Craniocervical Artery Research Articles

Supported bridge position in one-stop coronary and craniocervical CT angiography: A randomized clinical trial.

The routine patient arm position differs between coronary CT angiography (CTA) and craniocervical CTA protocols. To investigate the clinical feasibility of supported bridge position (SBP) in combined coronary and craniocervical CTA. Prospective enrollment included patients with suspected coronary artery disease (CAD) or craniocervical artery disease (CCAD) from February 2022 to November 2022. Patients were divided into three groups: coronary or craniocervical CTA according to CAD or CCAD using standard position (group 1), combined CTA with naturally arm-down position (group 2) and SBP (group 3). Statistical analysis of objective image quality, such as noise and contrast-to-noise ratio (CNR), subjective image quality, patient position and radiation dose was performed among the three groups. Two hundred and one patients (median age, 67 years; 138 men) were included. In terms of CNR for cardiac segment, group 1 and group 3 had no statistical difference, both significantly higher than group 2 (group 1, 12.56±2.05; group 2, 10.4±2.43; group 3, 11.94±2.22; P<0.05). Subjective image evaluation revealed no statistically significant differences among the three groups of coronary arteries (P>0.05). Additionally, the lateral project value of scout images at the heart level indicated a significant difference (119.48±12.19, 182.34±25.09, and 140.58±19.68 of patients, for group 1, group 2, and group 3, respectively, P<0.05). No statistical differences were observed in between group 1 and group 3 (cardiac scan, 15.77 [15.07-16.37] mGy vs. 14.88 [12.19-18.81] mGy; craniocervical scan, 7.85 [7.69-8.01] mGy vs. 7.88 [7.88-7.89] mGy; all P>0.05). However, group 2 had a higher dose (19.54 [16.86-22.85] mGy and 10.87 [10.86-10.87] mGy, for cardiac and craniocervical scans, respectively). In comparison with a naturally arm-down position, SBP, which aligns the humerus bones with the spinal column, can provide diagnostic image quality at routine dose level of standard position CTA.

Necessary to continue imaging spontaneous cervical artery dissecting pseudoaneurysms after one year?

Background and purposeThe value of long-term serial imaging of dissecting pseudoaneurysm (dPSA) is poorly characterized. This study investigated the long-term radiographic evolution of dPSA. MethodsWe performed a query in our institutional craniocervical artery dissection registry to identify cases with spontaneous dPSA who had at least one year of follow-up with serial angiographic imaging. We performed Wilcoxon rank-sum pairwise comparison test to determine if there was a significant change in the aneurysm size over time. ResultsThis observational cohort study included 76 patients (46 females; 64 dPSA in the internal carotid artery [ICA] and 12 in the vertebral artery [VA]) with a median age of 49.5 years (range 24-77). The initial median dPSA size was 8 mm (interquantile range(iqr) = 5.88-11mm), and the final median dPSA size was 7 mm (iqr = 4-11 mm). Most patients had either no change or reduction in dPSA size in the serial follow-up, with no significant change over time. All the patients had favorable outcomes at the last follow-up, and most patients were symptom-free from dPSA (92 %). Two patients (2.6%) experienced recurrent ischemic strokes in the same territory as the initial ischemic stroke without any change in dPSA size. ConclusionFurther serial scans for dPSA after one year may be deferred in the absence of interim clinical symptoms as most dPSA either remains stable or decreases in size. Recurrent stroke, although a rare event, was not associated with an increase in dPSA size.

Effect of collateral circulation in patients with multiple craniocervical artery stenoses.

