Carotid Artery Dissection Research Articles

A systematic review and meta-analysis of carotid artery stenting using the transcervical approach.

Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis. A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded. Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I2=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I2=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I2=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I2=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I2=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I2=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I2=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I2=37.6% and 95% CI: 11.3-16.1, P=0.48, I2=0%, respectively). TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis.

Completion imaging techniques and their clinical role after carotid endarterectomy: Systematic review of the literature.

Completion imaging has been suggested for the intraoperative quality control assessment of the carotid endarterectomy technical success, in order to immediately resolve pathologic findings and accordingly improve patients' outcome. The aim of this study was to present existing evidence of different completion imaging techniques after carotid endarterectomy and their role on clinical outcome. A systematic review was performed searching in MEDLINE, CENTRAL, and Cochrane databases including studies reporting on completion imaging techniques after carotid endarterectomy. A total of 12,378 patients in 35 studies (20 retrospective and 15 prospective) underwent a completion imaging technique after carotid endarterectomy: in 19 studies, 5340 patients underwent arteriography; in 5 studies, 2095 angioscopy; in 21 studies, 5722 DUS; and in 2 studies, 150 patients underwent transcranial Doppler. Ten studies assessed > 1 imaging technique. The mean age was 67 ± 7 years old (69% males) with common co-morbidities to be hypertension (74%), smoking (64%), and hyperlipidemia (54%). Almost half of the patients (4949; 44%) were treated for symptomatic disease. In 1104 (9.7%) patients, a major defect was identified intra-operatively, while in 329 patients (2.9%), a minor defect. Common pathological findings were the presence of mural thrombus, carotid dissection, residual stenosis, and intimal flaps. An immediate re-intervention was undertaken in 75% (790/1053) of the patients to treat a major intra-operative imaging finding. In patients with re-intervention, only 2.3% (14/609) had an intra-operative stroke and 0.8% (5/609), a transient ischemic attack, while only 1.4% (8/575) had a stroke and 0.2% a transient ischemic attack (1/575) during 30-day post-operative period. No intra-operative death was reported. In the same period, the restenosis rate of internal and common carotid artery was 0.5% (3/575) and 0.2% (1/575), respectively. Completion imaging techniques can detect defects in almost 10% of patients that may lead to immediate intra-operative surgical revision with low intra-operative stroke/transient ischemic attack rate and low early carotid restenosis. During the 30-day follow-up period, in those patients, the incidence of stroke/transient ischemic attack may be low but present. This review cannot provide any evidence on which completion imaging technique is better, and the clinical impact conferred by each technique in the absence of a randomized control studies.

Endovascular recanalization for symptomatic subacute and chronically occluded internal carotid artery: feasibility, safety, a modified radiographic classification system, and clinical outcomes

To evaluate the feasibility and safety of endovascular recanalization for symptomatic subacute and chronic internal carotid artery occlusion (ICAO); to propose a newly modified radiographic classification of ICAO that can rigorously identify suitable candidates for endovascular ICAO treatment. We included 42 consecutive patients who had ICAO with ischaemic symptoms refractory to medical therapy. We examined the symptomatology, complications, follow-up results and radiographic images of ICAO receiving attempted endovascular treatment. We attempted to stratify all radiographic images into categories based on morphological occlusion patterns, occlusion segments and distal ICA reconstitution on digital subtraction angiography (DSA). Four types (A-D) of radiographic ICAO were identified. We redefined type B as having a tapered stump but no distal lumen. The rate of successful recanalization was 83.33% (35/42 ICAOs; type A, 18/20; type B, 7/10; type C, 10/11; type D, 0/1). The perioperative complication rate was 11.90% (5/42), including 3 asymptomatic distal embolisms, 1 symptomatic cerebral infarction and 1 asymptomatic carotid artery dissection. None of these technique-related complications led to severe neurological damage or death. Modified Rankin Scale (mRS) scores after 1-20 months of follow-up were significantly decreased in successfully revascularized patients (P < 0.001). There was no significant change in mRS scores in the 7 patients in whom recanalization failed (P > 0.05). Endovascular recanalization seems to achieve technical success and clinical improvement for symptomatic subacute and chronic ICAO. Additionally, our newly modified radiographic classification of ICAO may be valuable in assessing the technical feasibility and safety of procedures in symptomatic ICAO patients.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Eagle Syndrome: An Unusual Cause of Stroke Successfully Treated by Angioplasty and Mechanical Thrombectomy

