Posterior Circulation 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.

Cervicocranial arterial dissection. Experience in 57 patients

Cervicocranial arterial dissection (CIAD) is an important cause of stroke. To describe the clinical and imaging characteristics of patients with CIAD. An anonymous registry was made including all patients admitted to a private hospital with a diagnosis of CIAD. Patients were subdivided as having an anterior or posterior circulation dissection (ACD or PCD, respectively). Fifty-seven patients aged 40 ± 8 years (60% women) were included in the study, 39 with PCD and 18 with ACD. Cervical pain was the most common symptom. CIAD was diagnosed with no clinical or imaging signs of stroke in 49% of patients. Fifty one percent of patients had focal neurological deficits and 72% had a NIH stroke score below five. No significant differences between patients with ACD or PCD were found. Fifty patients received antiplatelet therapy (simple or dual), seven patients were anticoagulated and 13 were subjected to stenting due to progression of stenosis with hemodynamic involvement or bilateral dissection with scarce collaterals. The lesion was located in V3 segment in 27 patients and cervical segment of the internal carotid in 16 cases. A favorable Modified Rankin Scale (0-2) was achieved in 85.9%, with a trend towards achieving better functional prognosis in PCD. Due to the greater availability of non-invasive imaging methods, 50% of these patients with CIAD did not have a stroke. Thus, an earlier and more timely management is feasible.

Characteristics and relative factors of headache caused by cervicocerebral artery dissection.

To analyze the characteristics and relative factors of headache and neck pain due to cervicocerebral artery dissection (CAD). A total of 146 consecutive patients with CAD in Zhengzhou, China (2010-2017) were observed and registered prospectively. There were 60 (60/146) cases who complained of headache and neck pain, and we analyzed the characteristics of pain according to their clinical features. For the 130 (130/146) patients with complete clinical laboratory data, they were divided into two groups according to pain, and the relative factors of pain were analyzed. The headache and neck pain in 60 CAD patients was mostly acute onset (98.3%), 70.6% (12/17) of patients with anterior circulation dissection and 88.4% (38/43) of patients with posterior circulation dissection complained of moderate to severe pain. 41.2% (7/17) of patients with anterior circulation dissection had temporal pain, while 46.5% (20/43) of the patients with posterior circulation dissection had occipital pain. There were 23.5% (4/17) and 32.6% (14/43) of patients with anterior and posterior circulation dissection complained of throbbing pain, respectively, 23.5% (4/17) and 20.9% (9/43) of patients with anterior and posterior circulation dissection complained of pulsating pain. The pain could occur in the ipsilateral (40.0%), bilateral (52.7%), or contralateral (7.3%) sites of the dissection. In the 130 patients, there were 56 cases (43.1%) in the pain group, and 74 cases (56.9%) in the non-pain group. Multivariate logistic regression analysis showed that female gender (OR 4.01, 95% CI 1.63-9.85, P = 0.002), posterior circulation (OR 3.18, 95% CI 1.39-7.28, P = 0.006), history of headache (OR 4.72, 95% CI 1.08-20.52, P = 0.039), and low-density lipoprotein less than 1.8mmol/L (OR 2.90, 95% CI 1.15-7.34, P = 0.025) were risk factors of the occurrence of the pain related to CAD. The headache and neck pain caused by CAD is a moderate to severe pain occurring suddenly. The pain nature may be diverse but mostly like throbbing and pulsating. When the dissected artery is located in the posterior circulation, the pain is mostly in the occipital region, and mostly in the temporal region when the dissected artery is located in the anterior circulation. The pain can occur in ipsilateral, bilateral, or contralateral of the dissection. In addition, several factors might contribute to the occurrence of headache and neck pain.

The Headache and Neck Pain in Ischemic Stroke Patients Caused by Cervicocerebral Artery Dissection. A Case-Control Study

