Stroke Caused by Cervical Artery Dissection

Abstract

Cervical artery dissection (CAD) is the cause of stroke in 10–25% of young adults but occurs also in patients aged 60 years and older. Diagnosis of CAD requires the detection of characteristic CAD features in vascular imaging, most frequently by visualization of a mural hematoma. Magnetic resonance imaging has a higher sensitivity than neurosonography but can be falsely negative within the first days after CAD onset. The intramural bleeding is not a reason to withhold IV thrombolysis in patients with acute ischemic stroke attributable to CAD. Acute endovascular treatment has been shown feasible and might be considered an alternative to IV thrombolysis alone, worthwhile to be studied in more detail. Antiplatelets and anticoagulants are both used to prevent stroke in CAD patients. The findings of five large meta-analyses across observational data did not suggest any superiority of either treatment approach. Two randomized controlled trials do compare anticoagulation versus antiplatelets in CAD. One trial has been published, the other is ongoing, and participation is encouraged to increase the level of therapeutic evidence. Non-vitamin K oral anticoagulants have been used in few CAD patients. Currently, these direct oral anticoagulants should not be used in CAD patients except in the setting of properly designed studies. Angioplasty and stenting are usually reserved for CAD patients with recurrent ischemic events despite antithrombotic therapy, when hemodynamic infarction is impending in ruptured dissecting aneurysms or in iatrogenic CAD. If there are arguments against angioplasty and stenting in such patients, surgery might be considered.