We report a case of a 50-year-old male presenting with right arm weakness and mixed aphasia after motorcycle accident. Basal CT/MR imaging showed absence of acute brain lesions and left internal carotid artery (ICA) wall hematoma at C1-C2 level close to a prominent styloid process. Multiphase CT angiography confirmed ICA dissection and a hypertrophic styloid process compressing the ICA at the same level; ipsilateral intracranial blood flow delay and good collateral circulation were present in the latest CTA phases [1]. Due to Patient neurological status deterioration, with progressive global aphasia and right hemiplegia onset, digital subtraction angiography (DSA) was performed urgently. DSA confirmed the CTA findings together with slowing of cerebral blood flow above the dissection; after mechanical thrombectomy by aspiration followed by balloon angioplasty, good blood flow and vessel caliber restoration were obtained. Post-procedural control and follow-up findings are described together with revision of the recent literature on the possible association between cerebral ischemic stroke and Eagle syndrome.

Oculomotor Nerve Palsy that Developed after Endovascular Treatment in an Acute Stroke Patient with a Dissecting Occlusion of the Extracranial Internal Carotid Artery

Oculomotor nerve palsy is underrecognized clinical manifestation of extracranial internal carotid artery (ICA) dissection. Herein we report a case of complete oculomotor nerve palsy following endovascular revascularization, which developed in a patient with acute stroke due to extracranial ICA dissecting occlusion. We also discuss about the development mechanism of oculomotor nerve palsy, considering the vascular anatomy and the possibility of periprocedural complications during endovascular treatment.

The use of a proximal protection system, a reperfusion catheter, and new-generation mesh stents in combined endovascular therapy for a long, symptomatic dissection of the right internal carotid artery.

The use of a proximal protection system, a reperfusion catheter, and new-generation mesh stents in combined endovascular therapy for a long, symptomatic dissection of the right internal carotid artery.

Collet-Sicard Syndrome Secondary to Internal Carotid Artery Dissection: A Firing Link.

Collet-Sicard Syndrome Secondary to Internal Carotid Artery Dissection: A Firing Link.

Treat the vessel, save the heart: a rare case of spontaneous sensitive carotid artery dissection.

Treat the vessel, save the heart: a rare case of spontaneous sensitive carotid artery dissection.

A unique temporary collateral pathway between carotid-vertebrobasilar arteries in a carotid dissection patient

BackgroundIn adults, the anastomosis between carotid and vertebrobasilar arteries is usually the posterior communicating artery, sometimes the primitive trigeminal artery. In this case, the basilar artery fed the internal carotid artery through the pontine-to-tentorial artery anastomosis after severe stenosis from traumatic carotid dissection.Case presentationA 32-year-old female was diagnosed with ischemic stroke caused by traumatic carotid artery dissection. Aspirin (100 mg/day) and clopidogrel (75 mg/day) were prescribed. Digital subtraction angiography performed 6 days after stroke onset showed a dissection in the cervical segment of left internal carotid artery with severe local stenosis, and a collateral pathway from BA to the cavernous segment of internal carotid artery through the lateral pontine and tentorial artery. Without interventional therapy, clinical symptoms improved significantly within 10 days after onset. At 3-month follow-up, left common carotid artery angiography showed the stenosis had been significantly improved with a residual aneurysm. There was no collateral pathway between carotid-vertebrobasilar arteries, and a residual small artery originated from the posterior vertical segment of cavernous internal carotid artery. The small artery was clearly visualized by 3-dimensional rotational angiography and identified the tentorial artery.ConclusionTo the author’s knowledge, this is the first report of a collateral pathway between carotid vertebrobasilar arteries through the pontine-to-tentorial artery anastomosis. Meanwhile, tentorial artery origination directly from the cavernous segment of internal carotid artery is rare and easily mistaken for persistent primitive trigeminal artery. 3-dimensional rotational angiography can provide sensitive and accurate diagnostic assessment of the small artery, and may be a useful tool for screening of abnormal small arteries.

