Ischemic Stroke In Young People Research Articles

Short-Term and Long-Term Risk of Recurrent Vascular Event by Cause After Ischemic Stroke in Young Adults

Cause of ischemic stroke in young people is highly variable; however, the risk of recurrence is often presented with all subtypes of stroke grouped together in classification systems such as the Trial of ORG (danaparoid sodium [Orgaran]) 10172 in Acute Stroke Treatment (TOAST) criteria, which limits the ability to individually inform young patients with stroke about their risk of recurrence. To determine the short-term and long-term risk of recurrent vascular events after ischemic stroke at a young age by stroke cause and to identify factors associated with recurrence. This cohort study used data from the Observational Dutch Young Symptomatic Stroke Study, a prospective, multicenter, hospital-based cohort study, conducted at 17 hospitals in the Netherlands between 2013 and 2021. Eligible participants included 30-day survivors of an initial, neuroimaging-proven ischemic stroke (aged 18-49 years). Data analysis was conducted from June to July 2023. Diagnosis of a first-ever, ischemic stroke via neuroimaging. The primary outcome was short-term (within 6 months) and long-term (within 5 years) recurrence risk of any vascular event, defined as fatal or nonfatal recurrent ischemic stroke, transient ischemic attack, myocardial infarction, and revascularization procedure. Predefined characteristics were chosen to identify factors associated with risk of recurrence (cause of stroke, age, sex, stroke severity, and cardiovascular health factors). A total of 1216 patients (median [IQR] age, 44.2 [38.4-47.7] years; 632 male [52.0%]; 584 female [48.0%]) were included, with a median (IQR) follow-up of 4.3 (2.6-6.0) years. The 6-month risk of any recurrent ischemic event was 6.7% (95% CI, 5.3%-8.1%), and the 5-year risk was 12.2% (95% CI, 10.2%-14.2%)The short-term risk was highest for patients with cervical artery dissections (13.2%; 95% CI, 7.6%-18.7%). Other factors associated with a recurrent short-term event were atherothrombotic stroke, rare causes of stroke, and hypertension. The long-term cumulative risk was highest for patients with atherothrombotic stroke (22.7%; 95% CI, 10.6%-34.7%) and lowest for patients with cryptogenic stroke (5.8%; 95% CI, 3.0%-8.5%). Cardioembolic stroke was associated with a recurrent long-term event, as were diabetes and alcohol abuse. The findings of this cohort study of 1216 patients with an ischemic stroke at a young age suggest that the risk of recurrent vascular events was high and varied by cause of stroke both for short-term and long-term follow-up, including causes that remained concealed when combined into 1 category in the routinely used TOAST criteria. This knowledge will allow for more personalized counseling of young patients with stroke.

Ischemic stroke on the background of antiphospholipid syndrome(clinical case)

The article presents clinical and paraclinical features and criteria for diagnosis, drug therapy of antiphospholipid syndrome as one of the common causes of ischemic stroke in young people. Criterion and non-criterion diagnostic factors of making a diagnosis were distinguished. In addition, we present a clinical case of ischemic stroke in a young female patient due to a newly diagnosed primary criterion antiphospholipid syndrome, which will allow clinicians to diagnose the pathology more accurately.

Прогнозирование и профилактика ишемического инсульта у лиц молодого возраста в зависимости от генетического полиморфизма с использованием приложения для смартфонов

