Multiple Cervical Artery Dissections Research Articles

Spontaneous Multiple Cervical Artery Dissections and Recurrent Deep Vein Thrombosis in a Young Adult.

Spontaneous Multiple Cervical Artery Dissections and Recurrent Deep Vein Thrombosis in a Young Adult.

Immunological mechanisms in multiple spontaneous cervical artery dissection: An illustrative case and review of the literature

Dissection of the cervical arteries is the leading cause of stroke in young adults, yet the etiology and pathogenesis of this event remain unclear. However, a growing number of data in the literature support the potential implications of immunological mechanisms in the pathogenesis. Several large patient groups and multicentre cohorts have reported significant associations with recent infections and elevated inflammatory markers. There are also several case reports and case series suggesting an association with various autoimmune disorders and viral infections. Some case reports have also detailed cervical artery dissections linked to the use of biological therapies for other pathologies. In the present case, a 38-year-old female patient with triple spontaneous cervical artery dissection presented multiple potential trigger factors as recent infection, autoimmune thyroid disease, primary thrombophilia and hyperhomocysteinemia. This report sought first presents this case, and then reviews the existing relevant literature data regarding the potential immunological mechanisms implicated in the pathogenesis of cervical artery dissection.

Determinants and outcome of multiple and early recurrent cervical artery dissections.

To assess putative risk factors and outcome of multiple and early recurrent cervical artery dissection (CeAD). We combined data from 2 multicenter cohorts and compared patients with multiple CeAD at initial diagnosis, early recurrent CeAD within 3 to 6 months, and single nonrecurrent CeAD. Putative risk factors, clinical characteristics, functional outcome, and risk of recurrent ischemic events were assessed. Of 1,958 patients with CeAD (mean ± SD age 44.3 ± 10 years, 43.9% women), 1,588 (81.1%) had single nonrecurrent CeAD, 340 (17.4%) had multiple CeAD, and 30 (1.5%) presented with single CeAD at admission and had early recurrent CeAD. Patients with multiple or early recurrent CeAD did not significantly differ with respect to putative risk factors, clinical presentation, and outcome. In multivariable analyses, patients with multiple or early recurrent CeAD more often had recent infection (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.29-2.53), vertebral artery dissection (OR 1.82, 95% CI 1.34-2.46), family history of stroke (OR 1.55, 95% CI 1.06-2.25), cervical pain (OR 1.36, 95% CI 1.01-1.84), and subarachnoid hemorrhage (OR 2.85, 95% CI 1.01-8.04) at initial presentation compared to patients with single nonrecurrent CeAD. Patients with multiple or early recurrent CeAD also had a higher incidence of cerebral ischemia (hazard ratio 2.77, 95% CI 1.49-5.14) at 3 to 6 months but no difference in functional outcome compared to patients with single nonrecurrent CeAD. Patients with multiple and early recurrent CeAD share similar risk factors, clinical characteristics, and functional outcome. Compared to patients with single nonrecurrent CeAD, they are more likely to have recurrent cerebral ischemia at 3 to 6 months, possibly reflecting an underlying transient vasculopathy.

A case report of multiple cervical artery dissection after peripheral type facial palsy and use of steroids

BackgroundCervical artery dissection is one of the most important causes of ischemic stroke in young age patients. However, multiple cervical artery dissection simultaneously involving the anterior and posterior circulation is uncommon. Here, we would like to report a case of a patient with bilateral vertebral artery (VA) and internal carotid artery dissection (ICA) after a use of systemic steroid due to peripheral facial palsy.Case presentationA 44-year-old man with hypertension visited emergency department due to recurrent vertigo. He was receiving methyl prednisolone for two weeks for the treatment of right peripheral type facial palsy which occurred after retro-orbital headache. Neurologic examination revealed severe ataxia at left side. Sensory for pain and temperature was declined in the right arm and leg. Diffusion-weighted image showed an acute ischemic lesion at the whole territory of posterior-inferior cerebellar artery. Severe stenosis was observed from bilateral VAs and ICAs on conventional magnetic resonance angiography. Intramural hematoma and intimal flap was observed from the high-resolution MRI.ConclusionsPeripheral type facial palsy is an unusual presentation of carotid dissection. Steroids aggravate arterial dissection by increasing blood pressure and blood vessel fragility by its negative effect on connective tissue strength. Use of steroid in patients with peripheral type facial palsy with severe headache may need caution.

