Cervical Carotid Artery Dissection Research Articles

Endovascular reconstruction of high cervical and long-segment carotid artery dissections with Leo plus stent.

Endovascular reconstruction has emerged as a viable alternative for carotid artery dissections (CADs) that are unresponsive to antithrombotic therapy. However, high cervical and long-segment CADs pose challenges during endovascular treatment due to their distal location and tortuous anatomy. We presented our experiences using endovascular reconstruction with the Leo plus stent for this type of CAD. We conducted a retrospective review of patients with high cervical and long-segment CADs treated using the Leo plus stent. We analyzed patient demographics, clinical presentations, procedural features, complications, and follow-up outcomes. A total of 17 patients (mean age, 48.1years) with 17 CADs were identified. Seven of these dissections were accompanied by pseudoaneurysm. The mean length of the dissection was 5.7cm, and the mean degree of stenosis was 92.3%. A single Leo plus stent was deployed in 15 patients, while another Wallstent carotid stent was used in 2 cases. All stents were successfully positioned in their intended sites. The average degree of residual stenosis was 22.2%. There were no perioperative complications. With a median follow-up duration of 29months, no ischemic stroke events occurred. All but one Leo plus stent remained patent during follow-up, and all 7 pseudoaneurysms had disappeared at the last radiological assessment. Our experience in treating high cervical and long-segment CADs with the Leo plus stent demonstrates that this approach is practical, safe, and effective, as evidenced by long-term observations. The Leo Plus stent appears to be a suitable option for managing this type of CAD.

Mechanical Thrombectomy in a 12-Month-Old Infant with Acute Ischemic Stroke Possibly due to Internal Carotid Artery Dissection: A Case Report.

Stroke in children is a rare but devastating disease. Although endovascular treatment has been reported to be safe and effective in the treatment of stroke with large vessel occlusion in this population, there are still limitations and controversies. In this case report, we describe a 12-month-old girl who was admitted to the hospital with acute onset of left-sided hemiplegia and confusion, which turned out to be due to a large infarct in the right middle cerebral artery territory, possibly caused by dissection of the right cervical internal carotid artery. Aspiration thrombectomy was successfully performed, and the patient was able to walk a few steps and raise her left upper extremity at the 12-month follow-up. The aspiration-only technique in thrombectomy may be safe and technically feasible to treat acute ischemic stroke with large vessel occlusion in children as young as 12 months, although large-volume prospective studies are needed.

Blunt Traumatic Cerebrovascular Injury and Stroke: The Need for a High Index of Suspicion when Initial Vascular Imaging is Negative - A Single Center Case Series. (P14-5.019)

<h3>Objective:</h3> NA <h3>Background:</h3> Acute ischemic stroke (AIS) from traumatic cerebrovascular injury (TCVI) leads to approximately 4800 US strokes annually; often as sequelae of cervical arterial dissection. CT angiography (CTA) is typically used for screening, but this modality has limitations of low sensitivity, particularly for low-grade dissections. Our case series illustrates the importance of high index of suspicion in trauma patients to pursue further vessel imaging when there is unexplained AIS. <h3>Design/Methods:</h3> Case series. <h3>Results:</h3> Our series consists of 2 patients admitted to Trauma ICU following motor vehicle collisions. The 1st patient was a 22-year-old woman with left precentral gyrus infarction on diffusion-weighted MRI. Initial CTA showed dissection of cervical right internal carotid artery (ICA) which did not explain her infarction. Echocardiogram was also unrevealing so digital subtraction angiography was pursued, which revealed dissection of the left supraclinoid ICA not seen on CTA. The 2nd patient was a 15-year-old man with bilateral frontal infarctions on diffusion-weighted MRI. His initial CTA showed dissection of cervical left ICA. There was no explanation for his right frontal infarction on further workup so CTA was repeated after 4 days, which showed additional dissection involving the right cervical ICA not seen initially. Etiology of AIS in both cases was unexplained initially but repeat or alternate imaging helped unveil previously undetected ipsilateral dissections. <h3>Conclusions:</h3> Undetected traumatic dissection can result in devastating neurologic sequelae including further strokes and worsening dissection. It can also lead to unnecessary workup such as thrombophilia testing in younger patients. These patients are often hidden from the view of neurologists as they are typically managed by trauma surgeons and literature regarding TCVI is predominantly in surgical journals. We hope to increase awareness and emphasize the importance of a high index of suspicion to pursue further vessel imaging in unexplained stroke so that appropriate treatment can be initiated rapidly. <b>Disclosure:</b> Dr. Asif has nothing to disclose. Dr. Habib has nothing to disclose. Dr. Samkutty has nothing to disclose.