Введение. Ежегодно заболеваемость ишемическим инсультом в Российской Федерации неуклонно растет, часто поражая лиц трудоспособного возраста. В молодом возрасте традиционные причины инсульта встречаются значительно реже, чем в общей популяции. Группу молодых пациентов, перенесших ишемический инсульт, необходимо обеспечить расширенным медицинским обследованием с включением методов генотипирования, цель которых – разработка персонифицированных мер первичной и вторичной профилактики. Цель работы. Использовать разработанное нами программное обеспечение для мобильных устройств, позволяющее рассчитать риск возникновения ишемического инсульта с учетом генетической предрасположенности пациента, разработать схему профилактики заболевания. Материалы и методы. Проанализированы генетические, клинические и лабораторные результаты обследования 280 человек. Первую группу составили пациенты с ишемическим инсультом (n = 180) в возрасте от 22 до 45 лет (средний возраст – 33,4 ± 6,57 года, в том числе 38 пациентов испытали повторный ишемический инсульт). Вторая группа – пациенты с ишемическим инсультом (n = 50) в возрасте от 52 до 100 лет (средний возраст – 73,4 ± 8,24 года). Группу контроля (третья группа) составили практически здоровые люди (n = 50) в возрасте от 20 до 43 лет (средний возраст – 31,5 ± 5,82 года). Всем пациентам выполняли компьютерную томографию головного мозга, ультразвуковое исследование брахиоцефальных артерий, эхокардиографию. Всем исследуемым однократно выполнены анализы венозной крови на наличие генетической предрасположенности к тромбофилии, фармакогенетические исследования. Результаты. Разработанная программа для операционной системы Android «Прогнозирование и индивидуализированная профилактика ишемического инсульта» внесена в реестр программ для ЭВМ 21 октября 2020 г. под регистрационным номером 2020663019. Программа позволяет рассчитывать риск возникновения ишемического инсульта, а также коэффициент прогнозирования риска его повторного развития в зависимости от полученных анализов ДНК на наличие генетической предрасположенности к сосудистым катастрофам. Применяя свою разработку, мы осуществили новый подход к вторичной профилактике у пациентов, переживших инсульт. Заключение. Использование устройств дистанционного мониторинга может радикально помочь в реализации индивидуально подобранных программ профилактики ишемического инсульта. Генетический паспорт пациента позволит осуществить возможность проведения адекватной патогенетической терапии и профилактику острых нарушений мозгового кровообращения. Background. Every year, the incidence of ischemic stroke (IS) in the Russian Federation is steadily increasing, often affecting people of employable age. At a young age, the typical causes of stroke are much less common than in the general population. A group of young patients suffered from ischemic stroke (IS) needs to be provided with an extended medical examination involving genotyping methods aimed at the development of personalized measures of primary and secondary prevention. Objective. To use our software developed for mobile devices, which allows us to calculate the risk of IS taking into account the genetic predisposition of the patient thereby to develop a scheme for the pathology prevention. Materials and methods. The genetic, clinical and laboratory results of 280 patients examination have been analyzed. Group I consisted of patients with IS (n = 180) aged 22 to 45 years (mean age 33.4 ± 6.57, including 38 patients who experienced recurrent IS. Group II included patients with IS (n = 50) aged 52 to 100 years (mean age 73.4 ± 8.24 years). Group III, the control one, consisted of apparently healthy individuals (n = 50) aged 20 to 43 years (mean age 31.5 ± 5.82 years). All patients underwent computed tomography of the brain, ultrasound examination of the brachiocephalic arteries, and echocardiography. Pharmacogenetic investigations as well as venous blood tests were once performed in all the subjects to reveal a genetic predisposition to thrombophilia. Results. The programme for the Android operating system has been designed which allows calculating the risk of IS development as well as the risk predicting coefficient of the recurrent IS, on the basis of the DNA tests obtained to reveal a genetic predisposition to so called 'vascular catastrophes' (21.10.2020 the programme 'Prediction and individualized prevention of ischemic stroke' was included in the register of computer programmes, registration No. 2020663019). Applying our product, we have implemented a new approach to the secondary prevention in stroke survivors. Conclusion. The use of remote monitoring devices can dramatically help in the implementation of tailor-made IS prevention programmes. The genetic passport of the patient will make it possible to carry out an adequate pathogenetic therapy and prevention of acute cerebral circulation disorders.

Risk factors for stroke recurrence in young patients with first-ever ischemic stroke: A meta-analysis.

At present, the incidence rate of ischemic stroke in young people is increasing yearly, and the age of onset is increasingly young. Therefore, primary and secondary prevention of ischemic stroke in young people, especially secondary prevention, is particularly crucial. We aimed to comprehensively evaluate risk factors for stroke recurrence in first-ever young ischemic stroke (YIS) patients. The meta-analysis was used to quantitatively analyze the research results on risk factors for stroke recurrence in first-ever YIS patients both domestically and internationally. Stata12.0 software was used for heterogeneity testing, publication bias analysis, sensitivity analysis, and the calculation of combined odds ratios and 95% confidence intervals. The odds ratio (OR) values of the relationship between hypertension and hyperlipidemia and recurrence of first-ever YIS were 1.54 (1.05-2.26) and 1.12 (1.00-1.25), respectively. The OR values of male sex, type 2 diabetes, smoking, drinking and YIS recurrence were 1.66 (0.98-2.79), 1.01 (0.64-1.59), 1.21 (0.83-1.76), and 1.28 (0.82-2.53), respectively. The relationship between male sex, type 2 diabetes, smoking, drinking and YIS recurrence was ambiguous. Hypertension and hyperlipidemia are important risk factors for stroke recurrence in first-ever YIS patients, and active intervention should be taken.