Letter by Gallerini et al Regarding Article, “Characteristics and Outcomes of Patients With Multiple Cervical Artery Dissection”

We read with great interest the study of Bejot et al1 evaluating the characteristics and outcomes of patients with single and multiple cervical artery dissection (CeAD). In particular, good outcome (with only 12% of moderate-to-severe handicap at 3 months and none had died) was observed irrespectively of single or multiple vessel involvement. As major ischemic stroke because of artery-to-artery embolism is reasonably the main cause of disability in such patients and its prevention with antithrombothic therapy is considered effective,2 early diagnosis of dissection plays a key role to administer proper therapy, to prevent major stroke, and to reduce long-term disability. Thus an efficient …

Characteristics and Outcomes of Patients With Multiple Cervical Artery Dissection

Little is known about factors contributing to multiple rather than single cervical artery dissections (CeAD) and their associated prognosis. We compared the baseline characteristics and short-term outcome of patients with multiple to single CeAD included in the multicenter Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) study. Among the 983 patients with CeAD, 149 (15.2%) presented with multiple CeAD. Multiple CeADs were more often associated with cervical pain at admission (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.10-2.30), a remote history of head or neck surgery (OR, 1.87; 95% CI, 1.16-3.00), a recent infection (OR, 1.71; 95% CI, 1.12-2.61), and cervical manipulation (OR, 2.23; 95% CI, 1.26-3.95). On imaging, cervical fibromuscular dysplasia (OR, 3.97; 95% CI, 2.04-7.74) and the presence of a pseudoaneurysm (OR, 2.91; 95% CI, 1.86-4.57) were more often seen in patients with multiple CeAD. The presence of multiple rather than single CeAD had no effect on functional 3-month outcome (modified Rankin Scale score, ≥3; 12% in multiple CeAD versus 11.9% in single CeAD; OR, 1.20; 95% CI, 0.60-2.41). In the largest published series of patients with CeAD, we highlighted significant differences between multiple and single artery involvement. Features suggestive of an underlying vasculopathy (fibromuscular dysplasia) and environmental triggers (recent infection, cervical manipulation, and a remote history of head or neck surgery) were preferentially associated with multiple CeAD.

Predictors of Delayed Stroke in Patients with Cervical Artery Dissection

Stroke in patients with acute cervical artery dissection may be anticipated by initial transient ischemic or nonischemic symptoms. Identifying risk factors for delayed stroke upon cervical artery dissection. Cervical artery dissection patients from the multicenter Cervical Artery Dissection and Ischemic Stroke Patients study were classified as patients without stroke (n = 339), with stroke preceded by nonstroke symptoms (delayed stroke, n = 244), and with stroke at onset (n = 382). Demographics, clinical, and vascular findings were compared between the three groups. Patients with delayed stroke were more likely to present with occlusive cervical artery dissection (P < 0.001), multiple cervical artery dissection (P = 0.031), and vertebral artery dissection (P < 0.001) than patients without stroke. No differences were observed in age, smoking, arterial hypertension, hypercholesterolemia, migraine, body mass index, infections during the last week, and trauma during the last month, but patients with delayed stroke had less often transient ischemic attack (P < 0.001) and local signs (Horner syndrome and cranial nerve palsy; P < 0.001). Occlusive cervical artery dissection, multiple cervical artery dissection, and vertebral artery dissection were associated with an increased risk for delayed stroke. No other risk factors for delayed stroke were identified. Immediate cervical imaging of cervical artery dissection patients without ischemic stroke is needed to identify patients at increased risk for delayed ischemia.

Pneumococcal Meningitis, Cerebral Venous Thrombosis, and Cervical Arterial Dissection

Pneumococcal meningitis in adults is widely associated with intracranial complications, which occur in up to 74.7% of the patients. Case report. We report the case of a 40-year-old white female with pneumococcal meningitis after a sinus surgery, who developed a concomitant cerebral venous thrombosis and multiple cervical artery dissections. Following treatment with antibiotics and intravenous heparin, she had complete neurological recovery. Vascular complications should always be remembered and adequately treated in patients with bacterial meningitis. Cervical arterial dissections should be investigated as potential embolic sources of intracranial ischemic lesions.

