Cervicocephalic Arterial Dissection Research Articles

Persistent headache attributed to past cervicocephalic artery dissection: clinical characteristics and contributors to headache persistence.

Persistent headache/facial/neck pain attributed to past cervicocephalic arterial dissection is under-documented in literature. Our main goal was to evaluate clinical characteristics and contributors to this persistence. A retrospective cohort study which included patients with a radiologically confirmed cervicocephalic arterial dissection (2015-2020) in a Portuguese tertiary hospital. Headache persistence was identified through clinical records. A questionnaire aimed to characterize headache in three moments: previous, persistent, and headache at the time of the interview (on average 2.5 years post-event). Ninety-two patients were identified; 24 (26.1%) had headache persistence ≥3 months, and 20 (22.2%) on average after 2.5 years post-event. There were no differences regarding demographics and vascular risk factors among patients with (n = 22) and without (n = 68) headache persistence. The first group had higher previous headache history (68.2% vs 4.4%, p < 0.001), delay in diagnosis (3.6 vs 1.9 days, p < 0.001), and headache/cervicalgia as the first symptom (81.8% vs 41.2%, p < 0.001). At the time of the interview, 20% still reported daily headache. A logistic regression model depicted headache history (OR = 59.8, p < 0.001), acute headache/cervicalgia (odds ratio, OR = 25.4, p = 0.005), posterior circulation dissection (OR = 7.6, p < 0.001), and less than 4 points by National Institutes of Health Stroke Scale score (OR = 5.0, p = 0.025) as contributors to headache persistence. Headache persistence post-cervicocephalic arterial dissection is common, and frequently affects patients daily. As it potentially affects functional outcomes and quality of life, the contributors identified in this study may help clinicians manage patients after the acute event.

Influence of endothelial function and arterial stiffness on the behavior of cervicocephalic arterial dissections: An observational study.

BackgroundThe mechanical and physiological properties of the arterial wall might affect the behavior of spontaneous cervicocephalic arterial dissections (CCAD). We aimed to determine the effects of endothelial function and arterial stiffness on the clinical characteristics and outcomes of CCAD using brachial flow-mediated dilation (FMD) and brachial-ankle pulse wave velocity (PWV).MethodsFrom a single-center database, we identified patients admitted from April 2011 to December 2021 with a diagnosis of CCAD who underwent both FMD and PWV. FMD was classified as normal and decreased according to institutional thresholds. PWV was categorized into tertiles. Comparative and multivariable analyses were performed to determine the effects of FMD and PWV values on major clinical outcomes.ResultsA total of 146 patients (age: 47 ± 11 years; men: 77.4%) were included. The main presentation was ischemic stroke in 76.7% of the patients, while 23.3% presented with headache or other symptoms. Healing of the dissection was observed in 55.8%. In multivariable analysis, Normal FMD levels (vs. decreased; adjusted OR: 4.52, 95% CI [1.95 −10.52]) were associated with spontaneous healing of the dissection. Highest PWV tertile (vs. lowest; adjusted OR: 17.05, 95% CI [3.07–94.82]) was associated with ischemic presentation. There was a higher ischemic stroke recurrence in the 3rd PWV tertile, and more frequent aneurysmal enlargement in the lowest PWV tertile, but their frequency was low, precluding multivariable analysis.ConclusionIn spontaneous CCAD, preserved endothelial function was associated with spontaneous arterial healing. Arterial stiffness is associated with ischemic presentation.

Recanalization and Functional Outcome in Patients with Cervico-cephalic Arterial Dissections.