A Case of Ruptured Middle Cerebral Artery Aneurysm with Cervical Carotid Artery Dissection

A Case of Ruptured Middle Cerebral Artery Aneurysm with Cervical Carotid Artery Dissection

Flow Diverter Reconstruction of Internal Carotid Artery (Loop) Dissections with or without Associated Pseudoaneurysms

Endovascular treatment of cervical internal carotid artery (ICA) loop dissections in acute stroke interventions can be challenging. Flow diverters can effectively reconstruct vessel loops and treat the injured vessel and provide a safe conduit for intracranial catheterization. We retrospectively reviewed our neurointerventional database and identified all patients with ICA loop dissections treated with flow diverters in the acute setting between August 2016 and September 2020. Patient demographics, procedural data, imaging follow-up results, and clinical outcome information were collected. Seven patients with a mean age of 62 years (range: 43-85 years) who underwent reconstruction of an ICA (loop) dissection with flow diverters were included. Four ICA dissections were treated with the Surpass Streamline flow diverter and 3 with the Pipeline embolization device. All cases were technically successful. All stroke cases achieved intracranial flow ≥thrombolysis in cerebral infarction 2B. Observed intracranial hemorrhages were all asymptomatic. All cases showed patent flow diverter(s) with or without (carotid) stent(s) on follow-up imaging. Semielectively treated patients did not show a change from baseline modified Rankin scale related to the procedure. Patients with acute stroke had a modified Rankin scale ≤2 in 4 of 5 cases (80%) at 3 months. Two patients died due to medical issues unrelated to the procedures. No patient showed new or recurrent symptoms. Use of flow diverters, in some cases in conjunction with (carotid) stents, is an effective treatment option for cervical carotid artery (loop) dissections.

213 Can Styloid Process and Internal Carotid Artery Anatomy Be Used to Predict Carotid Artery Dissection?

Abstract Aim Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighbouring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis. Method Retrospective data was collected from two central London hospitals over five years. CCAD cases were identified from individuals who underwent computer topography angiography (CTA) of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls. Results Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5mm and styloid process-internal carotid distance was 5.14mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for non-dissection. Conclusions In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements cannot be used to predict the possibility of a CCAD following trauma.

O28 Can styloid process and internal carotid artery anatomy be used to predict carotid artery dissection?

Abstract Introduction Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighbouring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis. Method Retrospective data was collected from two central London hospitals over five years. CCAD cases were identified from individuals who underwent computer topography angiography (CTA) of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls. Result Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5 mm and styloid process-internal carotid distance was 5.14 mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for non-dissection. Conclusion In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements can not be used to predict the possibility of a CCAD following trauma. Take-home Message Anatomy of the styloid process and calcification of the styloid-hyoid ligament are highly variable and many independent factors may contribute to the risk of cervical carotid artery dissection. Radiological measurements of the styloid process alone cannot be used to predict risk and likelihood of cervical carotid artery dissection.

Can Styloid Process and Internal Carotid Artery Anatomy be Used to Predict Carotid Artery Dissection?

Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighboring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis. Retrospective data was collected from 2 central London hospitals over 5 years. CCAD cases were identified from individuals who underwent computer topography angiography of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls. Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5 mm and styloid process-internal carotid distance was 5.14 mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for nondissection. In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements can not be used to predict the possibility of a CCAD following trauma.