The main etiopathogenetic factors, features of the clinical course, diagnosis and treatment of ischemic stroke in young people

This article deals with the topical issue of today — ischemic strokes in young people. Currently, there are more than 150 identified causes of ischemic stroke, the most common of them are antiphospholipid syndrome, Fabry disease, genetic mutations, acquired and congenital thrombophilia, heart defects, a number of infectious agents, comorbid nosologies (migraine), and the use of narcotic agents. Special attention was paid to the monogenic disorders, which begin from an ischemic stroke or in which this type of stroke is one of the leading characteristics. The article shows in detail the characteristic features of each pathology, methods of diagnosis and ways of treatment, which is necessary in the work of a neuropathologist and doctors of other specialties.

Global Burden, Risk Factor Analysis, and Prediction Study of Ischemic Stroke, 1990-2030.

Ischemic stroke (IS), 1 of the 2 main subtypes of stroke, occurs because of brain ischemia caused by thrombosis of a cerebral blood vessel. IS is one of the most important neurovascular causes of death and disability. It is affected by many risk factors, such as smoking and a high body mass index (BMI), which are also critical in the preventive control of other cardiovascular and cerebrovascular diseases. However, there are still few systematic analyses of the current and predicted disease burden and the attributable risk factors of IS. Based on the Global Burden of Disease 2019 database, we used age-standardized mortality rate and disability-adjusted life year to systematically present the geographical distribution and trends of IS disease burden worldwide from 1990 to 2019 by calculating the estimated annual percentage change and to analyze and predict the death number of IS accounted by 7 major risk factors for 2020-2030. Between 1990 and 2019, the global number of IS deaths increased from 2.04 million to 3.29 million and is expected to increase further to 4.90 million by 2030. The downward trend was more pronounced in women, young people, and high sociodemographic index (SDI) regions. At the same time, a study of attributable risk factors of IS found that 2 behavioral factors, smoking and diet in high sodium, and 5 metabolic factors, including high systolic blood pressure, high low-density lipoprotein cholesterol, kidney dysfunction, high fasting plasma glucose, and a high BMI, are major contributors to the increased disease burden of IS now and in the future. Our study provides the first comprehensive summary for the past 30 years and the prediction of the global burden of IS and its attributable risk factors until 2030, providing detailed statistics for decision-making on the prevention and control of IS globally. An inadequate control of the 7 risk factors would lead to an increased disease burden of IS in young people, especially in low SDI regions. Our study identifies high-risk populations and helps public health professionals develop targeted preventive strategies to reduce the global disease burden of IS.

On some pathogenetic mechanisms of ischemic stroke in young people (literature review)

On some pathogenetic mechanisms of ischemic stroke in young people (literature review)

Persistent trigeminal artery: rare cause of ischemic stroke in young people

A young girl, 17-years-old, history of drug addiction, followed for thrombophilia with a right hemiplegia due to a left superficial sylvian infarction for 6 months, hospitalized for etiological exploration. Cerebral magnetic resonance imaging showed a sequela of left frontal ischemia due to occlusion of the superficial branches of the left middle cerebral artery (Figure. 1), with the presence of an artery connecting the basilar trunk and the left internal carotid artery, also called the persistent trigeminal artery (Figure. 2).