Cervico-cephalic arterial dissections (CeAD) are an important cause of stroke in young patients. This study aimed to determine the frequency and predictors of recanalization in spontaneous CeAD and to study the effect of recanalization on functional outcomes. We identified patients presenting with acute ischemic stroke secondary to CeAD from the CT angiography (CTA) database of the Calgary Stroke Program. Dissections were diagnosed based on standard clinical and imaging findings. At the discretion of treating stroke Neurologists, the patients were either treated with single antiplatelet or dual antiplatelet or triple therapy. Follow-up imaging with CTA, magnetic resonance imaging, and DSA was completed, and a Modified Rankin scale (mRS) was performed to determine the outcome. Fifty-six patients with CeAdD were studied. Thirty-four patients (18 VAD; vertebral artery dissection and 16 CAD; carotid artery dissection) were followed up for recanalization. Complete recanalization was observed in 27 subjects; 13 patients with VAD recanalized in comparison to 14 with CAD (p = 0.40). All non-recanalized patients had hypertension. A good clinical outcome (mRS ≤ 2) was observed in 47 patients. Interestingly, the likelihood of a good neurological outcome was not influenced by recanalization status. There was no difference in clinical outcome for different sites in VAD, whereas patients with intracranial CAD had severe strokes (NIHSS > 21). CeAD has good recanalization rates and neurological outcomes, with recanalization seen even in vessels with initial complete occlusion. The presence of hypertension may influence recanalization. The efficacy of dual antiplatelets and heparin for early recanalization needs to be assessed in future clinical trials.

The inflammatory markers and prognosis of cervicocephalic artery dissection: a stroke center study from a tertiary hospital.

Cervicocephalic artery dissection (CeAD) is the most common cause of ischemic stroke in young adults. Although the exact cause is unknown, inflammation is thought to have a role. Here, we investigated the relationship between CeAD and inflammation. Patients diagnosed with CeAD in our stroke center were evaluated retrospectively, and their demographic and clinical features were recorded. The C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell, neutrophil and lymphocyte counts, platelet/lymphocyte ratio (PLR), and neutrophil/lymphocyte ratio (NLR) were recorded on admission. Modified Rankin scores (mRS) were noted on admission and at 6 months to evaluate the dependency status and functional outcome of each patient. Of the 95 patients in the study, 70 (73.7%) were male, and the mean age was 44.4 ± 9.8 years. Patients with high WBC count, ESR, PLR, and NLR frequently had mRS scores of 3-6 at admission; these differences were significant (p = 0.04, p = 0.02, p = 0.04, and p = 0.02, respectively). At 6 months, patients with high CRP and ESR at admission also had significantly poorer prognoses (p < 0.001, p = 0.002, respectively). PLR and NLR values were higher in patients with mRS of 3-6. But there were no significant differences between the good and poor prognosis groups regarding PLR and NLR (p = 0.22, p = 0.05, respectively). Inflammation may have a role in the prognosis of CeAD, and inflammatory markers can be evaluated as auxiliary tests for determining prognosis.

Misdiagnosis of Cervicocephalic Artery Dissection in the Emergency Department.

Background and Purpose- Cervicocephalic artery dissection is an important cause of stroke. The clinical presentation of dissection can resemble that of benign neurological conditions leading to delayed or missed diagnosis. Methods- We performed a retrospective cohort study using statewide administrative claims data from all Emergency Department visits and admissions at nonfederal hospitals in Florida from 2005 to 2015 and New York from 2006 to 2015. Using validated International Classification of Diseases, Ninth Revision, CM codes, we identified adult patients hospitalized for cervicocephalic artery dissection. We defined probable misdiagnosis of dissection as having an Emergency Department treat-and-release visit for symptoms or signs of dissection, including headache, neck pain, and focal neurological deficits in the 14 days before dissection diagnosis. Multivariable logistic regression was used to compare adverse clinical outcomes in patients with and without probable misdiagnosis. Results- Among 7090 patients diagnosed with a dissection (mean age 52.7 years, 44.9% women), 218 (3.1% [95% CI, 2.7%-3.5%]) had a preceding probable Emergency Department misdiagnosis. After adjustment for demographics and vascular risk factors, there were no differences in rates of stroke (odds ratio, 0.82 [95% CI, 0.62-1.09]) or in-hospital death (odds ratio, 0.26 [95% CI, 0.07-1.08]) between dissection patients with and without a probable misdiagnosis at index hospitalization. Conclusions- We found that ≈1 in 30 dissection patients was probably misdiagnosed in the 2 weeks before their diagnosis.