Based on previous findings, collateral circulation in the brain is vital in mitigating cerebral ischemia's effects and influencing stroke risk. This retrospective study examined collateral circulation, admission ischemic stroke status, and long-term recurrence in patients with multiple craniocervical artery stenoses. Consecutive symptomatic internal carotid artery (ICA) stenosis patients from the First Affiliated Hospital of Soochow University were recruited. Baseline data including medical histories and neurological function at admission were collected. Imaging techniques assessed collateral compensative capacity. Multivariate logistic regression analysis was used to investigate the association between collateral circulation and case status. A total of 559 patients with symptomatic ICA stenosis were included, among whom 153 (27.4%) had concurrent moderate to severe vertebro-basilar artery (VBA) stenosis. Dizziness, weakness/numbness, and slurring of speech were the primary symptoms in all patients. Over 36 months, 71 (12.7%) patients experienced a recurrence of acute ischemic stroke (AIS). In multivariate analysis, collateral circulation was found to be negatively associated with AIS (regional leptomeningeal collateral [rLMC] scores: OR: 0.798, 95% CI: 0.743-0.857, p < 0.001; Tan scores: OR: 0.478, 95% CI: 0.336-0.679, p < 0.001). Meanwhile, the collateral circulation scores were significantly associated with the recurrence of AIS within 3 years (rLMC scores: OR: 0.926, 95% CI: 0.860-0.997, p = 0.042; Tan scores: OR: 0.467, 95% CI: 0.306-0.712, p < 0.001). Most associations remained significant in the subgroup of patients with VBA stenosis. Favorable collateral circulation in multiple craniocervical artery stenosis patients reduced long-term ischemic event recurrence. Stratifying treatment risks is essential for optimizing outcomes.

Extra-anatomic revascularization and a new cannulation strategy for preoperative cerebral malperfusion due to severe stenosis or occlusion of supra-aortic branch vessels in acute type A aortic dissection

ObjectivesAcute type A aortic dissection (ATAAD) with severe stenosis or occlusion of the true lumen of aortic arch branch vessels often leads to an increased incidence of severe postsurgical neurological complications and mortality rate. In this study, we aimed to introduce our institutional extra-anatomic revascularization and cannulation strategy with improved postoperative outcomes for better management of patients with cerebral malperfusion in the setting of ATAAD. MethodsTwenty-eight patients with ATAAD complicated by severe stenosis or occlusion of the aortic arch branch vessels, as noted on combined computed tomography angiography of the aorta and craniocervical artery, between January 2021 and June 2022 were included in this study. Basic patient characteristics, surgical procedures, hospitalization stays, and early follow-up results were analyzed. ResultsThe median follow-up duration was 16.5 months (interquartile range: 11.5–20.5), with a 100% completion rate. The 30-day mortality rates was 7.1% (2/28 patients); two patients had multiple cerebral infarctions on preoperative computed tomography and persistent coma. Postoperative transient neurological dysfunction occurred in 10.7% (3/28) of the patients, and no new permanent neurological dysfunction occurred. Of all the patients, 3.6% (1/28) had novel acute renal failure. No other deaths, secondary surgeries, or serious complications occurred during the early follow-up period. ConclusionsUse of extra-anatomic revascularization and a new cannulation strategy before cardiopulmonary bypass is safe and feasible and may reduce the high incidence of postoperative neurological complications in patients with ATAAD and cerebral malperfusion.

One-stop combined CT angiography of coronary and craniocervical arteries: recommended as the first examination for patients suspected of coronary or craniocervical artery disease.

To investigate the potential diagnostic value of one-stop combined CT angiography (CTA) as the first examination for patients suspected of coronary artery disease (CAD) or craniocervical artery disease (CCAD), and compare its clinical performance with two consecutive CTA scans. Patients with suspected but unconfirmed CAD or CCAD were prospectively enrolled and grouped randomly to undergo coronary and craniocervical CTA using the combined protocol (group 1) or the consecutive protocol (group 2). Diagnostic findings were evaluated for both the targeted and non-targeted regions. The objective image quality, overall scan time, radiation dose, and contrast medium dosage were compared between the two groups. Each group enrolled 65 patients. A substantial number of lesions were found in non-targeted regions, which was 44/65 (67.7%) by patients for group 1 and 41/65 (63.1%) for group 2, reiterating the necessity of extending the scan coverage. Specifically, lesions in non-targeted regions were detected more often for patients suspected of CCAD than for those suspected of CAD (71.4% vs 61.7%). With 21.5% (~51.1s) reduction of scan time and 21.8% (~20.8mL) less contrast medium as compared to the consecutive protocol, high-quality images were obtained by the combined protocol. One-stop combined CTA enables effective detection of lesions in non-targeted regions at a lower cost of scan time and contrast medium than two separate examinations and is thus worth taking as the first examination for patients suspected of CAD or CCAD. • Extending the scan range for coronary or craniocervical CTA has the potential to reveal lesions in non-targeted regions. • One-stop combined CTA as enabled on high-speed wide-detector CT delivers high-quality images at a lower cost of contrast medium and operational time than two consecutive CTA scans. • Patients with suspected but unconfirmed CAD or CCAD may benefit from the one-stop combined CTA in the first examination.