Distribution of risk factors of ischemic stroke in Chinese young adults and its correlation with prognosis

BackgroundThe risk factors for ischemic stroke in young people are complex, varied and closely related to prognosis. This study aims to analyze the risk factors for ischemic stroke in Chinese young people and to explore the main factors influencing the prognosis.MethodA total of 444 patients aged 16 to 45 years with ischemic stroke admitted to Suzhou tertiary hospital from 2011 to 2019 were retrospectively analyzed. Risk factors were identified according to the IPSS definition of pediatric stroke and the TOAST classification. All patients were followed up, and the modified Rankin score was used to evaluate the prognosis. Logistic regression analysis was used to explore the influencing factors of poor prognosis.ResultsAmong the patients, 12 risk factors were found according to the IPSS definition of pediatric stroke, and 5 types of stroke were found according to the TOAST classification. A total of 299 patients had a good prognosis. Anemia, venous sinus thrombosis, isolated large-vessel occlusion, and high baseline NIHSS score were significant risk factors.ConclusionThe IPSS definition enables patients to be classified on the basis of more risk factors than other classification methods. The prognosis of ischemic stroke in young people is generally good in the 5 years following the event. Anemia, venous sinus thrombosis, isolated large-vessel occlusion and high baseline NIHSS score were associated with poor prognosis.

Bilateral Internal Carotid Artery Dissection as a Possible Complication in a patient with Covid-19 infections and coughing.

Background:Cervical carotid dissection is one of the causes of ischemic stroke in young people. Most of the patients with carotid dissection do not have connective tissue diseases (Marfan syndrome, Ehlers-Danlos syndrome). It seems that dissection may occur without an obvious cause or may follow environmental injuries like vigorous neck movements, chiropractic manipulation, emesis, severe coughs, and some infections. We present a case of bilateral carotid dissection in a patient following coronavirus infection and severe coughs.Case Presentation:A 38-year-old right-handed man presented with recurrent episodes of transient right hemiparesis and aphasia. He had a history of coronavirus infection and severe persistent, nonproductive cough 7 days before the onset of his symptoms. Carotid angiography showed tapered flame-like appearance in proximal segment of left ICA starting about 2 cm distal to the carotid bulb caused complete occlusion of left ICA and in right CCA angiography there is pseudo aneurysm in right cervical ICA just before the Petrous segment. In 3 months in follow up DSA there is evidence of complete occlusion of right pseudo aneurysm and recanalization of left ICA without stenosis.Conclusion: COVID-19 may have role in the processes that eventually led to CAD

Традиционные и редкие причины ишемического инсульта у лиц 18–50 лет

The article discusses the epidemiological data on the incidence of ischemic stroke (IS) in persons aged 18–50 years, the frequency of various subtypes of IS, depending on the region according to the TOAST classification. Based on recent studies, the frequency of the main traditional risk factors for IS in young people is given, as well as our own data on the frequency of detection of various subtypes of IS on admission and the main risk factors in 145 people aged 18–45 years. The article describes other, moderate causes of stroke at a young age, taking into account modern diagnostic capabilities.

Temporal Trends in the Risk Factors and Clinical Characteristics of Ischemic Stroke in Young Adults

ObjectivesThis study aimed to analyze the risk factors of ischemic stroke in young adults of different ages; explore the changes in these risk factors with time; analyze the clinical characteristics of ischemic stroke in young adults; and assess how to better prevent ischemic stroke in young adults. MethodsAll patients with ischemic stroke who presented to the Department of Emergency Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School were enrolled. The data of patients aged 18–50 years were retrospectively evaluated for two periods, January–December 2008 and January–December 2018. Additionally, we collected the data of patients aged 51–90 years with ischemic stroke in the same ward in 2018. The subjects were divided into three groups: ischemic stroke in young people in 2008 (“Youth 2008”), ischemic stroke in young people in 2018 (“Youth 2018”), and ischemic stroke in elderly people in 2018 (“Senior 2018”). Risk factors, clinical characteristics and test indices were recorded and analyzed statistically. ResultsThe “Youth 2008” group included 28 patients—19 males (67.9%) and 9 females (31.2%) with a male-to-female ratio of 2.11:1. The “Youth 2018” group included 23 patients—20 males (87.0%) and 3 females (13.0%) with a male-to-female ratio of 6.67:1. The “Senior 2018” group included 210 patients—150 males (71.4%) and 60 females (28.6%) with a male-to-female ratio of 2.50:1. The risk factors in “Youth 2018” were higher than those in “Youth 2008” in terms of hypertension, hyperglycemia, and hypercholesterolemia without significant difference. Smoking and hypertrophic cardiomyopathy were significantly increased (P < 0.05) in this population. Smoking, hypercholesterolemia, and hypertrophic cardiomyopathy were more prevalent among the “Youth 2018” group than among the “Senior 2018” group, whereas carotid plaques, hypertension, and atrial fibrillation were less common in the younger group (P < 0.05). There was no significant difference between the younger and older groups in terms of thrombolysis rate, cerebral infarction type, and complications, except pulmonary infections (P < 0.05). ConclusionsThere was no significant change in the main risk factors of ischemic stroke in young adults during the 10-year period. Traditional risk factors—smoking and hypertrophic cardiomyopathy—were still common but with a significantly greater prevalence, whereas carotid plaques, hypertension, and atrial fibrillation had become less common. The clinical characteristics, other than pulmonary infection, were not significantly different between the younger and older patients with ischemic stroke.