New ischemic lesions on brain magnetic resonance imaging in patients with blunt traumatic cerebrovascular injury.

Patients with blunt cerebrovascular injuries are at risk of thromboembolic stroke. Although primary prevention with antithrombotic therapy is widely used in this setting, its effectiveness is not well defined and requires further investigation. The aim of this study was to evaluate the utility of magnetic resonance imaging (MRI)-detected ischemic brain lesions as a possible future outcome for randomized clinical trials in this patient population. This prospective observational study included 20 adult blunt trauma patients admitted to a level I trauma center with a screening neck CTA showing extracranial carotid or vertebral artery injury. All subjects lacked initial evidence of an ischemic stroke and were managed with antithrombotic therapy and observation and then underwent brain MRI within 30 days of the injury to assess for ischemic lesions. The MRI scans included diffusion, susceptibility, and Fluid-attenuated Inversion Recovery (FLAIR) sequences, and were reviewed by two neuroradiologists blinded to the computed tomography angiography (CTA) findings. Eleven CTAs were done in the emergency department upon admission. There were 12 carotid artery dissections and 11 unilateral or bilateral vertebral artery injuries. Median interval between injury and MRI scan was 4 days (range, 0.1-14; interquartile range, 3-7 days). Diffusion-weighted imaging evidence of new ischemic lesions was present in 10 (43%) of 23 of the injured artery territories. In those injuries with ischemic lesions, the median number was 8 (range, 2-25; interquartile range, 5-8). None of the lesions were symptomatic. Blunt cerebrovascular injury was associated with a higher mean ischemic lesion count (mean count of 3.17 vs. 0.14, p < 0.0001), with the association remaining after adjusting for injury severity score (p < 0.0001). In asymptomatic blunt trauma patients with CTA evidence of extracranial cerebrovascular injury and treated with antithrombotic therapy, nearly half of arterial injuries are associated with ischemic lesions on MRI. Therapeutic/care management, level IV.

AMPHETAMINE-RELATED CORONARY ARTERY DISSECTION LEADING TO CARDIAC ARREST

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized etiology of acute coronary syndrome (ACS) in young adults. Amphetamine use has been linked to aortic, carotid and renal artery dissections. We present a rare case of SCAD attributed to amphetamine abuse and presented as

A Novel COL3A1 c.2644G>T; p.(Gly882Cys) Variant in a Turkish Family with Vascular Ehlers-Danlos Syndrome

Vascular Ehlers-Danlos syndrome (vEDS) is an autosomal dominant disease, also known as EDS type IV. The estimated prevalence for all EDS varies between 1/10,000 and 1/25,000 with EDS type IV representing approximately 5-10% of the cases. The vascular complications may affect all anatomical areas, with a tendency toward arteries of large and medium diameter. vEDS diagnosis is a challenging process. Patients usually have different phenotypic features and are unaware of the diagnosis at the time of initial vascular complications. The authors report the case of a 39-year-old male patient with EDS type IV, who developed internal carotid artery dissection and was diagnosed with clinical findings, imaging modalities, and a novel pathogenic COL3A1 variant.

Delayed bilateral internal carotid artery dissection following motor vehicle accident: time to make its screening a part of trauma protocol?

Delayed bilateral internal carotid artery dissection following motor vehicle accident: time to make its screening a part of trauma protocol?

A Massage Did What?

Internal Carotid Artery (ICA) dissection is a condition that occurs when a layer of the arterial wall begins to tear which may form a clot that limits blood flow. It is characterized by pain over the head, face or neck. Some may present with pulsatile tinnitus or visual disturbances. It is an uncommon cause of ischemic stroke that can occur in the setting of trauma or even spontaneously. It is usually related to an underlying connective tissue disease such as, Marfan or Ehlers-Danlos. But it can also present in those with fibromuscular dysplasia or atherosclerosis. Here we present a case of ICA dissection following manual manipulation.