Retrospective Comparative Analysis of Clinical and Imaging Features of Craniocervical Artery Dissection: Spontaneous CAD vs. Minor Traumatic CAD.

Background and ObjectivesCraniocervical artery dissection (CAD) is the most common cause of ischemic stroke in young adults. The etiologies of CAD can be classified into three types, such as spontaneous (sCAD), minor traumatic (mtCAD), and genetic origin. Recent studies indicated that clinical presentations and imaging features could guide management and inform prognosis. This retrospective analysis sought to compare the clinical and imaging features of sCAD vs. mtCAD in providing evidence-based advice on medical treatment, functional rehabilitation, secondary stroke prevention, and prognosis, ultimately formulating clinical guidelines in managing CAD.MethodsIn total, 148 patients with CAD were identified from the medical records database and subdivided into sCAD and mtCAD based on the clinical presentations and imaging features. A retrospective comparative analysis was performed according to their clinical presentations and imaging features.ResultsPatients with mtCAD are significantly younger than sCAD with 120 cases of sCAD average aged 43.61 ± 12.75, while 28 cases of mtCAD average aged 35.68 ± 14.54. Patients with mtCAD had more cases of neck pain compared to sCAD. Patients with mtCAD had more cases of CAD at extracranial locations compared to sCAD. Patients with mtCAD had more cases of multiple site dissection compared to sCAD. Double lumen and intramural haematoma are the most common imaging findings with mtCAD patients having statistical significantly more cases of intramural haematoma and long tapering stenosis.ConclusionPatients with mtCAD were presented at a much younger age with symptoms of neck pain compared to sCAD. Patients with mtCAD predominantly presented at extracranial sites with more prominent features of multiple site dissection, intramural haematoma, and long tapering stenosis. These clinical and imaging features can translate into clinical practice guidelines for patients with CAD to improve the optimal functional outcome and reduce both morbidity and mortality.

Neutrophil and lymphocyte ratio in craniocervical artery dissection and prognostic correlations of the blood biomarkers

Background &amp; Objective: The aim of this study was to investigate the relationship of neutrophil to lymphocyte ratio (NLR) and other blood cells markers in craniocervical artery dissection patients and the dynamic changes of these biomarkers during the disease course, and effects on prognosis of the patients. Method: Cranial MR imaging, cranial and cervical MR angiography and DSA were examined, and diffusion weighted imaging (DWI) was performed to show the acute lesion(s). Results: Forty-six patients with craniocervical artery dissection were included in this study; they had a mean age of 42 years. Almost 60% of the patients (n=27) were admitted during acute state. Almost 2/3 of cases had extracranial dissection (n=31) and nearly 40% of the patients (n=18) had trauma. Neutrophil to lymphocyte ratio (NLR) was observed to be higher in the acute phase of the disease while the ratio decreased in the chronic phase. Low hemoglobin, high lymphocyte and a high NLR were found to have a negative correlation with the National Institutes of Health Stroke Scale (NIHSS). Conclusion: Elevation of neutrophil was higher in acute craniocervical artery dissection as a marker of acute inflammatory response. High NLR, low hemoglobin and high eosinophil levels were associated with worse prognosis and functional outcomes.

Assessment of association between the carotid web and dissection in spontaneous internal carotid artery dissection patients using vessel wall MRI.

Internal carotid artery dissection (ICAD) is the major cause of ischemic stroke in young to middle-aged people. Recognition of predisposing factors may facilitate in early individual risk prediction and expand treatment. To evaluate the association between a carotid web and dissection in patients with ICAD using vessel wall magnetic resonance imaging (VW-MRI). A retrospective study was conducted of 223 patients who underwent VW-MRI. Of these patients, 58 patients with craniocervical artery dissection (CCAD) (33 ICAD and 25 vertebrobasilar artery dissection [VBAD]) were included. The control group (n = 165) consisted of patients without arterial dissection who had undergone VW-MRI . The presence of a carotid web in the posterior aspect of carotid bulb was recorded. The distance between the carotid web and start of dissection in ICA was recorded. The presence of a carotid web showed a significant difference between the ICAD, VBAD, and control groups (19 [57.6%] vs. 5 [20%] vs. 36 [21.8%], respectively; P < 0.001). In multi-nominal analysis, the presence of a carotid web showed a significant difference between the ICAD and VBAD groups and the ICAD and control groups (P < 0.05), with odds ratios of 5.41 (95% confidence interval [CI]=1.634-17.973) and 4.81 (95% CI=2.176-10.651), respectively. Out of 19 ICAD patients with carotid web, 16 had occurrence of dissection in the C1 segment of the ICA with a mean distance of 1.91 ± 1.71 cm from the carotid web. Presence of a carotid web was more frequent in patients with ICAD. The carotid web may be one of the predisposing factors for development of dissection in patients with ICAD.