Multiple Cervical Artery Dissection in a Volleyball Player

Multiple Cervical Artery Dissection in a Volleyball Player

Vasomotion in Multiple Spontaneous Cervical Artery Dissections

The etiology of spontaneous cervical artery dissection (sCAD) is still unknown, even though an underlying arteriopathy impairing vasomotion has often been suspected. This study was undertaken to investigate: (1) spontaneous, (2) endothelial-dependent, and (3) endothelial-independent vasodilation in patients with multiple sCAD. In 19 consecutive patients with multiple carotid or vertebral artery dissections high-resolution ultrasound was used to assess spontaneous and endothelial-independent dilations (isosorbide dinitrate-mediated) in the common carotid, vertebral and brachial arteries, and endothelial-dependent dilation (flow-mediated arterial dilation) in the brachial arteries alone. The same parameters were measured in 19 healthy subjects matched for age, sex, and height (controls). Ultrasound studies were performed by one investigator, and off-line analysis by another investigator who was blinded to the clinical data and study status (patient or control). Spontaneous and endothelial-independent dilations were significantly impaired in the carotid (P=0.0006 and P<0.0001, respectively) and vertebral arteries (P=0.0121 and P=0.0047, respectively) of patients as compared with controls, whereas no statistically significant differences were found in the brachial arteries; conversely, endothelial-dependent dilation of the brachial arteries was significantly lower in patients as compared with controls (P<0.0001). Patients with multiple sCADs have a significantly impaired vasomotion, which may predispose to dissection.

Familial Cervical Artery Dissections

Genetic risk factors are thought to play a role in the etiology of spontaneous cervical artery dissections (CAD). However, familial CAD is extremely rare. In this study we analyzed patients with familial CAD and asked the question whether familial CAD has particular features. Seven families with 15 CAD patients were recruited. All patients were carefully investigated by a neurologist, a neuroradiologist, and a dermatologist for clinical characteristics. From 11 patients a skin biopsy was performed to study the morphology of the connective tissue and to analyze the coding sequences of COL3A1, COL5A1, COL5A2, and part of COL1A1. The mean age of the patients (n=15, 9 women) at their first dissection was 36.2 years (median age 32 years, range 18 to 59). Two patients had bilateral CAD. One patient had a right and a left internal carotid artery dissection in successive weeks, another patient had 5 dissections over a period of 8 years. A high intrafamilial correlation was found between the affected vessels (ie, the carotid and the vertebral arteries) and between ages at the first dissection. In 1 patient we found clear and reproducible ultrastructural abnormalities in the skin biopsy, but the second patient from the family was not studied, because he died as a result of CAD before this study. The dermal connective tissue aberrations in the examined patient were similar to mild findings in patients with vascular Ehlers-Danlos syndrome (EDS type IV), but might be iatrogenic and related to long-term corticosteroid inhalation therapy. All other analyzed patients showed normal connective tissue morphology. In patients from 6 families we analyzed the whole coding sequence of COL3A1, COL5A1, and COL5A2, and from part of COL1A1. A missense mutation in the COL3A1 gene (leading to a G157S substitution in type III procollagen) was detected in both patients from 1e family. Two patients from another family carried a rare nonsynonymous coding polymorphism in COL5A1 (D192N); 1 of them carried also a rare variant in COL5A2 (T12337). Familial CAD patients are young and probably are at high risk for recurrent or multiple CAD. Ultrastructural alterations of the dermal connective tissue might not be an important risk factor for familial CAD. However, the finding of a COL3A1 mutation revealed the presence of an inherited connective tissue disorder in 1 family.