Malformación y fístula arteriovenosa de carótida externa

Introducción: Las malformaciones Arteriovenosas a nivel de las arterias carótidas ya sea externa o interno y de acuerdo a su flujo no mantienen una alta incidencia, por tanto, no existen datos o bases de datos que nos ayuden con estadísticas y ayudas específicas en el diagnóstico y tratamiento de las mismas. Una fístula carótida-cavernosa se traduce en una comunicación anormal entre arterias y venas dentro del seno cavernoso y puede clasificarse como directa o dural e indirecta o de bajo flujo. Las fistulas carotideas directas con frecuencia son de origen traumático y también pueden ser causados por la ruptura de un aneurisma, Síndrome de Ehlers-Danlos tipo IV, o intervención iatrogénica, hipertensión, displasia fibromuscular, Ehlers-Danlos tipo IV y disección de la Arteria Carótida Interna.&#x0D; Objetivo: Describir un caso clínico de Malformación y Fistula Arteriavenosas de Carotidea Externa.&#x0D; Material y métodos: Estudio descriptivo retrospectivo, presentación de caso clínico.&#x0D; Resultados: Se describe un caso clínico de paciente femenina de 28 años de edad habitante de zona amazónica que presenta hace larga data malformación a nivel de hemicara la cual ha ido aumentando de tamaño a través de los años; a pesar de la realización temprana de métodos diagnósticos la patología no pudo ser confirmada y por ende el tratamiento adecuado no ha podido ser aplicable aumentando significativamente las complicaciones y apareciendo lesiones de órganos concomitantes que han empeorado el cuadro.&#x0D; Conclusiones: En la región cérvico facial las malformaciones arteriovenosas son raras y siguen siendo un tema controvertido. La principal etiología a este nivel son los traumatismos, seguido de infecciones, pubertad, embarazo, pero también es frecuente que sean espontáneas de origen congénito. El tratamiento es controvertido, y no está claramente establecido, es una decisión tomada entre paciente, cirujano y radiólogo intervencionista. El único tratamiento definitivo es una escisión completa radical de toda la tumoración, acompañada de sus riesgos. Entre ellos están la alta tasa de sangrado intraoperatorio (a veces incontrolable por la presencia de estructuras vitales como las arterias carótida, vertebral y subclavia, y las venas yugulares). También está la probable recidiva, debido a que depende de gran cantidad de vasos y es necesaria una resección radical de la malformación. Por último, las secuelas estéticas que puede conllevar la recesión, necesitando colgajos microvascularizados o pediculados, ya que los colgajos libres producen cambios en la vascularización y fibrosis que contribuyen a un ambiente isquémico con la consiguiente recidiva

Emergency carotid artery revascularization using Casper-RX stent: A single-center experience.

Casper-RX (MicroVention, Aliso Viejo, California, USA) is a dual-layer closed cell stent recently introduced as a carotid artery revascularization device. Although its effectiveness and safety has been proved in elective cases, there are contradictive results regarding its patency in emergency settings. The purpose of the study is to present our single-center experience with the Casper-RX stent in the emergency interventions. Consecutive patients who underwent emergency carotid artery stenting using Casper-RX system with or without additional intracranial thrombectomy between August 2016 and June 2019 at our institution were included. Primary end point was the short-term patency of the carotid stents evaluated before hospital discharge by use of Doppler ultrasonography. Twenty-nine procedures performed on 28 patients were included in the study. All stents were patent on final angiograms. Acute stent occlusion was observed only in one case (3.4%) with a spontaneous cervical internal carotid artery dissection the day after the procedure. In 26 (89.6%) cases, an additional intracranial thrombectomy was performed with a successful recanalization rate of 96.1%. Seven adverse events occurred peri-/post-procedural: two cases (6.9%) with iatrogenic dissection of distal cervical internal carotid artery during intracranial thrombectomy, two parenchymal hematoma type 2 (6.8%), and three patients (10.3%) developed massive infarction. This study supports the safety and efficacy of the Casper-RX stent in emergency endovascular carotid artery revascularization procedures.