Stenting as a treatment for cranio-cervical artery dissection: Improved major adverse cardiovascular event-free survival.

Cranio-cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement. COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥ 18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1year evaluating MACE as the primary endpoint. One-hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including sneezing, carrying heavy load, chiropractic manipulation. Stent was placed in 10 (10%) subjects (extracranial carotid n=9; intracranial carotid n=1; extracranial vertebral n=1) at the physician's discretion along with medical management. Reasons for stent placement were early development of high-grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in-hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year. In this single high-volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high-grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

Colchicine for prevention of vascular inflammation in Non-CardioEmbolic stroke (CONVINCE) - study protocol for a randomised controlled trial.

Inflammation contributes to unstable atherosclerotic plaque and stroke. In randomised trials in patients with coronary disease, canukinumab (an interleukin-1B antagonist) and colchicine (a tubulin inhibitor with pleiotropic anti-inflammatory effects) reduced recurrent vascular events.Hypothesis: Anti-inflammatory therapy with low-dose colchicine plus usual care will reduce recurrent vascular events in patients with non-severe, non-cardioembolic stroke and TIA compared with usual care alone. CONVINCE is a multi-centre international (in 17 countries) Prospective, Randomised Open-label, Blinded-Endpoint assessment (PROBE) controlled Phase 3 clinical trial in 3154 participants. The intervention is colchicine 0.5 mg/day and usual care versus usual care alone (antiplatelet, lipid-lowering, antihypertensive treatment, lifestyle advice). Included patients are at least 40 years, with non-severe ischaemic stroke (modified Rankin score ≤3) or high-risk TIA (ABCD2 > 3, or positive DWI, or cranio-cervical artery stenosis) within 72 hours-28 days of randomisation, with qualifying stroke/TIA most likely caused by large artery stenosis, lacunar disease, or cryptogenic embolism. Exclusions are stroke/TIA caused by cardio-embolism or other defined cause (e.g. dissection), contra-indication to colchicine (including potential drug interactions), or incapacity for participation in a clinical trial. The anticipated median follow-up will be 36 months. The primary analysis will be by intention-to-treat. The primary outcome is time to first recurrent ischaemic stroke, myocardial infarction, cardiac arrest, or hospitalisation with unstable angina (non-fatal or fatal). CONVINCE will provide high-quality randomised data on the efficacy and safety of anti-inflammatory therapy with colchicine for secondary prevention after stroke. First-patient first-visit was December 2016. Recruitment to complete in 2021, follow-up to complete in 2023.

The Added Value of Vessel Wall MRI in the Detection of Intraluminal Thrombus in Patients Suspected of Craniocervical Artery Dissection.