Spontaneous cervical artery dissection

Cervical artery dissection (CAD) is now recognized as an important arterial cause of ischemic stroke in younger patients. Data concerning epidemiology, specific risk factors, and pathogenesis are accumulating but there are still no large-scale, prospective, population-based studies. Long-term follow-up and data estimating risk of recurrent CAD are needed.1–5 In this issue of Neurology , Arnold et al.6 report the results of the largest, multicenter analysis of CAD to date. Sex differences in CAD were correlated with clinical and prognostic variables. Arnold et al. found a preponderance of men; however, women were 5 years younger when CAD occurred and more often had multiple CAD. These findings are consistent with most earlier studies.1–4 In a study of 200 patients, Schievink et al.1 …

The ICAM-1 E469K polymorphism is a risk factor for multiple cervical artery dissections

Aims: Intercellular adhesion molecule 1 (ICAM-1) contributes to the inflammatory response by promoting adhesion between white blood cells and endothelial cells. The 469K allele of ICAM-1 encodes an alternatively spliced short isoform (ICAM-1-S) with modified inflammatory immune response. Longoni et al. recently found a genetic association between ICAM 469K and cervical artery dissections (CAD).

Multiple cervical artery dissections

A 49-year-old man with a history of bilateral vertebral artery dissections (figure, A) presented with a left internal capsular infarct. A new left internal carotid artery dissection was found on angiography (figure, B, C). There were no findings of connective …

Spontaneous multiple cervical artery dissection: two case reports and a review of the literature

Although spontaneous cervical artery dissection (CAD) is an uncommon cause of stroke in the general population, it accounts for 10–25% of cerebrovascular events in young to middle-aged patients. Two or more vessels are involved in fewer than 15% of dissections, but multiple spontaneous CADs are likely to be underestimated owing to frequent spontaneous recanalization and the possible oligo-symptomatic presentation. An extensive review of the literature shows that in the last 30 years only 28 cases of multiple CADs have been reported, and that in half of these patients symptoms were minor and transient. We describe two cases of multiple spontaneous CADs presenting as transient ischemic attack (TIA), in which only a specific diagnostic flow-chart allowed us to recognize multiple vessel involvement and start the appropriate therapy.

Arterial wall properties in multiple spontaneous cervical artery dissection. An ultrasound study.

P120 Background: An underlying arteriopathy related to a generalized extracellular matrix defect is suspected in spontaneous cervical artery dissection. We selected patients with multiple spontaneous cervical artery dissection (MSCAD) to study carotid arteries morphology and common carotid arteries hemodynamic properties. Method: 12 patients with MSCAD (mean age 48±6, 50% of women) were consecutively and prospectively included during an eighteen month period and were compared with 12 ischemic stroke patients matched for age and sex. Cases and controls had ultrasound measurement of each common carotid artery diameter change in systole and diastole, during 3 to 5 cardiac cycles. This parameter was expressed as percentage. Post-processing of the ultrasonic signals was performed using computer-assisted image analysis. Results: There was no difference in diameter of common carotid and internal carotid arteries between cases and controls, just as intima-media thickness measurement. Whereas, the average of common carotid artery relative diameter change was significantly higher in cases than in controls (13.6% versus 10.6%, p=0.005) Conclusion: As common carotid artery relative diameter change is a one-dimensional assessment reflecting the elastic properties of the artery wall, our preliminary results suggest that an underlying arteriopathy may be present in multiple spontaneous cervical artery dissection.

Arterial wall properties in multiple spontaneous cervical artery dissection. An ultrasound study.

P120 Background: An underlying arteriopathy related to a generalized extracellular matrix defect is suspected in spontaneous cervical artery dissection. We selected patients with multiple spontaneous cervical artery dissection (MSCAD) to study carotid arteries morphology and common carotid arteries hemodynamic properties. Method: 12 patients with MSCAD (mean age 48±6, 50% of women) were consecutively and prospectively included during an eighteen month period and were compared with 12 ischemic stroke patients matched for age and sex. Cases and controls had ultrasound measurement of each common carotid artery diameter change in systole and diastole, during 3 to 5 cardiac cycles. This parameter was expressed as percentage. Post-processing of the ultrasonic signals was performed using computer-assisted image analysis. Results: There was no difference in diameter of common carotid and internal carotid arteries between cases and controls, just as intima-media thickness measurement. Whereas, the average of common carotid artery relative diameter change was significantly higher in cases than in controls (13.6% versus 10.6%, p=0.005) Conclusion: As common carotid artery relative diameter change is a one-dimensional assessment reflecting the elastic properties of the artery wall, our preliminary results suggest that an underlying arteriopathy may be present in multiple spontaneous cervical artery dissection.