Acute Internal Carotid Artery Dissection Research Articles

Long-term outcome of cervical artery dissection

ObjectiveThe aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches. MethodsA retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022. ResultsThirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner’s syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days. ConclusionsThe majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.

Young stroke secondary to fibromuscular dysplasia causing carotid artery dissection

Background: Fibromuscular dysplasia (FMD) is a rare, medium-sized arteriopathy affecting less than 7% of the population. It affects predominantly young women of childbearing age. Stroke caused by fibromuscular dysplasia of the carotid artery is uncommon and reported to range between 0.6% by angiography and 1.1% by autopsy. Case presentation: A 35-year-old mother of two children, previously well, was admitted to our hospital with right-sided spastic hemiparesis with upper motor neuron type facial nerve palsy. Non-contrast CT (NCCT) brain on admission revealed left-sided middle cerebral arterial territory infarction with possible hemorrhagic transformation with midline shift. She had progressive neurological features where NCCT brain in 24 hours showed an increase in the size of the hemorrhage. Magnetic resonance imaging (MRI) of the brain, including angiogram of neck vessels, revealed acute dissection of the left internal carotid artery with acute thrombosis, left frontoparietal hemorrhagic infarction, and the constellation of MRI showed features suggestive of left cervico-cranial fibromuscular dysplasia complicated by acute internal carotid artery dissection. She was started on low-dose aspirin, and 40 mg of atorvastatin and anticoagulants were not started because of the bleeding risk as she had a hemorrhagic transformation infarction. She was discharged and referred for inward physiotherapy and planned to repeat the MRI brain with the neck vessel angiogram in three weeks and arranged digital subtraction angiography in three months. Unfortunately, she was lost for follow-up. Conclusion: Detailed evaluation of the young patients with ischaemic stroke is helpful to diagnose rare diseases such as FMD involving carotid arteries leading to a better treatment choice between anticoagulation vs. antiplatelet therapy

Endovascular treatment of acute internal carotid artery dissections: technical considerations, clinical and angiographic outcome.

In acute internal carotid artery dissection (a-ICAD) with concomitant intracranial large vessel occlusion or haemodynamic impairment, the effectiveness of medical treatment is limited and endovascular therapy (EVT) can be considered. Feasibility, safety and outcome of EVT in a-ICAD are not well described yet. From an institutional database, we retrospectively selected consecutive patients treated for a-ICAD between January 2007 and July 2015. We assessed recanalization results defining <50% residual stenosis and mTICI ≥2b as successful. Procedural adverse events and symptomatic haemorrhages were reported as well as clinical outcome at 90days defining a mRS ≤2 as favourable. Follow-up angiographies were reviewed and retreatments reported. In the defined period, 73 patients (mean age 48years (31-73), mean NIHSS 11 (0-27)) received EVT for a-ICAD. The majority (60%) had tandem occlusions. Cervical artery reconstruction was successful in 100% and intracranial thrombectomy in 85%. Thrombus formation (18%) and thromboembolism (20%) were the most frequent adverse events but clinically relevant only in 8%. Symptomatic haemorrhage occurred in 5%. Clinical outcome was favourable in 64%, with a lower chance after tandem occlusion (55 vs. 79%, p=0.047). Death rate was 10%. None of the patients developed recurrent ischaemic symptoms, but control angiography revealed abnormal findings of the reconstructed ICA in 38% leading to retreatment in 17%. EVT of a-ICAD is feasible with a predominantly favourable clinical outcome. Improvement of devices and techniques is warranted to reduce the risk of thrombus formation and thromboembolism during treatment and insufficient vessel wall healing thereafter.

Immediate surgery for acute internal carotid artery dissection and thrombosis during filter deployment prior to stenting: a case report

Carotid artery stenting (CAS) is a validated option in the treatment of selected extracranial carotid artery stenosis. Carotid artery dissection during CAS is a rare but potentially devastating complication. We report a case of acute dissection and thrombosis of the left internal carotid artery during filter tip wire engaging maneuvers, complicated by intraoperative complete blindness of the left eye. Immediate conversion to carotid endarterectomy was performed under general anesthesia with electroencephalographic monitoring. The patient was discharged home symptomless and remains asymptomatic eight months after the operation, with normal left internal carotid patency and fully recovered eyesight. In conclusion, the management of acute carotid occlusion during CAS requires emergent evaluation and definitive endovascular or open surgical repair to minimize neurologic morbidity. We advocate that all endovascular procedures are carried out in a well-established surgical environment.