Patients with craniocervical artery dissection (CCAD) have a high short-term risk of ischemic stroke, which is frequently associated with thromboembolism. Previous studies have demonstrated the utility of three-dimensional vessel wall MR imaging (3D-VWMRI) in the diagnosis of dissection. Few have investigated the value of 3D-VWMRI in the detection of intraluminal thrombus. The purpose of the current study was to evaluate the added value of 3D-VWMRI for thrombus identification in patients suspected of CCAD. One hundred and four patients (mean age, 44.2 years ± 13.2) suspected of CCAD and scheduled for digital subtraction angiography (DSA) were prospectively enrolled in the study and underwent VWMRI examination. The diagnostic performance of 3D-VWMRI for CCAD was evaluated using receiver operating characteristic (ROC) analysis with the final diagnosis results as the reference. The presence/absence of intraluminal thrombus on 3D-VWMRI/DSA was independently determined. The sensitivity and specificity of 3D-VWMRI for intraluminal thrombus detection were assessed with DSA serving as the reference. The odds ratio (OR) was used to evaluate the correlation between thrombus presented on 3D-VWMRI/DSA and ischemic stroke. The 3D-VWMRI had high sensitivity (90.0%) and specificity (94.3%) in identifying arteries with CCAD. The area under the ROC curve was 0.96. With DSA as the reference, the sensitivity and accuracy of 3D-VWMRI for the detection of intraluminal thrombus were 97.4% and 79.0%, respectively. An intraluminal thrombus present on 3D-VWMRI was strongly associated with a territorial ischemic stroke (OR: 30.0; 95% confidence interval: 9.1-98.4; P < .001). In conclusion, 3D-VWMRI with a 3.0-T MR system had a high diagnostic performance for CCAD and offered added value for detecting intraluminal thrombus.

Early Anticoagulation or Antiplatelet Therapy Is Critical in Craniocervical Artery Dissection: Results from the COMPASS Registry

Introduction: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young patient population. Recent studies reported a low rate of major adverse cardiac events (MACEs) in patients with CeAD, with no significant difference between patients randomized to anticoagulation or antiplatelet therapy. Objective: To compare the effectiveness of anticoagulation and antiplatelet therapy in patients with CeAD. Methods: All CeAD patients from 2015 to 2017 were consecutively identified by an electronic medical record-based application and enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE defined as stroke, transient ischemic attack (TIA), or death. Results: The cohort included 111 CeAD patients (age 53 ± 15.9 years, 56% Caucasian, 50% female). CeAD was detected by magnetic resonance (5%), computed tomography (88%), or catheter angiography (7%). CeAD was noted in the carotid (59%), vertebral (39%), and basilar (2%) arteries, 82% of which were extracranial dissections. CeAD was classified as grade I, II, III, and IV in 16, 33, 19, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%) of patients, including violent sneezing (21%), carrying a heavy load (19%), sports/recreational activity (11%), chiropractic manipulation (9%), abrupt/prolonged rotation of head (9%), and prolonged phone use (9%). At presentation, 41% had a stroke, 5% had TIA, 39% had headache, and 36% were asymptomatic. Favorable outcome defined as a modified Rankin Scale score of 0–2 was noted in 68% at 3 months and 71% at 12 months. The rate of MACEs at 3 and 12 months was 11 and 14%, respectively, with more events observed in patients who were not receiving anticoagulation/antiplatelet therapy due to contraindications (p = 0.008). Conclusions: We report diagnostic characteristics, as well as short- and long-term outcomes of CeAD. A high MACE rate was observed within the first 2 weeks of CeAD diagnosis, notably in patients not initiated on anticoagulation or antiplatelet therapy.

Abstract TP125: Stent as a Treatment for Cranio-Cervical Artery Dissection: Improved Major Adverse Cardiovascular Events-Free Survival

Introduction: Cranio-Cervical Artery Dissection (CeAD) is a relatively common cause of cerebrovascular event in young subjects for which no clear treatment strategy is established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement. Methods: COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center prospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1-year evaluating MACE as the primary end-point. Results: One-hundred eleven patients were enrolled (age 53 ± 15.9, 56% Caucasian, 50% male, BMI 28.9 ± 9.2). Grade 1, 2, 3, and 4 blunt vascular injury noted in 16%, 33%, 19%, and 32%, respectively. Forty-percent of dissections were due to known trauma. A predisposing factor was noted in the majority (78%), including violent sneezing, carrying heavy load, sports/recreation activity, chiropractic manipulation, and abrupt/prolonged head rotation. Stent was placed in 11 (10%) subjects (extracranial carotid n=8; intracranial carotid n=2; extracranial vertebral n=2) at the physician’s discretion. Similar to the CADISS trial, there was no significant difference between antiplatelet/anticoagulant groups in terms of MACE. Stented patients experienced fewer MACE than non-stented patients (log rank p=0.1), as depicted in the Kaplan-Meier curve (Figure 1). The CeAD patients with stents did not experience any MACE events in the 1-year follow-up. Conclusion: In this single high-volume center cohort of CeAD patients, we report a promising strategy of MACE prevention using stent placement. This data will help sample size estimation for a future randomized trial.