Long-term outcome of cervical artery dissection : IPSYS CeAD: study protocol, rationale, and baseline data of an Italian multicenter research collaboration.

Long-term consequences of cervical artery dissection (CeAD), a major cause of ischemic stroke in young people, have been poorly investigated. The Italian Project on Stroke at Young Age - Cervical Artery Dissection (IPSYS CeAD) project is a multicenter, hospital-based, consecutively recruiting, observational, cohort study aimed to address clinically important questions about long-term outcome of CeAD patients, which are not covered by other large-scale registries. Patients with radiologically diagnosed CeAD were consecutively included in the registry. Baseline demographic and clinical variables, as well as information on risk factors, were systematically collected for each eligible patient. Follow-up evaluations were conducted between 3 and 6 months after the initial event (t1) and then annually (t2 at 1 year, t3 at 2 years , and so on), in order to assess outcome events (long-term recurrent CeAD, any fatal/nonfatal ischemic stroke, transient ischemic attack (TIA), or other arterial thrombotic event, and death from any cause). Between 2000 and 2019, data from 1530 patients (age at diagnosis, 47.2 ± 11.5 years; women, 660 [43.1%]) have been collected at 39 Italian neurological centers. Dissection involved a single vessel in 1308 (85.5%) cases and caused brain ischemia in 1303 (85.1%) (190 TIA/1113 ischemic stroke). Longitudinal data are available for 1414 (92.4%) patients (median follow-up time in patients who did not experience recurrent events, 36.0 months [25th to 75th percentile, 63.0]). The collaborative IPSYS CeAD effort will provide novel information on the long-term outcome of CeAD patients. This could allow for tailored treatment approaches based on patients' individual characteristics.

The Incidence of Ischemic Stroke and Its Associated Factors in Young Adults in Kermanshah Over a Seven-Year Period

Background: Cerebrovascular accidents are the most prevalent debilitating neurological disease and the third leading cause of death in the world. Although the incidence of stroke increases with age, its prevalence is growing in the young. Objectives: In the present study the incidence of ischemic stroke and its associated risk factors was investigated in young adults in the city of Kermanshah, Iran over a seven-year period. Methods: The present study was conducted on 122 patients below the age of 45 years who hospitalized with ischemic stroke in the Department of Neurology of Imam Reza Hospital in Kermanshah between 2007 and 2014. Data, including age, gender, history of hypertension, smoking status, the history of heart disease, taking high-risk medications, the history of internal diseases, hyperlipidemia, diabetes mellitus and causes of stroke were recorded in the designed a checklist. Results: The incidence of ischemic stroke had been growing in individuals under the age of 45 years in Kermanshah during 2007 - 2014. The mean and standard deviation of age was 37.33 ± 7.05 years among participants. They included 57 female (46.7%) and 65 males (53.3%). The most prevalent risk factors in the study patients respectively comprised the history of hypertension (30.3%), smoking status (28.7%), the history of heart disease (26.2%), taking high-risk medications (23.8%), the history of internal diseases (22.9%), hyperlipidemia (20.5%) and diabetes mellitus (18.8%). Early atherosclerosis (23.8%) was also found to be the most common cause of ischemic stroke in these patients. Conclusions: There is a considerable increase in the incidence of ischemic stroke in young people. Control of the risk factors, raising public awareness, and changing lifestyle are crucial for preventing cerebrovascular accidents and their associated complications and death.

Should statins be included in standard care following ischemic stroke in young people?

Should statins be included in standard care following ischemic stroke in young people?

