment of a persistent vertebral artery pseudoaneurysm. Most CCAD involved the extracranial ICA. The clinical presentation is variable, most patients having an ischemic stroke or TIAs. The short- and long-term outcome are usually favorable with either anticoagulant or platelet antiaggregant therapy. A medical initial approach to the management of extracranial CCAD is recommended for most patients.

Plasma homocysteine concentration, C677T MTHFR genotype, and 844ins68bp CBS genotype in young adults with spontaneous cervical artery dissection and atherothrombotic stroke

BACKGROUND AND PURPOSE

The role of mild hyperhomocysteinemia as a risk factor for cerebral ischemia may depend on stroke subtype. To test this hypothesis, we undertook a prospective case-control study of a group of patients with spontaneous cervical artery dissection (sCAD), a group of patients with atherothrombotic stroke (non-CAD), and a group of control subjects.

METHODS

Fasting total plasma homocysteine (tHcy) concentration, C677T MTHFR genotype, and 844ins68bp CBS genotype were determined in 25 patients with sCAD, 31 patients <45 years of age with non-CAD ischemic stroke, and 36 control subjects. Biochemical data in the patient groups were obtained within the first 72 hours of stroke onset.

RESULTS

Median tHcy levels were significantly higher in patients with sCAD (13.2 micromol/L; range, 7 to 32.8 micromol/L) compared with control subjects (8.9 micromol/L; range, 5 to 17.3 micromol/L; 95% CI, 1.05 to 1.52; P=0.006). Cases with tHcy concentration above the cutoff level of 12 micromol/L were significantly more represented in the group of patients with sCAD compared with control subjects (64% versus 13.9%; 95% CI, 2.25 to 44.23; P=0.003); a significant association between the MTHFR TT genotype and sCAD was also observed (36% versus 11.1%; 95% CI, 1.10 to 19.23; P=0.045). No significant difference in tHcy levels and in the prevalence of thermolabile MTHFR was found between patients with non-CAD ischemic stroke and control subjects and between patients with sCAD and non-CAD ischemic stroke. The distribution of the 844ins68bp CBS genotype and the prevalence of subjects carrying both the TT MTHFR and 844ins68bp CBS genotypes were not significantly different among the 3 groups.

CONCLUSIONS

Our results are consistent with the hypothesis that increased plasma homocysteine levels and the TT MTHFR genotype may represent risk factors for sCAD. In contrast, their role in atherothrombotic strokes remains a contentious issue.

Spontaneous Arterial Dissection

There is no controlled study for the best treatment or management of cervico-cerebral artery dissection (CAD). Rationale initial empiric treatment in acute CAD to prevent secondary embolism is partial thromboplastin time (PTT)-guided anticoagulation by intravenous heparin followed by anticoagulation with warfarin. Carotid surgery for treatment of CAD is not recommended anymore with the possible exception of persisting severe stenosis of the proximal internal carotid artery (ICA). There could be use of carotid angioplasty by balloon dilatation and stenting in selected cases of severe cerebral hemodynamic impairment by bilateral CAD. Duration of secondary prophylaxis by anticoagulation is best guided by Doppler sonography follow-up, and should be continued until normalization of blood flow or until at least 1 year after the vessel is occluded. There is no evidence that pseudoaneurysms increase the risk for embolic complication, and there is no evidence for surgery or continuation of anticoagulation in patients with pseudoaneurysms. Caution should be recommended for exercises that involve excessive head movements (eg, bungee jumping, trampoline jumping, and chiropractic maneuvers). The patient should be informed that recurrent rate is low in nonfamilial cases. Doppler sonography is a low-cost and high-sensitivity method for patients at risk.

Endovascular therapy of traumatic injuries of the extracranial cerebral arteries

The field of neuroendovascular therapy is rapidly growing. New technology and operators' expertise are developing at a pace that will make this discipline progressively more available and successful. For patients who have traumatic injuries of the extracranial arteries, endovascular therapy offers a new dimension to the treatment of these injuries and the prevention of stroke. Because many of these patients are likely to be critically ill, it is important to keep in mind the principles of their management before, during, and after the procedure, thus assuring the best chance for a successful outcome. Furthermore, some of the issues related to their neurointensive care will serve as guides for the need for endovascular therapy, as well as its timing.