Background and purposeThe symptom of headache and neck pain is common in patients with cervicocerebral artery dissection (CAD). We attempt to screen ischemic stroke patients with CAD based on the characteristics of the pain. MethodsEighty-one consecutive ischemic stroke patients with CAD from 2010 to 2017 and 84 consecutive ischemic stroke patients with large artery atherosclerosis (LAA) were registered prospectively and observed in Zhengzhou, China. Those ischemic stroke patients complained of headache and neck pain were categorized into 2 groups. By analyzing the difference of headache and neck pain in 2 groups, we summarized characteristics of the pain secondary to CAD. ResultsThere were 34 patients in CAD group and 19 patients in LAA group. As for patients in CAD group, the pain could be located in the ipsilateral (41.9%), bilateral (41.9%), or contralateral (16.1%) side of the dissected artery, but in LAA group the pain was often in both sides (68.4%). When the dissected artery was involved in anterior circulation, 55.6% of CAD patients had pain in temporal and when involved in posterior circulation, 65.2% of CAD patients had pain in the occipital and neck. Patients with CAD had a higher prevalence of throbbing pain (30.0%), while pulsating pain (43.8%) was more common in LAA group. Patients often presented with severe pain (46.9%) in CAD group, while less frequently (11.8%) in LAA group, with a significant difference (P = .003). And there was a significant difference between the length (≥20 mm) of the involved artery and severity of the pain (P = .028) in CAD group. ConclusionsIschemic stroke patients caused by CAD tend to suffer from headache and neck pain, which may be severe and throbbing, compared with those resulting from LAA. The anterior circulation dissection has a higher prevalence of temporal pain while posterior circulation dissection is typically more associated with occipital and neck pain.

Abstract TP217: Different Features of Anterior and Posterior Circulation Dissections

Introduction: The features of vascular images and risk factors might be different according to the location of the cervicocerebral artery dissection. Hypothesis: We investigate whether the risk factors, neuroimaging features, and imaging outcomes differ according to the dissection site (anterior vs. posterior circulation). Methods: Consecutive patients who presented with ischemic symptoms and underwent brain vascular imaging within seven days after the onset of symptoms were enrolled. Demographic characteristics, putative risk factors, imaging findings, and types of antithrombotic medication were assessed between anterior circulation dissection (ACD) and posterior circulation dissection (PCD). The baseline and follow-up vascular images (6 months or 1 year after the onset of symptoms) were compared to determine the prognostic difference in the reverse of the lesion. Results: A total of 117 patients (n=32 with ACD and n=85 with PCD) were eligible for these analysis. The median delay from symptom onset to baseline vascular imaging was a day (IQR 1, 2). Patients with PCD were older (OR=1.5 by increasing 10 years old [1.02-2.03], p=0.038) and had a dissection associated with exercise or neck manipulation more frequently (OR=4.8 [1.2-18.1], p=0.019) compared to patients with ACD. Arterial stenosis or occlusion was the most common imaging feature (94% in ACD vs. 86% in PCD, p= 0.345). Aneurysm or pseudoaneurysm was identified in 9.4% of ACD and 24.7% of PCD (p=0.067). Among patients with PCD, vertebral artery was the most common lesion site (65% [53-74%]). The complete reverse on the follow-up images at the 6 months or 1 year was identified in 9 patients with ACD and 11 patients with PCD (45% vs. 22%, p=0.054). Neither anticoagulation nor antiplatelet demonstrated significant differences between the frequency of the complete reverse on the follow-up vascular images in patients with ACD and PCD (33% vs. 21%, p=0.613 for anticoagulation; 44% vs. 23%, p=0.087 for antiplatelet). Conclusions: These results substantiate the difference in the risk factors and radiologic features according to the dissection site. There was no difference in efficacy of antiplatelet and anticoagulant drugs at complete reverse of the lesion after cervicocerebral artery dissection.

Endovascular Treatment of Intracranial Artery Dissection: Clinical and Angiographic Follow-Up

Background. Intracranial artery dissections are rare and many controversies exist about treatment options. The aim of this study was to evaluate the efficacy and safety of the endovascular approach in patients with an intracranial dissection presenting with different symptoms. Methods. We prospectively evaluated the clinical features and treatment outcomes of 30 patients who had angiographically confirmed nontraumatic intracranial dissections over 4 years. Patients were followed up for 17 months, and their final outcomes were assessed by the modified Rankin Score (mRS) and angiography. Results. Sixteen (53.3%) patients had a dissection of the anterior circulation, whereas 14 (46.7%) had a posterior circulation dissection. Overall, 83.3% of the patients suffered a subarachnoid hemorrhage (SAH). Grade IV Hunt and Hess score was seen in 32% of the SAH presenting cases. Parent artery occlusion (PAO) with coil embolization was used in 70% of the cases. The prevalence of overall procedural complications was 23.3%, and all were completely resolved at the end of follow-up. No evidence of in-stent occlusion/stenosis or rebleeding was observed in our cases during follow-up. Angiography results improved more frequently in the PAO with coil embolization group (100%) than in the stent-only-treated group (88.9%) (P = 0.310) and the unruptured dissection group (5/5, 100%) in comparison with the group that presented with SAH (95.8%) (P = 0.833). Conclusion. Favorable outcomes were achieved following an endovascular approach for symptomatic ruptured or unruptured dissecting aneurysms. However, the long-term efficacy and durability of these procedures remain to be determined in a larger series.