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.

Cervical artery dissection - retrospective analysis of 19 cases

Cervical artery dissection is a common cause of stroke in young adults. It might occur shortly after a forceful neck trauma or a minor injury. However, spontaneous dissection is also common, which is associated with genetic, anatomical or environmental risk factors. Cervical artery dissection can produce a broad spectrum of clinical presentation varying from local symptoms to focal neurological deficits determined by the arterial territory involved. Early recognition is important since immediate initiation of treatment can significantly improve patient outcomes. While clinical features may raise suspicion for dissection, the diagnosis has to be confirmed by neuroimaging findings. The purpose of this paper is to give an overview on cervical (carotid and vertebral) artery dissections while presenting 19 cases. During three years, we evaluated the clinical features, risk factors, diagnostic and therapeutic procedures of these patients admitted with extracranial artery dissection. The prognosis of the disease can vary, 42% of our patients became asymptomatic. Orv Hetil. 2019; 160(22): 861-868.

Rivaroxaban in cervical and "cervico-cerebral" artery dissections: a new therapeutic option?

Antiplatelet agents and vitamin K antagonists (VKA) are usually used in the treatment of cervical (carotid or vertebral) artery dissections (CADs); however, data about the use of direct oral anticoagulants (DOACs) in these conditions are very limited. DOACs have proven to be effective in stroke reduction in non-valvular atrial fibrillation and, when possible, they are preferred to warfarin because of their better safety profile. We describe four cases of CADs and, firstly in literature, cervico-cerebral (CCADs) in young patients (average age of 42years) treated with rivaroxaban 20mg daily. Three of these four dissections had affected the vertebral artery (condition with an unfavorable prognosis and more often complicated by subarachnoid hemorrhages), and the other one was a carotid dissection at the extra-intracranial passage. All patients were followed clinically and with serial neurosonological examinations at 1, 3, and 6months and with magnetic resonance angiography (MRA) at 6months. All patients presented a good outcome with vascular recanalization without stroke recurrence or bleedings, even in patients with intracranial vertebral artery involvement. DOACs could be an alternative in young patients with CADs and their use could be considered in intracranial artery dissections too.

P.092 Eagles and Talons: A case of cervical artery dissection from Eagle syndrome and fibromuscular dysplasia

Background: Eagle syndrome (also known as stylohyoid syndrome) and fibromuscular dysplasia (FMD) are rare conditions that have both been shown to be associated with cervical artery dissections (CAD). Direct mechanical injury from a neighboring bony fragement can produce arterial dissections and is the proposed mechanism in Eagle syndrome. The etiology of FMD remains unclear, however, similar shearing stresses have been proposed. We present a case in which both of these conditions were present. Methods: Case report Results: A previously healthy 52 year old male presented with an acute left MCA syndrome with computer tomography angiography followed by convensional angiography confirming a complete occlusion of the left ICA at the carotid bifurcation with evidence of a dissection of the proximal cervical carotid artery. Luminal irregularities proximal to the dissection and also of the right ICA were in keeping with fibromuscular dysplasia. A carotid stent was placed and a thrombectomy was performed for a proximal left M2 occlusion. On further review of the CT, the patient had markedly elongated styloid processes bilaterally, meeting criteria for Eagle syndrome. Conclusions: Previous literature has not described these two conditions coexisiting. We question whether chronic mechanical stress from an elongated styloid process could lead to arteries having an irregular or beading appearance resembling fibromuscular dysplasia.