[Cervical artery dissection: recent data physiopathologic hypotheses]

INTRODUCTION

Cervicocranial arterial dissection is a major cause of cerebral infarction in young subjects. Traumatic and infectious factors are frequently suspected to be at the origin of cervicocranial artery dissection. However, they are usually too minor or too common to explain the vessel wall split-off. Underlying arteriopathy predisposing to dissections is therefore often suspected.

CURRENT KNOWLEDGE AND KEY POINTS

The hypothesis of an underlying arteriopathy is based in certain cases on either the discovery of hereditary connective tissue disorders (or secondary signs of these diseases) or their frequent association with vascular and cardiac morphological abnormalities, thus suggesting extracellular matrix abnormalities. Current histological and biochemical data do not suggest the existence of a unique form of the disease but rather indicate the presence of various matrix abnormalities that could involve one of the fibrillar components or its enzymatic regulation.

FUTURE PROSPECTS AND PROJECTS

Classification of dissections according to the various vascular wall alterations would therefore permit to better define recurrence and familial risks and to improve overall management of the patients.

Spontaneous dissection of the internal carotid artery: a nineteen-year clinical experience

PURPOSE

This article reviews our experience with internal carotid artery dissection (ICAD), evaluates the usefulness of Duplex scanning in diagnosis, provides current recommendations for treatment, and better defines long-term prognosis.

METHODS

The records from 1976 to 1995 of 24 patients who had 28 ICAD were reviewed. All diagnoses were confirmed by arteriography. Presenting symptoms, diagnostic tests, clinical management, and outcome were examined.

RESULTS

Nine patients had visual symptoms or headache, 10 had transient focal neurologic symptoms (TIA), and five had stroke. Five of the 19 who had visual symptoms or TIA had a stroke before the diagnosis of ICAD. Seventeen patients who had 19 ICAD underwent a Duplex scan at the time of presentation. Duplex scan identified 18 arterial abnormalities consistent with ICAD (sensitivity, 95%). Three patients died from stroke during the initial hospitalization. Of the 21 who survived, 12 were treated with anticoagulation therapy, six with aspirin, and three with aspirin and anticoagulation therapy. None of the 21 patients had a subsequent stroke. Six patients subsequently had an operation for residual occlusive disease or aneurysm. The mean duration of follow-up was 9.3 years. Two patients developed contralateral ICAD. During follow-up, 19 arteries were studied with Duplex scan, and seven had no residual evidence of ICAD.

CONCLUSIONS

Patients who have ICAD often have prodromal symptoms before stroke. If diagnosed early, treatment with anticoagulation may prevent stroke. Duplex scans are accurate for defining carotid abnormalities consistent with ICAD and for indicating the need for arteriography. Patients should undergo a follow-up Duplex scan to identify contralateral ICAD.

Intracranial aneurysms and cervicocephalic arterial dissections associated with congenital heart disease

OBJECTIVE

The number of patients with congenital heart disease who survive to adolescence and adulthood continues to increase. We review our experience with noninfectious intracranial aneurysms and cervicocephalic arterial dissections in patients with congenital heart disease, expanding the clinical spectrum of the cerebrovascular abnormalities that may be encountered in this group of patients.

METHODS

All patients with congenital heart disease and intracranial aneurysms of cervicocephalic arterial dissections, who were evaluated at the Mayo Clinic between 1969 and 1992, were identified.

RESULTS

Congenital heart disease was diagnosed in 3 (8%) of 36 children with intracranial aneurysms, in 5 (0.3%) of 1994 adults with intracranial aneurysms, in 1 (4%) of 25 children with cervicocephalic arterial dissections, and in 5 (2%) of 250 adults with cervicocephalic arterial dissections. The mean age of the 14 patients was 32 years (range, 13-58 yr). The congenital heart disorders consisted of complex cardiac anomalies in three patients (truncus arteriosus, transposition of the great arteries, and tricuspid atresia in one patient each), pulmonic valve or arterial stenosis in two patients, aortic coarctation in four patients, and bicuspid aortic valve in five patients. Only one patient had an intracranial aneurysm and coarctation of the aorta.

CONCLUSION

Individuals with a variety of congenital heart disorders may be at an increased risk of intracranial aneurysm development and cervicocephalic arterial dissection, particularly in adolescence. The muscular arteries of the head and neck are derived from neural crest cells and the neural crest is also of major importance in early cardiac development, suggesting that an abnormality of the neural crest may be the common pathogenetic factor explaining this association.