Abstract TP218: Black-Blood MRI; Efficacy in the Diagnosis of Cerebral Arterial Dissection and Changes Over Time

Background: Cerebral arterial dissection is considered a rare disease, but recent advances in diagnostic imaging have increased the likelihood of its diagnosis. In particular, Black-Blood (BB) MRI T1 weighted imaging (BB-MRI) enables the diagnosis of cerebral arterial dissection by reducing the signal in the vascular lumen and detecting a high signal from the hematoma in the false lumen. However, the changes in the hematoma over time are still unknown. In this study, these changes were investigated retrospectively. Methods: This study included patients who were admitted to the Stroke Department of the Japanese Red Cross Okayama Hospital from April 2015 to May 2019 and diagnosed with cerebral arterial dissection at discharge based on the imaging criteria of the spontaneous cervicocephalic arterial dissections study-Japan (SCADS-J). The ratios of the signal intensity from the arterial dissection sites to the signal intensity from the normal blood vessel walls (BB-ratio = dissected vessel wall T1 value/normal vessel wall T1 value) were calculated based on when the B-MRI images were taken. The period from the onset of the disease was analyzed. Results: During this study, 646 acute stroke patients were hospitalized, and cerebral arterial dissection was confirmed at discharge in 16 patients (mean age, 57 years; 14 men) based on the diagnostic imaging criteria of the SCADS-J. For the 12 patients who underwent BB-MRI within 1 week of onset, the BB-ratio increased over the first week and peaked at a median of 10.5 days (1st IQR 8.75-3rd 15.25), with a mean BB-ratio of 3.35 (SD 1.00). Discussion: The signal intensity of the BB-MRI T1 weighted images for intramural hematoma increased 1 week after the onset of cerebral arterial dissection. Therefore, diagnoses must account for the length of time elapsed since disease onset.

Posterior reversible encephalopathy syndrome due to autonomic dysreflexia in medullary infarction

The simultaneous occurrence of cervicocephalic arterial dissection and posterior reversible encephalopathy syndrome (PRES) is a rare entity. A healthy 33-year-old male with no known comorbidities had sudden onset pain in the neck, while he was doing strenuous physical labor. Over the next 2 days, he developed symptoms such as swaying to either side while walking, numbness on the left side of his body, painless progressive bilateral blurring of vision, and drooping of bilateral eyelids. On arrival at the emergency room, he was drowsy with a Glasgow Coma Score of 14 and complained of headache in addition to the preexisting symptoms. He also reported that his entire visual field was clouded and dark. On examination, he was detected to have a blood pressure of 220/120 mmHg with bilateral mild ptosis and nonreactive pupils. He had cortical blindness at the time of admission. He had significant gait and truncal ataxia but no other cerebellar signs. Motor system examination was unremarkable and plantars were flexor. No objective sensory deficit was demonstrable. Magnetic resonance imaging showed acute infarct in the vermis with vertebral artery dissection at V4 extending to the basilar artery. In addition, there were diffuse T2-hyperintensities in the bilateral occipital areas without restricted diffusion suggestive of posterior reversible encephalopathy syndrome [Figure 1]. He was admitted to the intensive care unit; the high blood pressure was treated aggressively with labetalol and hydralazine. Gradually, his vision improved over 48 h and back to normal acuity by 5 days. His magnetic resonance angiography with the neck vessels showed a dissection of the vertebral artery. His symptoms of medullary infarct persisted for a few weeks and then resolved completely. Young brainstem stroke with neck pain points to vertebral artery dissection. Concurrent worsening with autonomic fluctuation can be due to associated PRES and is to be considered as this situation is eminently treatable with good control of blood pressure at the earliest.

Recanalization of cervicocephalic artery dissection.

