Classification and management strategy of spontaneous carotid artery dissection

Abstract

ObjectiveSpontaneous carotid artery dissections (sCAD) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 sCAD patients and proposed a new classification for sCAD with prognostic and therapeutic significance. MethodsThis is a retrospective review of prospectively collected data from June 2018 to June 2023 of sCAD patients treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types. Type Ⅰ: intramural hematoma or dissection with < 70% luminal narrowing; type Ⅱ: intramural hematoma or dissection with ≥ 70% luminal narrowing; type Ⅲ: dissecting aneurysm; type ⅣA: extracranial carotid artery occlusion; type ⅣB: tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCAD. ResultsA total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 sCAD patients was 49.5 years, 78% were male, 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 (28.4%) type Ⅰ, 50 (25.4%) type Ⅱ, 60 (30.5%) type Ⅲ, and 31 (15.7%) type Ⅳ dissections. During a mean hospitalization length of 11.4±47.0 days, there were 9 recurrent strokes (4.6%) after medical treatment, 2 (1.0%) type Ⅲ dissections, 7 (3.6%) type Ⅳ dissections, all ipsilateral, and 1 death. Overall, there were 7 (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent stroke and 3 (1.5%, all type Ⅲ dissections) recurrent TIA in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine (51.8%) type I dissections were completely recanalized after antithrombotic therapy. A total of 19 (38 %) of type II dissections and 44 (73%) of type III dissections received endovascular treatment (EVT) for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight (33%) type IVB dissections received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all p > .05). Favorable outcome was achieved in 168 (93.9%) patients. ConclusionsThis study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcome should undergo further research.