Severe ischemic stroke due to progression of cervical carotid artery dissection

Severe ischemic stroke due to progression of cervical carotid artery dissection

動脈解離により血管腔が間歇的に閉鎖し，一過性脳虚血症状を繰り返したと考えられた頸部内頸動脈解離の1 例

症例は66 歳の女性．30 秒～1 分間程度持続する一過性の右上肢脱力発作を繰り返し発症した．脳血管撮影により頸部頸動脈解離の診断に至った．患者には，約1 カ月前に頸部への鈍的外傷歴があった．急性期の脳虚血巣はMRI では認められず，MRI および造影CT において解離病変部内に明らかな血栓が同定できないこと，非脳虚血発作時の脳血流検査で脳血流低下や脳血流予備能低下も認められないことから，当初，脳虚血発作の発症機序を特定できなかった．血管内視鏡による病変部観察の結果，解離した血管壁が可動性を有するフラップ形状を呈しており，偽腔内へ流入する血流により解離フラップが血管腔を閉塞するように上昇運動する状態が観察されたことから，解離血管壁が間歇的に血管腔を閉鎖することが本症例の病態生理と推測された．頸動脈ステント留置術により解離血管壁を固定した結果，脳虚血症状は消失した．

Stroke prevention by endovascular treatment of carotid and vertebral artery dissections

IntroductionEndovascular intervention for cervical carotid artery dissection (CAD) and vertebral artery dissection (VAD) may be indicated in specific circumstances.ObjectiveTo review our institutional experience with endovascular treatment of cervical dissections over...

Cervical Artery Dissections: A Review

BackgroundCervical artery dissection (CeAD) is an infrequent, yet potentially devastating, cause of stroke. While uncommon, CeAD is important for emergency physicians to quickly diagnose and treat because of the potential for cerebral ischemia, stroke, blindness, or death. To our knowledge, no review articles in the emergency medicine literature have been published on CeAD. A literature search of MEDLINE/PubMed, Embase, and other major abstracts in the English language was performed for the following terms: cervical artery, vertebral artery, and carotid artery dissection. The search included all titles from January 1, 2010 to February 28, 2015 and other relevant articles. ObjectivesWe sought to review the epidemiology, pathophysiology, risk factors, and clinical presentation for extracranial CeAD in the adult population, explore recent research on diagnosing this disorder, evaluate the most current research on treatment options, and summarize the prognosis of CeAD. DiscussionCeAD is an uncommon but important cause of stroke in the young that is likely caused by multifactorial processes. The diagnosis should be considered in those with underlying risk factors, a remote history of minor trauma, and concerning signs and symptoms. The condition should be pursued via magnetic resonance imaging or computed tomography angiography. Treatment should be aimed at preventing additional complications, including recurrent stroke or transient ischemic attack, with antiplatelets, anticoagulants, or even endovascular or surgical therapy. ConclusionOverall, the prognosis of patients with CeAD is good, with relatively low death rates. However, the diagnosis should not be missed, because treatment may help prevent worsening or persistent ischemia, recurrent dissection, and death.

355 Endovascular Management of Cervical Carotid and Vertebral Artery Dissection

Abstract Endovascular intervention for cervical carotid artery and vertebral artery dissections (CAD and VAD) may be indicated in specific circumstances. We reviewed a prospectively maintained database from January 1996 to January 2016 of extracranial dissections undergoing endovascular intervention. There were 116 patients, including 93 in the CAD cohort and 23 in the VAD cohort, with a mean age of 44.9 years (range 5-76) and mean postprocedure follow-up of 41.6 months (range 1-146). Interventions included stent placement (n = 104), coil occlusion of parent artery (n = 11), or stenting with contralateral vessel coil occlusion (n = 1). The 2 cohorts were well matched in age, sex, dissection etiology, and admission/follow-up modified Rankin Scale (mRS) (P = .362, .371, .175, .355, and .835, respectively). The CAD cohort was significantly more likely to undergo stent placement or have failed medical therapy (P 3) in the CAD cohort (P = .014). Six (9.0%) patients of spontaneous etiology also reported recent chiropractic manipulation. The permanent morbidity/mortality rate was 3.4%, including 2 deaths, with a stroke rate of only 0.9% over 4825 patient-years. At last follow-up, 31 of 93 (33.3%) CAD patients and 10 of 23 (43.5%) VAD patients disabled prior to intervention were nondisabled at last follow-up; no patients in either cohort were worsened. In a long-term experience, endovascular management of CAD and VAD is highly effective in specific indications, with an acceptable complication profile. CAD requiring intervention is more likely than VAD to have failed medical therapy, present with thromboembolic events and pseudoaneurysms, and undergo primary stent placement, whereas VAD is more likely to undergo treatment for traumatic occlusions with recanalization.