Mechanisms of Single and Multiple Borderzone Infarct: Transcranial Doppler Ultrasound/Magnetic Resonance Imaging Correlates

Background and Purpose: Hemodynamic patterns after borderzone (BZ) infarction are variable and dynamic. However, stroke mechanisms in different types of BZ infarctions have not been systematically studied by magnetic resonance angiography (MRA) and transcranial Doppler ultrasonography (TCD). Methods: Forty-nine patients who experienced a stroke limited to the territory of either the superficial or internal borderzone proved on MRI included in our registry, corresponding to 4% of 1,200 patients with ischemic stroke, were studied. All these patients underwent MRA, extracranial Doppler ultrasonography, TCD and other investigations from the standard protocol of our registry. Twenty of them (41%) had a posterior BZ infarct, 14 (29%) an anterior BZ infarct, 10 (20%) a subcortical BZ infarct and 5 (10%) bilateral BZ infarcts. Results: Unilateral internal carotid artery (ICA) tight stenosis or occlusion ipsilateral to the lesion was present in 14 patients (70%) with a posterior BZ infarct, in 72% of those with an anterior BZ infarct, in 80% of those with a subcortical BZ infarct and in 80% of those with bilateral BZ infarcts. TCD showed cross-filling of the middle cerebral artery via the anterior communicating artery in 5 patients (25%) with a posterior BZ infarct and 10% had an increased mean flow velocity (MFV) in the ipsilateral P1 posterior cerebral artery (PCA). In patients with an anterior BZ infarct, 3 (23%) had an MFV increase in the contralateral A1 anterior cerebral artery (ACA), and 2 (15%) had a higher MFV in the ipsilateral PCA. An elevated velocity at midline depths with reversed A1 ACA flow direction was seen in 2 patients (20%) with a subcortical infarct, and 1 patient (10%) had an MFV increase in the ipsilateral P1 PCA. Left ventricular systolic dysfunction (ejection fraction <40%) was present in 50% of patients with a posterior BZ infarct, in 36% of those with an anterior BZ infarct, in 20% of those with a subcortical BZ infarct and bilateral BZ infarcts each. Conclusion: The association of severe ICA stenosis or occlusion with cardiopathies and left ventricular dysfunction may play a critical role in those with BZ infarcts having inadequate collateral supply, while a cardioembolism or acute ICA dissection may also cause BZ infarction due to the rapidity of the occlusive process and the inability of the cerebral vasculature to recruit collateral pathways quickly enough.

Cerebral microembolism in acute spontaneous internal carotid artery dissection.

The rate and risk factors for early ischemic recurrence in patients with internal carotid artery dissection (ICAD) are largely unknown. Serial transcranial Doppler (TCD) monitoring of microembolic signals (MES) was performed in 28 consecutive patients with acute ICAD. MES were identified in 13 patients, and early ischemic recurrence occurred in 7. Six of 13 patients with MES and 1 of 15 without MES experienced early ischemic recurrence (p = 0.029). MES detection on serial TCD monitoring may be associated with an increased risk of early ischemic recurrence in patients with acute ICAD.

Infection-Associated Unilateral and Bilateral Carotid Artery Dissection

Internal carotid artery dissection represents a rare cause of ischemic stroke and its pathogenesis remains unknown. Yet a probable contributing mechanism is infection-mediated damage to the arterial wall. We present two cases of unilateral and bilateral internal carotid artery dissection preceded by a pharyngitis and by a flu-like syndrome respectively. Both patients were investigated by computed tomography, magnetic resonance imaging and angiography, echo-color Doppler and transcranial Doppler. We emphasize the pivotal role of MRI and ultrasound in the diagnosis and follow-up of acute internal carotid artery dissection and suggest that an infection may act as a triggering factor.