Abstract 3626: Cranio Cervical Arterial Dissection; Radiologic Variants And The Natural History, Treatment, And Prognosis

Background and Objective: Craniocervical arterial dissection (CCAD) is believed to have a relatively benign natural history &amp; generally is managed with anticoagulation or antiplatelet therapy.The purpose of this study is to identify whether clinicoradiological parameters affect prognosis of CCAD. Methods: 26 patients(M: F=12:14, mean age=41.57) with clinical evidence of CCAD and at least one of the following suggestive imaging findings on either CT Angiography or MR angiography were included. Suggestive imaging findings include:1) arterial stenosis,2) arterial occlusion, 3) ectatic change of lumen,4) pseudoaneurysm,and 5) dissection flap. The temporal clinical and radiological evolution of CCAD findings were analyzed by a stroke neurologist and neuroradiologist respectively. Results: 69.2% had spontaneous dissections (n=18/26), and 30.7%had a history of trauma (n=8/26). 15 patients presented with strokes(15/26, 57.6%), three patients had TIA(11.5%), 13 patients had neck pain (50%), and 6 patients presented with Horner’s syndrome (21%). Anterior circulation dissection contributed 23%(6/26) of all dissections and posterior circulation dissections were 76.9%(20/26), while the vast majority of cases were unilateral,3.8% of cases were bilateral(1/26). Although 38.4% (n=10/26) were lost to follow up, 61%(n=16/26) had at least one follow up vascular imaging study. Neuroradiologic evaluation of these patients revealed arterial stenoses, arterial occlusions, ectatic changes of the lumen, pseudoaneurysms, and dissection flaps. Pseudo aneurysms were present in 15.4%(n:4/26) of cases.Recanalization had occurred in 75% (12/16), while 25 % did not recanalize within 2-5 months with a mean duration of 71 days.All patients were managed with anticoagulation or antiplatelet therapy. During the follow up period, all patients were stable, without any additional neurologic sequelae.50%(n=4/8) of the traumatic cases were associated with stroke while spontaneous dissections were associated with strokes in approximately 61%(n=11/18).With regards to age we found that 70% of patients between the ages of 38 - 65 years of age had developed strokes while only 30% of those aged 21 - 35 years old had developed strokes. Conclusion: The results revealed a distinction in the prognosis based upon age and the CCAD subtypes. Younger patients were less likely to present with a stroke than their older counterparts.Radiologic subtypes of CCAD as previously demonstrated in our previous study(Lee et al) supported our data which revealed that patients with pseudoaneurysm and intimal flap do not change over time despite treatment.With medical management, more than half of the arterial stenoses after craniocervical dissection improved within a relatively short period of time and no further neurologic sequelae were observed.