BACKGROUND AND PURPOSE:While there exists a substantial literature on the risk factors and clinical manifestations of cervical artery dissection (CeAD) including carotid and vertebral artery, little is known about postdissection recanalization. The goal of our study was to provide a descriptive analysis of CeAD and recanalization after dissection with neuroimaging follow up.METHODS:We retrospectively analyzed 51 consecutive patients with confirmed diagnoses of CeAD based on neuroimaging. Demographic data, risk factors, and dissection characteristics were recorded. Neuroimaging studies were performed at 0, 3, 6, and >6 months.RESULTS:Among 51 cases, the mean age of dissection (mean ± standard error) was 49.4 ± 1.92 years, and female comprised 58.8% of the patients. Extent of stenosis was 100% dissection in 37.3%, 51%–99% in 41.2%, and <51% in 21.5%. The most common presenting symptoms were headache (54.9%), neck pain (49.0%), and dizziness/gait imbalance (39.2%). The most common associated risk factors were recent history of trauma to the head and neck (41.2%) and hypertension (41.2%). In follow-up imaging, overall, 47.1% (24/51) had complete recanalization (CR), while 35.3% (18/51) did not; in the former group, 75% (18/24) recanalized completely during the first 6 months following symptom onset. A majority (84.3%) of the patients were discharged home, 15.7% were discharged to a facility, and no mortality was reported. Interestingly, location, type-/nature of dissection, and treatment did not statistically appear to influence the likelihood of recanalization.CONCLUSIONS:The recanalization of CeAD occurs mainly within the first 6 months after symptom onset, following which healing slows down. The study did not find an association between location, pattern, or nature of dissection on artery recanalization.

Recurrent cervicocephalic artery dissection in a patient with Churg-Strauss syndrome treated with long-term corticosteroid therapy

Recurrent cervicocephalic artery dissection in a patient with Churg-Strauss syndrome treated with long-term corticosteroid therapy

Treatment of Extracranial Arterial Dissection: the Roles of Antiplatelet Agents, Anticoagulants, and Stenting.

Cervicocephalic arterial dissection (CeAD) is the most commonly identified cause of stroke in young healthy individuals. The management of acute ischemic stroke due to the diagnosed or suspected CeAD is well established and is appropriate for thrombolysis. There is a substantial risk of stroke recurrence in the early post-stroke period. The optimum method of stroke prevention in the subacute period remains debatable. In our review, we focused on the management of recurrent stroke in CeAD, the choice of various antithrombotic agents for stroke risk reduction with regard to specific pathogenetic mechanisms of dissections, and the utility of endovascular therapy. Recent studies suggest that various pathogenetic types of CeAD based on radiologic characteristics may be associated with greater risk of thrombogenicity, especially in the early post-stroke period. The use of anticoagulants has been shown to be effective in the eliminating microembolic signals (MES) detected by transcranial Doppler (TCD). The only randomized trial that compared combinations of antiplatelet agents and vitamin K-agonist anticoagulation did not find significant difference in risk of stroke, major bleeding, or mortality. The benefit of dual antiplatelet therapy cannot be excluded. Limited data on the use of direct oral anticoagulant agents (DOAC) is currently available. Endovascular therapy with stenting, while potentially effective, may pose significant risk of complications. Therefore, it needs to be carefully considered on a case-to-case basis. The recurrence of ischemic stroke in patients with CeAD is overall rare. No significant difference in treatment with various antiplatelet and anticoagulant agents has been shown in randomized trials. Only a few studies were based on radiological characteristics of dissections. An ongoing randomized trial is investigating the role of MES and the efficacy of antiplatelet versus anticoagulation agents. The role of DOAC agents has yet to be determined in clinical trials. Stenting in CeAD is an effective revascularization technique and may be considered in selected patients. However, current data is only based on low evidence level findings from small studies, lacking longitudinal outcomes and prognosis.

Etiopathogenic Factors of Cerebrovascular Disease in Young Adults: A Review of the Literature

Cerebrovascular disease (CVD) has been studied for many years, representing a cause of high morbidity and mortality; it has a great impact at a social, economic, and psychological level in the young adult population. There are different etiological factors that we do not find in the adult population, for that it is important to know how to differentiate them. There is no definitive etiological factor in this population given that the epidemiologic profile fluctuates considerably throughout regions and provinces, even if the same country is considered to make comparisons. CVD in young adults is caused by many etiological factors, predominantly the rare ones, such as cardioembolic, small vessel disease, due to thrombophilias, and undetermined cause. Despite being the main cause, the undetermined etiology is overestimated because it deserves for a detailed investigation in search of one of the rare causes, also, because of the lack of more complex studies in centers worldwide. No atherosclerotic large vessels diseases, such as cervicocephalic artery dissection, moyamoya disease, systemic vasculitis, and other rare syndromes should be considered to make an accurate diagnosis approach.