Posttraumatic cerebrovascular injuries in children. A systematic review.

Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner. We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019. After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF's and TA's, and data from randomized controlled trials is lacking. While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children.

Abstract 99: Early Anticoagulation or Antiplatelet Therapy is Critical in Cranio-Cervical Artery Dissection: Results From the COMPASS Registry

Introduction: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young. Recent studies reported a low rate of major adverse cardiac events (MACE) in patients with CeAD, with no significant difference between patients randomized to antiplatelet or anticoagulation. Methods: All patients from 2015-2017 consecutively identified by an electronic medical record-based application were enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE (stroke/transient ischemic attack [TIA]/death). Results: The cohort included 111 CeAD patients, (age 53 ±15.9 years, 56% white, 50% female) detected by magnetic resonance (5%), computed tomography (88%) and catheter (7%) angiography. CeAD was noted in the carotid (66%), vertebral (42%) and basilar (2%) arteries, with 83% of them being extracranial. CeAD was classified as grade 1, 2, 3 and 4 in 16%, 33%, 19%, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%), including 21% violent sneezing, 19% carrying heavy load, 11% sports/recreation activity, 9% chiropractic manipulation, 9% abrupt/prolonged rotation of head, and 9% prolonged phone use. At presentation, 41% had stroke, 39% had headache, 5% had TIA, and 15% were asymptomatic. Favorable outcome defined as modified Rankin score of 0-2 was noted in 68% at 3 months and 71% at 12 months. Rate of MACE was 14%, with more events observed in patients not on antiplatelet/anticoagulant therapy due to contraindications (p=0.008, Fig 1). Conclusions: We report diagnostic characteristics and short- and long-term outcomes of CeAD. A high MACE rate was observed within the first week of CeAD diagnosis, especially in patients not initiated on antiplatelet/anticoagulant therapy.

Abstract WP548: Incidence and Prevalence of Headache in Cranio-Cervical Artery Dissection Patients

Introduction: Spontaneous craniocervical artery dissection (CeAD) occurs commonly in healthy individuals without known risk factors for stroke, whereas traumatic CeAD varies widely from penetrating trauma to motor vehicle crashes to minor movements of the neck. Headache (HA) and cervical pain occur in up to 75% of patients with CeAD. Yet, there are limited data on the incidence of new HA in CeAD patients after diagnosis. Methods: All patients from January 2015 to May 2017 consecutively identified by an electronic medical record-based application were enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging during acute hospital visits. Patients were consented and followed for 12 months for HA status and HA Impact Test-6 (HIT-6) score (little to no impact: 49 or less, some impact: 50-55, substantial impact: 56-59, severe impact 60+). Results: The cohort included 111 CeAD patients (age 53 ± 15.9 years, 56% Caucasian, 50% female). Prevalence of reported HA at baseline was 40% (n=44) of enrolled patients; yet, there was no reportable difference between HA and no HA based on dissection location (carotid n=62; vertebral n=41; or basilar n=2; p=0.445). At baseline, 43% of patients categorized their HA as severely impacting their lives based on HIT-6. At the 3-month follow up, there was an incidence of 16% (n=11) who now reported HA but had no HA at baseline. At 3 months, 57% of patients categorized their HA as severely impacting on their life. At the 12-month follow up, there was an incidence of 7% (n=4) who now reported HA but no previous HA at baseline or 3 months. At 12 months, 58% of patients were classified into the severe impact category determined using HIT-6 calculations. HA status was not found to be associated with stroke or traumatic brain injury from CeAD (p = non-significant). Conclusions: We report the incidence and prevalence of HA within the CeAD population over a 12-month period. A high prevalence level was observed (40%) within the baseline history of CeAD diagnosis, with incremental incidence of new HA (16% and 7%) reported at 3 months and 12 months, respectively. There was no association found between HA status and stroke, dissection location or traumatic brain injury.