Abstract T P24: Neurointervention for Acute Ischemic Stroke Caused by Carotid Dissection

Introduction: Data related to the treatment of patients with acute ischemic stroke caused by carotid artery dissection is scarce. Methods: We retrospectively reviewed our interventional stroke database Sep 2010 - Jan 2014 to investigate the clinical and radiological characteristics of patients presenting with tandem cervical and intracranial occlusions due to cervical carotid dissection. Results: Out of 504 consecutive patients treated with endovascular therapy for acute ischemic stroke during the study period, 12 (2.5%) patients were observed to have cervical carotid artery dissection as the underlying etiology. Mean age was 56±13 years, 75% were male, 50% received IV t-PA, mean NIHSS was 20±5, 75% had CT ASPECTS≥7, and mean time from last known normal to groin puncture was 6±3 hours. There were 4 MCA M1, 1 MCA M2 and 7 ICA-T occlusions. Extracranial carotid stent was used in 58% and angioplasty in 8% of cases. In 33% of the cases, the carotid dissection was not stented due to the fear of hemorrhagic transformation in cases of IV thrombolysis (presumably increased risk if dual antithrombotics used). IA tPA was used in 41% of cases, while Merci in 16%, Penumbra in 58%, and stentretrivers in 50%. Intracranial TICI 2b-3 reperfusion was achieved in 91% of patients, with PH2 hemorrhage in 8% and mRS at 90 days in 45% of cases. Conclusions: Carotid dissections with associated intracranial occlusions are often refractory to IV tPA and present with a high stroke severity. These lesions are amenable to endovascular therapy resulting in high rates of reperfusion with an acceptable safety profile.

Extreme Conditioning Programs: Potential Benefits and Potential Risks.

CrossFit, Insanity, Gym Jones, and P90X are examples of extreme conditioning programs (ECPs). ECPs typically involve high-volume and high-intensity physical activities with short rest periods between movements and use of multiple joint exercises. Data on changes in fitness with ECPs are limited to CrossFit investigations that demonstrated improvements in muscle strength, muscular endurance, aerobic fitness, and body composition. However, no study has directly compared CrossFit or other ECPs to other more traditional forms of aerobic and resistance training within the same investigation. These direct comparisons are needed to more adequately evaluate the effectiveness of ECPs. Until these studies emerge, the comparisons with available literature suggest that improvements in CrossFit, in terms of muscular endurance (push-ups, sit-ups), strength, and aerobic capacity, appear to be similar to those seen in more traditional training programs. Investigations of injuries in ECPs are limited to two observational studies that suggest that the overall injury rate is similar to that seen in other exercise programs. Several cases of rhabdomyolysis and cervical carotid artery dissections have been reported during CrossFit training. The symptoms, diagnosis, and treatment of these are reviewed here. Until more data on ECPs emerge, physical training should be aligned with US Army doctrine. If ECPs are included in exercise programs, trainers should (1) have appropriate training certifications, (2) inspect exercise equipment regularly to assure safety, (3) introduce ECPs to new participants, (4) ensure medical clearance of Soldiers with special health problems before participation in ECPs, (4) tailor ECPs to the individual Soldier, (5) adjust rest periods to optimize recovery and reduce fatigue, (6) monitor Soldiers for signs of overtraining, rhabdomyolysis, and other problems, and (7) coordinate exercise programs with other unit training activities to eliminate redundant activities and minimize the risk of overuse injuries.