Prognosis of intracranial dissection relates to site and presenting features

Intracranial arterial dissection is relatively rare and generally considered to have a worse outcome than extracranial arterial dissection. It is a clinically significant entity that can cause severely disabling ischaemic stroke or subarachnoid haemorrhage (SAH). Only a few large case series of intracranial arterial dissection have been reported, particularly in the anterior circulation, but it is being increasingly recognized with advances in non-invasive angiographic diagnostic procedures. Patients with posterior circulation dissection appear to present more commonly with SAH and are traditionally said to have a worse outcome. Treatment options remain controversial and include medical therapy, as well as endovascular and surgical intervention. We reviewed the clinical features and outcome of 25 patients who had been treated for intracranial dissection at The Royal Melbourne Hospital over a period of 5 years. We recorded patient age, clinical presenting features, neuroimaging findings, treatment, and outcome assessment at 90 days using the modified Rankin Score (mRS). Eleven patients had anterior circulation dissection, while 14 had posterior circulation dissection; and overall 12 patients had cerebral ischaemia while 13 had subarachnoid haemorrhage (SAH). Almost all intracranial arterial dissections occurred spontaneously, without a history of trauma. Patients were relatively young, especially those in the group with ischaemia, with an average age of 39 years. Hypertension was the most commonly identified vascular risk factor. Eight out of 12 patients with ischaemia (66.7%) had anterior circulation dissection, while posterior circulation dissection occurred in 10 of 13 patients with SAH (76.9%). Location of anterior circulation dissection was variable, while the terminal vertebral artery segment was most commonly involved in the posterior circulation group. Most of the patients in the ischaemic group received medical therapy ( n = 10/12), while 10 out of 13 (76.9%) patients with SAH underwent endovascular and/or surgical intervention. There was a trend towards more favourable outcome at 90 days (mRS ⩾3) in the ischaemic group ( n = 10/12, 83.3%) compared to the SAH group ( n = 6/13, 46.2%), but this did not reach statistical significance ( p value = 0.097). The mortality rate was 16.7% ( n = 2/12) in the ischaemia group, and 7.7% in the SAH group ( n = 1/13), not significant. Among all the ischaemic group patients who received medical therapy, there were no deaths or development of secondary intracranial bleeding complications including SAH at 90 days. Our series suggest that it is possible to divide patients with intracranial dissection into two groups: (i) an ischaemia group, associated with a more favourable clinical outcome even when treated with antiplatelet or anticoagulation therapy; or (ii) a SAH group with a less favourable prognosis. The mortality rate, especially in patients with SAH who are generally treated with endovascular and/or surgical intervention, is less than previously reported. Anterior circulation involvement appears more common than traditionally perceived. The spontaneous occurrence of intracranial dissection in a relatively young age group, the predominant site of dissection in the artery at some distance from its tethered proximal segment, and the commonly observed hypertension, together raise the possibility of spontaneous dissection in arteries prematurely weakened by accelerated atherosclerosis.

45. Prognosis of Intracranial Dissection relates to site and presenting features

Background: Intracranial arterial dissection is relatively rare and generally considered to have worse outcome than extracranial arterial dissection. It is however a clinically significant entity which causes severely disabling ischaemic stroke or subarachnoid haemorrhage. Only a few large case series have been reported, but there is increased recognition with advance in non-invasive angiographic diagnostic procedures. Patients with posterior circulation dissection appear to present more commonly with subarachnoid hemorrhage and are said to have a worse outcome. The choices of treatment including medical therapy, and endovascular and surgical intervention, remain controversial.

Cerebral CT and MRI findings in cervicocephalic artery dissection.

To explore the frequency and patterns of brain infarction and other brain manifestations in cervicocephalic artery dissection (CCAD) and to evaluate the correlation between vessel wall findings and infarctions. The medical records and films of 136 consecutive CCAD patients diagnosed in Oulu University Hospital during the 20-year period since 1982 were reviewed. Five patients with no brain imaging were excluded. One-hundred-and-twenty-seven patients underwent cerebral CT and four patients MRI. Brain infarction was detected in 73 patients (56%), 43 of whom had cerebral infarction associated with anterior circulation dissection and 30 cerebellar infarction associated with posterior circulation dissection. Occlusion of the dissected vessel was accompanied by infarction in 76%, irregular stenosis in 40%, and other findings in 12%. Of the anterior circulation infarctions, territorial and subcortical infarctions and territorial infarctions with fragmentation, which are considered embolic, accounted for 95%, while only 5% were in the watershed area and considered hemodynamic. Intracranial posterior circulation dissection rarely caused infarction (in 1/11 of the dissected vessels), whereas intracranial anterior circulation dissection resulted in infarction more commonly (9/12). Altogether 23% of patients with intracranial CCAD had subarachnoid hemorrhage. Hemorrhagic transformation was present in five patients. More than half of CCAD patients have cerebral or cerebellar infarction at CT or conventional MR imaging. Occlusion of the dissected vessel is accompanied by infarction more often than other vessel wall abnormalities. Most cerebral infarctions caused by arterial dissections are of embolic origin. Intracranial dissections cause subarachnoid hemorrhage in more than 20% of patients.

A Dissecting Aneurysm of the Posterior Inferior Cerebellar Artery

Dissecting aneurysms occur when blood extrudes into the wall of a vessel. Posterior circulation dissections are recognised as an important cause of cerbral infarction and subarachnoid haemorrhage(SAH), however posterior inferior cerebellar artery (PICA) aneurysmal dissections are rare. A 49-year-old man who presented with SAH was found to have a left PICA dissection on cerebral angiography. The lesion was treated with surgical clipping proximal to the dissection and a distal PICA to PICA anastomosis. The pathology, diagnosis, presentation and treatment of these difficult lesions is discussed.