Neurovascular manifestations of heritable connective tissue disorders. A review

BACKGROUND

Heritable disorders of connective tissue are recognized in a small minority of patients with neurovascular diseases. In this report, we review the neurovascular manifestations of four heritable connective tissue disorders: Ehlers-Danlos syndrome, Marfan's syndrome, osteogenesis imperfecta, and pseudoxanthoma elasticum, as well as two other systemic disorders with potential vascular manifestations: neurofibromatosis and polycystic kidney disease.

SUMMARY OF REVIEW

Typical neurovascular complications of Ehlers-Danlos syndrome are carotid-cavernous fistulae, intracranial aneurysms, and cervical artery dissections. Arterial dissections and intracranial aneurysms cause the majority of neurovascular symptoms in Marfan's syndrome. Neurovascular disease is uncommon in osteogenesis imperfecta, although carotid-cavernous fistulae and vertebral artery dissections have been reported. Neurovascular disease in pseudoxanthoma elasticum is characterized by intracranial aneurysms and cerebral ischemia caused by premature arterial occlusive disease. Intracranial occlusive arterial disease is the most common neurovascular manifestation of neurofibromatosis, followed by cervical arteriovenous fistulae and aneurysms and intracranial aneurysms. Intracranial aneurysms are the hallmark of polycystic kidney disease.

CONCLUSIONS

Recognition of an underlying generalized connective tissue disorder may be of considerable importance, although marked phenotypic heterogeneity often complicates the diagnosis of these disorders. Conversely, the association of certain neurovascular anomalies with generalized connective tissue disorders and recognition of their basic molecular defect may offer clues to the etiology and pathogenesis of these neurovascular diseases in general.

Alpha 1-antitrypsin deficiency in intracranial aneurysms and cervical artery dissection

The pathogenesis of ruptured intracranial aneurysms and cervical artery dissections is poorly understood but may be similar in these two disorders. We report four patients with alpha 1-antitrypsin deficiency who developed a ruptured intracranial aneurysm or spontaneous dissection of the cervical internal carotid artery. Three patients were heterozygous for the deficient allele (PiMZ or PiGZ) and one was homozygous (PiZZ). A deficiency of alpha 1-antitrypsin or one of the other protease inhibitors could result in degradation of the arterial wall through an imbalance between proteolytic enzymes and their inhibitors, thereby predisposing the arterial wall to dissection or aneurysm formation.

Recurrent spontaneous cervical-artery dissection

BACKGROUND

Spontaneous dissection of the internal carotid and vertebral arteries is increasingly recognized as a cause of ischemic stroke in young people. An underlying arteriopathy is often suspected in the pathogenesis of such dissection, but the frequency of recurrent dissection is unknown.

METHODS

We describe the long-term follow-up of 200 consecutive patients (104 women and 96 men) with spontaneous cervical-artery dissections evaluated at the Mayo Clinic between 1970 and 1990. All diagnoses were confirmed by angiography.

RESULTS

The mean age of the patients was 44.9 years (range, 16 to 76). Internal carotid arteries were affected in 150 patients, vertebral arteries in 37, and both in 13. Multivessel dissections were present in 28 percent of the patients. The mean follow-up was 7.4 years. Recurrent dissection occurred only in arteries not previously involved by dissection. A recurrent arterial dissection developed in 16 patients (8 percent)--within a month after the initial dissection in 4 patients (2 percent) and between 1.4 and 8.6 years later in 12 patients (a rate of 1 percent per year). The cumulative rate of recurrent dissection among patients followed for 10 years was 11.9 percent. Younger patients had a greater risk of recurrent dissection.

CONCLUSIONS

Although dissections in multiple cervical vessels are common at presentation, after the first month the risk of recurrent dissection is only about 1 percent per year.

Pure sensory stroke revealing a complex malformation of extra- and intracranial cerebral arteries

Pure sensory strokes (PSS) are usually due to thalamic lacunar infarcts. We report a case of PSS in a 34-year-old female suffering from migraine who complained of sudden isolated left-sided paresthesia involving face, upper and lower limbs. We found a complex vascular abnormality associating internal carotid artery occlusion, posterior cerebral artery agenesia, aneurysm at the posterior face of the carotid siphon and angiomatous rete at the top of the basilar artery. The acquired origin of the carotid artery occlusion by possible neonatal dissection is probable since this patient has a permeable carotid canal on CT scan.