IV Thrombolysis for Stroke Due to Cervicocephalic Arterial Dissection: What Is The Right Practice? (P2.3-061)

IV Thrombolysis for Stroke Due to Cervicocephalic Arterial Dissection: What Is The Right Practice? (P2.3-061)

New Warning for the Multiple Sclerosis Drug Alemtuzumab.

The Food and Drug Administration has added a black box warning for alemtuzumab (Lemtrada) stating that the drug, used in the treatment of relapsing multiple sclerosis, may cause ischemic and hemorrhagic stroke and cervicocephalic arterial dissection, rare but serious adverse effects.Nurses should teach patients prescribed this medication to recognize and seek emergency medical care if they develop any signs or symptoms of stroke.

Abstract WP390: Misdiagnosis of Cervicocephalic Artery Dissection in the Emergency Department

Introduction: Cervicocephalic artery dissection is an important cause of stroke, particularly in the young. The initial presentation of cervicocephalic artery dissection can resemble benign neurological conditions resulting in delayed or incorrect diagnosis. We therefore sought to quantify the rate of possible cervicocephalic artery dissection misdiagnosis and to assess the impact of misdiagnosis on patient outcomes in a large heterogeneous cohort. Methods: We performed a retrospective cohort study using administrative claims data from all ED visits and nonfederal hospitalizations in New York, California, and Florida from 2005-2015. Using previously validated ICD-9-CM codes, we identified patients hospitalized with a diagnosis of cervicocephalic artery dissection and no prior stroke diagnosis. Possible misdiagnosis of cervicocephalic artery dissection was defined as having a treat-and-release ED visit for headache, facial pain, neck pain, or Horner syndrome in the 14 days prior to a hospitalization for cervicocephalic artery dissection. Multivariable logistic regression was used to compare adverse clinical outcomes (stroke or death at the time of cervicocephalic artery dissection diagnosis) in patients with and without a possible misdiagnosis. Results: Among 8,874 patients diagnosed with cervicocephalic artery dissection (mean age 52.7 years, 44.1% women), 300 (3.4%; 95% CI, 3.0-3.8%) had a possible ED misdiagnosis. Patients with a possible misdiagnosis of cervicocephalic artery dissection were younger and more often women than those not misdiagnosed. Stroke occurred in 128 (42.7%; 95% CI, 37.0-48.5%) patients with a possible misdiagnosis of dissection and in 3,908 (44.0%; 95% CI, 43.0-45.1%, P =0.63) patients without a possible misdiagnosis of cervicocephalic artery dissection. After adjustment for demographics and vascular risk factors, there were no differences in rates of hospital death (OR 0.48; 95% CI, 0.20-1.9) or stroke (OR 0.94; 95% CI, 0.74-1.2). Conclusion: We found a low rate of possible misdiagnosis of cervicocephalic artery dissection in the ED. Possible misdiagnosis was not associated with stroke or death at the time of subsequent hospitalization for cervicocephalic artery dissection.

Chinese Cervicocephalic artery dissection study (CCADS): rationale and protocol for a multicenter prospective cohort study

BackgroundCervicocephalic artery dissection (CAD) is an important etiology of stroke in the youth. Findings from recent studies suggest it a “group of disease entities” with different underlying etiologies, presentations and prognosis, necessitating an integral study including various types of CAD to get a better understanding of this disease. In addition, Chinese patients with CAD are likely to carry different features from their western counterparts, which remains uncertain yet. Chinese Cervicocephalic Artery Dissection Study (CCADS) therefore aims at exploring the epidemiology, risk factors, clinical/radiological features, diagnosis and prognosis of CAD in Chinese patients.Methods/designCCADS is a multicenter prospective cohort study enrolling patients age ≥ 18 years with recent (<14 days after onset) CAD. Baseline clinical data, laboratory tests and imaging studies are performed within 3 days after admission, and follow-ups will be conducted through face-to-face interviews at discharge, 3 months, 6 months and 12 months after admission, when the modified Rankin Scale (mRS), cerebrovascular events, medication compliance, CAD evolution and so on are evaluated. Additional blood samples will also be collected at baseline, 3 and 12 months follow-up. The primary outcome is radiographic evolution of CAD; secondary outcomes include cerebrovascular events, major bleeding complications, all-cause mortality and functional independence.DiscussionThrough the integration of information on epidemiology, risk factors, clinical/radiological features and prognosis of various types of CAD in Chinese population, combined with the application of advanced imaging techniques, collection of potential blood biomarkers, and assessment of novel treatment strategies. CCADS will provide thorough information on CAD - the major cause of stroke in the youth, and play a role in prevention and treatment determination in the future.