Cannabis Use, Ischemic Stroke, and Multifocal Intracranial Vasoconstriction

Our objective was to evaluate the relationship between cannabis use and ischemic stroke in a young adult population. Forty-eight consecutive young patients admitted for acute ischemic stroke participated in the study. First-line screening was performed, including blood tests, cardiovascular investigations, and urine analysis for cannabinoids. If no etiology was found, 3D rotational angiography and cerebrospinal fluid analysis were performed. A control was planned through neurovascular imaging within 3 to 6 months. In this series, there was multifocal intracranial stenosis associated with cannabis use in 21% (n=10). Multifocal angiopathy associated with cannabis consumption could be an important cause of ischemic stroke in young people.

Stroke in Young People: The Increasing Role of Advanced Imaging

Ischemic stroke in young people is an unexpected event due to a wider variety of causes compared to the older population. This study highlights the increasing role of neuroimaging in the diagnosis, prognosis and treatment of young stroke patients. Thirty young adult patients (age range, 15-45 years) with acute ischemic stroke diagnosis were retrospectively included and studied at our institution during 2009. The mean age of patients was 35 years and 50% were men. The stroke etiology was established in 86% of cases (n=26), 7% (n=2) were due to atherosclerosis of the main vessels, 10% (n=3) were related to cardioembolism, 27% (n=8) were due to arterial dissection and 43% (n=13) responded to miscellaneous etiologies. The cause remained unexplained in 14% (n=4) of cases. The aims of neuroimaging in the challenging study of young stroke patients are to confirm the ischemic nature of the lesion, to determine its location, and to verify the patency of major neck and intracranial arteries. Both MRI and MSCT offer the best sensitivity and spatial resolution.

Long-Term Prognosis of Ischemic Stroke in Young Adults

There is limited information about long-term prognosis of ischemic stroke in young adults. Giving the potentially negative impact in physical, social, and emotional aspects of an ischemic stroke in young people, providing early accurate long-term prognostic information is very important in this clinical setting. Moreover, detection of factors associated with bad outcomes (death, recurrence, moderate-to-severe disability) help physicians in optimizing secondary prevention strategies. The present paper reviews the most relevant published information concerning long-term prognosis and predictors of unfavorable outcomes of ischemic stroke affecting young adults. As a summary, we can conclude that, in the long term, stroke in the young adult increases slightly the risk of mortality, implies higher risk of future cardiovascular events, and determines functional limitations in a significant percentage of patients. Nevertheless, in every individual case the prognosis has to be considered depending on several factors (stroke subtype, initial severity, cardiovascular risk factors) that determine the long-term outcomes.

Stroke in young people: imaging.

Stroke in young people is an unexpected event, whose causes are more heterogeneous than in the older population. Moreover, its diagnosis must exclude a large number of other diseases. Thereby, imaging plays an important role in the diagnostic approach of these patients. The aims of the neuroradiological work-up are to confirm that an acute ischemic lesion has occurred, to determine the location and the extent of the lesion, to verify the patency of major neck and intracranial arteries and to exclude eventual underling pathologies. In this sense, MRI offers the best sensitivity and spatial resolution. The more frequent causes of ischemic stroke in young people are considered and the correspondent characteristic imaging aspects are described.

Recurrent spontaneous cervical-artery dissection.

Spontaneous dissection of the internal carotid and vertebral arteries is increasingly recognized as a cause of ischemic stroke in young people. An underlying arteriopathy is often suspected in the pathogenesis of such dissection, but the frequency of recurrent dissection is unknown. We describe the long-term follow-up of 200 consecutive patients (104 women and 96 men) with spontaneous cervical-artery dissections evaluated at the Mayo Clinic between 1970 and 1990. All diagnoses were confirmed by angiography. The mean age of the patients was 44.9 years (range, 16 to 76). Internal carotid arteries were affected in 150 patients, vertebral arteries in 37, and both in 13. Multivessel dissections were present in 28 percent of the patients. The mean follow-up was 7.4 years. Recurrent dissection occurred only in arteries not previously involved by dissection. A recurrent arterial dissection developed in 16 patients (8 percent)--within a month after the initial dissection in 4 patients (2 percent) and between 1.4 and 8.6 years later in 12 patients (a rate of 1 percent per year). The cumulative rate of recurrent dissection among patients followed for 10 years was 11.9 percent. Younger patients had a greater risk of recurrent dissection. Although dissections in multiple cervical vessels are common at presentation, after the first month the risk of recurrent dissection is only about 1 percent per year.