Predictors of Cervical Vertebral and Carotid Artery Dissection During Blunt Trauma: Experience From a Level 1 Trauma Center

The current data available to identify the factors associated with vertebral and carotid artery dissection in the trauma setting are conflicting, and further research is needed to accurately assess these predictors. The data from 950 patients who had undergone neck computed tomography angiography (CTA) at a level 1 trauma center were analyzed. Of the 950 patients, 435 were included who had undergone neck CTA for blunt traumatic injuries. The mechanism of injury was classified as high or low impact according to the hospital criteria for trauma. Positive neurological signs included altered mental status (Glasgow coma scale score ≤15 than baseline) or focal neurological deficits. Fractures and dissections were radiologically confirmed. Multivariable logistic regression software was used to analyze the data. Of the 435 patients, 236 (54.25%) had experienced high-impact injuries, 124 (28.51%) had vertebral fractures (including 63 displaced fractures [50.81%]), and 180 (41.38%) had had positive neurological signs on presentation. Of the 435 patients, cervical carotid artery injury had been diagnosed in 9 (2.07%), and 18 patients (4.14%) had had a cervical vertebral artery injury (VAI). Carotid artery injuries did not have significant associations with positive neurological signs, age, sex, mechanism of injury, or vertebral fracture (P > 0.05 for all). Positive neurological signs and vertebral fractures were significant predictors for VAI (odds ratio, 3.19; P < 0.05; odds ratio, 9.81; P < 0.001, respectively). Age, sex, mechanism of injury, and displacement of the vertebral fracture were not significant predictors for VAI (P > 0.05 for all). Positive neurological signs and the presence of cervical vertebral fractures are significant predictors for VAI. All trauma patients with cervical spine fractures and/or positive neurological findings should be considered for surveillance imaging with neck CTA and/or magnetic resonance angiography for vascular injury screening.

Abstract TMP60: Association Between Pregnancy and Cervical Artery Dissection

Background and Purpose: Pregnancy is a risk factor for stroke. The mechanisms of stroke in pregnancy have not been well established. Cervical artery dissection may be one such mechanism, but it is unclear whether pregnancy is a risk factor for cervical artery dissection. Methods: We performed a cohort-crossover analysis using administrative claims data from all hospitalizations and emergency department visits involving nonfederal acute care hospitals in NY and FL between 2005-2015. We identified women ≥12 years old who were hospitalized for labor and delivery. Our outcome was cervical artery dissection, defined as carotid or vertebral artery dissection. We defined the period of risk as 6 months antepartum through 3 months postpartum. We compared each patient’s risk of dissection during this time period versus the corresponding 270-day period exactly 1 year later. Conditional Poisson models with robust standard errors were used to calculate incidence risk ratios (IRRs). Results: We identified 4,193,417 pregnancies among 3,061,413 women during our study period. There were 52 cases of cervical artery dissection during the peripartum period and 24 cases during the control period 1 year later. The incidence of cervical artery dissection was 12 (95% CI, 10-17) per million pregnancies versus 6 (95% CI, 4-9) per million patients during the control period 1 year later (IRR, 2.2; 95% CI, 1.3-3.5). Our findings were similar when we limited our outcome to cervical artery dissections complicated by ischemic stroke (IRR, 2.3; 95% CI, 1.1-5.1). Secondary analyses suggested that the heightened risk occurred in the peripartum and postpartum period (IRR,5.5; 95% CI, 2.6-11.7), not the antepartum period (IRR, 0.5; 95% CI, 0.2-1.2). Conclusions: In a large, population-based sample of women, pregnancy was associated with an increased risk of cervical artery dissection. This increased risk appeared to be limited to the peripartum and postpartum period.

Letter to the Editor Regarding “A Staged Therapy for Internal Carotid Artery Dissection Caused by Vascular Eagle Syndrome”

Letter to the Editor Regarding “A Staged Therapy for Internal Carotid Artery Dissection Caused by Vascular Eagle Syndrome”