Medical treatment for ischemic stroke due to cervicocephalic arterial dissection

Medical treatment for ischemic stroke due to cervicocephalic arterial dissection

Cervicocephalic arterial dissection

Background: Cervicocephalic arterial dissection (CCA) is common in ischemic strokes in young adult. It is a cause of cerebral or retinal ischemic events, especially when these clinical manifestations are preceded by or associated with focal symptoms.

Cervicocephalic arterial dissection in a Latin-American cohort: Are there any differences throughout the various stages of life? (P6.253)

Cervicocephalic arterial dissection in a Latin-American cohort: Are there any differences throughout the various stages of life? (P6.253)

Cervicocephalic Arterial Dissection

Cervicocephalic arterial dissection is not a common disease (2.5 % of total brain infarction) and its pathogenesis is still not fully understood. However, it seems that it is multifactorial And rarely seen in the postpartum priod.A 40-year-old female patient who referred to emergency department because she experienced right lower limb Paresis 10 days following the delivery and her Paresis was progressed within 72 hours. She has no history of DM ,HTN, preeclampsia and underlying cerebrovascular diseaseOn evaluations, Brain MRI revealed multiple infarction in the left MCA territory . ECG, TTE ,coagulation and rheumatologic tests were normal. leftextracranial carotid artery dissection was found in the cervical MRA.The likelihood of postpartum dissection is rare , But it could be due to vasculardamage associated with the Valsalva maneuver during labor ; hemodynamic and hormonal changes due to pregnancyare also involved.

Added Value of 3D Proton-Density Weighted Images in Diagnosis of Intracranial Arterial Dissection

BackgroundAn early and reliable diagnosis of intracranial arterial dissection is important to reduce the risk of neurological complication. The purpose of this study was to assess the clinical usefulness of three-dimensional high-resolution MRI (3D-HR-MRI) including pre- and post-contrast T1-weighted volumetric isotropic turbo spin echo acquisition with improved motion-sensitized driven equilibrium preparation (3D-iMSDE-T1) and proton-density weighted image (3D-PD) in detecting dissection and to evaluate the added value of 3D-PD in diagnosing intracranial arterial dissection.MethodsWe retrospectively recruited patients who underwent 3D-HR-MRI with clinical suspicion of arterial dissection. Among them, we selected patients who were diagnosed with definite dissection according to the Spontaneous Cervicocephalic Arterial Dissections Study criteria. For each patient, the presence of intimal flap, intramural hematoma, and vessel dilatation were evaluated independently by two neuroradiologists on each sequence. Interobserver agreement was assessed.ResultsSeventeen patients (mean age: 41 ± 10 [SD] years; 13 men) were diagnosed with definite dissection. The intimal flaps were more frequently detected on 3D-PD (88.2%, 15/17) than on 3D-iMSDE-T1 (29.4%, 5/17), and post-contrast 3D-iMSDE-T1 (35.3%, 6/17; P = 0.006 and P = 0.004, respectively). No significant difference was found in the detection rate of intramural hematomas (59–71%) and vascular dilatations (47%) on each sequence. Interobserver agreement for detection of dissection findings showed almost perfect agreement (k = 0.84–1.00), except for detection of intimal flaps on pre-contrast 3D-iMSDE-T1 (k = 0.62). After addition of 3D-PD to pre- and post-contrast 3D-iMSDE-T1, more patients were diagnosed with definite dissection with the initial MRI (88.2% vs. 47.1%; P = 0.039).ConclusionsThe intimal flap might be better visualized on the 3D-PD sequence than the 3D-iMSDE-T1 sequences, allowing diagnosis of definite dissection without follow-up imaging.