Extracranial and intracranial artery dissections: Experiences from a tertiary referral center

Background:&#x0D; Craniocervical artery dissection is an important cause of ischemic stroke&#x0D; especially in young and middle aged adults. In this study, we evaluated&#x0D; extracrainal and intracranial artery dissections in terms of etiologies, risk&#x0D; factors, stroke severity and functional outcomes. &#x0D; &#x0D; Methods: A&#x0D; total of 29 patients who were diagnosed with ischemic stroke due to&#x0D; extracranial or intracranial artery dissections were enrolled to this study.&#x0D; The ischemic stroke diagnosis was confirmed with diffusion weighted magnetic&#x0D; resonance imaging in all patients. Computed tomography angiography, magnetic&#x0D; resonance angiography and digital subtraction angiography were used to&#x0D; demonstrate the dissection. Demographic findings, risk factors and presence of&#x0D; trauma were evaluated. National Institute of Health Score Scale (NIHSS) was&#x0D; used for stroke severity assessment at disease onset. Functional outcomes were&#x0D; measured with Modified Rankin Scale (mRS) at the 3rd month. &#x0D; &#x0D; Results:&#x0D; Fifteen patients (51.72%) had carotid artery dissections while 12 patients&#x0D; (41.37%) had vertebral artery dissection (VAD), 1 (3.4%) had basilar artery&#x0D; dissection (BAD) and both VAD and BAD were seen in 1 patient (3.4%).&#x0D; Coagulopathy was detected in 12 patients (41.37%). Connective tissue disease&#x0D; was suspected in 3 patients (10.3%). In 6 patients, dissections occured after&#x0D; trauma. Nineteen patients (65.51%) presented with somatosensory deficits. The&#x0D; 3rd month mRS scores were in the range of 0-2 and no significant correlation&#x0D; was found in terms of risk factors, etiology and trauma history.&#x0D; &#x0D; Conclusion:&#x0D; Arterial dissection should be kept in mind for the clinical presentation of&#x0D; ischemic stroke in young adults. We think that better understanding of the risk&#x0D; factors, etiologies and clinical presentation of the dissections and early&#x0D; diagnosis-proper treatments might yield improved clinical outcomes.

Imaging-Based Diagnosis of Craniocervical Artery Dissections: A Strategy Focusing on the Pathological Condition and MRI Technique

Magnetic resonance imaging (MRI) is a non-invasive and useful imaging modality with a high contrast resolution to diagnose craniocervical artery dissections. However, to avoid misinterpretations and misdiagnosis, it is mandatory to understand not only the pathological condition of craniocervical artery dissection, but also the principles of MRI techniques. In this manuscript, the details of MRI findings, especially when using high-resolution vessel wall imaging, are discussed.

Stent-Retriever Thrombectomy Across Circle of Willis

Endovascular thrombectomy has become the gold standard for acute ischemic stroke intervention in appropriate patients. Occasionally, thrombectomy through the standard craniocervical artery related to the affected territory is not technically feasible due to patient-specific anatomic issues. This is a retrospective review of cases where intracranial access was achieved via an unaffected circulation across the Circle of Willis. A technically successful thrombectomy is described in detail in 3 cases along with technical challenges encountered. Thrombectomy across the Circle of Willis is a potential bailout technique for select, complex cases. Further investigation is warranted.

Combined CT angiography of the aorta and craniocervical artery: a new imaging protocol for assessment of acute type A aortic dissection.

To investigate the feasibility of combined computed tomography angiography (CTA) of the aorta and craniocervical artery in acute type A aortic dissection (ATAAD) and the value of incremental craniocervical information. Combined CTA of head, neck and aorta was performed in patients with suspected aortic dissection and 243 ATAAD patients were analyzed. The image quality and radiation dose were assessed. Valuable craniocervical CTA findings were determined for further surgical analysis. The mean dose-length product (DLP) was 314.11±29.31 mGy.cm. The image quality of craniocervical arteries were 100% diagnostic. Intimal flap involving carotid arteries was detected in 47% of patients, and significant stenosis of true lumen was observed in 60% of common carotid arteries (CCAs). Hypodensity and hypoplasia/occlusion of carotid arteries were also detected and apprised surgeons. The tortuosity of carotid artery was found in 90.9% of patients. Bilateral antegrade selective cerebral perfusion (ASCP) was performed in 21.1% of aortic arch surgery based on 7 hemodynamic variation types of the circle of Willis (CW) determined by cranial CTA information. A combined CTA of head, neck and aorta is feasible with low radiation dose and diagnostic image quality. Incremental information on craniocervical pathology and anatomy may be useful for surgery repair of ATAAD.