Risk Of Cervical Artery Dissection Research Articles

Recurrence of cervical artery dissection: A systematic review and meta-analysis.

Cervical artery dissection (CAD) involving the carotid or vertebral arteries is an important cause of stroke in younger patients. The purpose of this systematic review is to assess the risk of recurrent CAD. A systematic review and meta-analysis was conducted on studies in which patients experienced radiographically confirmed dissections involving an extracranial segment of the carotid or vertebral artery and in whom CAD recurrence rates were reported. Data were extracted from 29 eligible studies (n = 5898 patients). Analysis of outcomes was performed by pooling incidence rates with random effects models weighting by inverse of variance. The incidence of recurrent CAD was 4% overall (95% confidence interval (CI) = 3-7%), 2% at 1 month (95% CI = 1-5%), and 7% at 1 year in studies with sufficient follow-up (95% CI = 4-13%). The incidence of recurrence associated with ischemic events was 2% (95% CI = 1-3%). We found low rates of recurrent CAD and even lower rates of recurrence associated with ischemia. Further patient-level data and clinical subgroup analyses would improve the ability to provide patient-level risk stratification.

Migraine and the risk of cervical artery dissection: A systematic review and meta-analysis.

Migraine is a common, disabling chronic pain condition possibly related to changes in endothelial and vascular structure and function. Several observational studies have suggested an elevated risk of cervical artery dissection (CeAD) in patients with a history of migraine. We aimed to investigate this potential association using systematic review and meta-analytic methods. We utilized a pre-defined search protocol to identify and screen studies related to migraine and CeAD in PubMed, Embase, and the Web of Science Core Collection. We assessed the risk of bias and performed a meta-analysis of selected studies to assess the association between migraine and CeAD. We also performed subgroup analyses by migraine subtype, biological sex, and the use of stroke versus non-stroke controls. We identified 11 studies (N = 9857 patients) for inclusion in the meta-analysis. Meta-analysis showed an association between migraine and CeAD with an odds ratio of 1.74 (95%CI 1.38-2.19). There was high heterogeneity among the included studies (I2 = 61%). Publication bias was present but the Trim-Fill imputation suggested that the impact on results was likely minimal. Subgroup analyses revealed an association between migraine without aura and CeAD (OR 1.86, 95%CI 1.55-2.24) but not migraine with aura and CeAD (OR 1.15, 95%CI 0.71-1.88). There was no difference in the association between migraine and CeAD in men compared to women. A history of migraine is associated with an increased risk of CeAD. Further studies are needed to elucidate the potential pathophysiologic mechanisms underlying this association.

The association between cervical artery dissection and spinal manipulation among US adults.

Cervical artery dissection (CeAD), which includes both vertebral artery dissection (VAD) and carotid artery dissection (CAD), is the most serious safety concern associated with cervical spinal manipulation (CSM). We evaluated the association between CSM and CeAD among US adults. Through analysis of health claims data, we employed a case-control study with matched controls, a case-control design in which controls were diagnosed with ischemic stroke, and a case-crossover design in which recent exposures were compared to exposures in the same case that occurred 6-7months earlier. We evaluated the association between CeAD and the 3-level exposure, CSM versus office visit for medical evaluation and management (E&M) versus neither, with E&M set as the referent group. We identified 2337 VAD cases and 2916 CAD cases. Compared to population controls, VAD cases were 0.17 (95% CI 0.09 to 0.32) times as likely to have received CSM in the previous week as compared to E&M. In other words, E&M was about 5 times more likely than CSM in the previous week in cases, relative to controls. CSM was 2.53 (95% CI 1.71 to 3.68) times as likely as E&M in the previous week among individuals with VAD than among individuals experiencing a stroke without CeAD. In the case-crossover study, CSM was 0.38 (95% CI 0.15 to 0.91) times as likely as E&M in the week before a VAD, relative to 6months earlier. In other words, E&M was approximately 3 times more likely than CSM in the previous week in cases, relative to controls. Results for the 14-day and 30-day timeframes were similar to those at one week. Among privately insured US adults, the overall risk of CeAD is very low. Prior receipt of CSM was more likely than E&M among VAD patients as compared to stroke patients. However, for CAD patients as compared to stroke patients, as well as for both VAD and CAD patients in comparison with population controls and in case-crossover analysis, prior receipt of E&M was more likely than CSM.

Association between cervical artery dissection and spinal manipulative therapy –a medicare claims analysis

BackgroundCervical artery dissection and subsequent ischemic stroke is the most serious safety concern associated with cervical spinal manipulation.MethodsWe evaluated the association between cervical spinal manipulation and cervical artery dissection among older Medicare beneficiaries in the United States. We employed case-control and case-crossover designs in the analysis of claims data for individuals aged 65+, continuously enrolled in Medicare Part A (covering hospitalizations) and Part B (covering outpatient encounters) for at least two consecutive years during 2007–2015. The primary exposure was cervical spinal manipulation; the secondary exposure was a clinical encounter for evaluation and management for neck pain or headache. We created a 3-level categorical variable, (1) any cervical spinal manipulation, 2) evaluation and management but no cervical spinal manipulation and (3) neither cervical spinal manipulation nor evaluation and management. The primary outcomes were occurrence of cervical artery dissection, either (1) vertebral artery dissection or (2) carotid artery dissection. The cases had a new primary diagnosis on at least one inpatient hospital claim or primary/secondary diagnosis for outpatient claims on at least two separate days. Cases were compared to 3 different control groups: (1) matched population controls having at least one claim in the same year as the case; (2) ischemic stroke controls without cervical artery dissection; and (3) case-crossover analysis comparing cases to themselves in the time period 6–7 months prior to their cervical artery dissection. We made each comparison across three different time frames: up to (1) 7 days; (2) 14 days; and (3) 30 days prior to index event.ResultsThe odds of cervical spinal manipulation versus evaluation and management did not significantly differ between vertebral artery dissection cases and any of the control groups at any of the timepoints (ORs 0.84 to 1.88; p > 0.05). Results for carotid artery dissection cases were similar.ConclusionAmong Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups.

Influenza-Like Illness Is Associated With Increased Short-Term Risk of Cervical Artery Dissection

Abstract Introduction Non-traumatic Cervical Artery Dissection (CeAD) is a leading cause of ischemic stroke in the young. Influenza-like illnesses (ILI) trigger ischemic strokes. We hypothesized that influenza and ILI are associated with CeAD. Methods In a case-crossover study within the New York State (NYS) Department of Health Statewide Planning and Research Cooperative System (2006–2014), we used ICD-9 codes to exclude major trauma and to define CeAD, influenza, and the Centers for Disease Control defined ILI. We estimated the association of ILI and influenza with CeAD by comparing their prevalence in intervals immediately prior (0–30,0–90,0–180, and 0–365 days) to CeAD (case period) to their prevalence exactly one and two years earlier (control periods). Conditional logistic regression models generated odds ratios and 95% confidence intervals (OR, 95% CI). Models were adjusted for NYS estimates of influenza prevalence rates. Results Our sample included 3,610 cases of CeAD (mean age 52±16 years, 54.7% male, 6.2% Hispanic, 9.9% Black, 68.7% White). During case periods, 7.3% had one or more ILI. ILI was more likely within 90 days of CeAD compared to the same time interval one and two years before (0–15 days: adjusted OR 1.88, 95%CI 1.20–2.94; 0-30 days: adjusted OR 1.74, 95%CI 1.22–2.46; 0–90 days: adjusted OR 1.35, 95%CI 1.00–1.81). Influenza trended with CeAD (adjusted OR 1.86, 95%CI 0.37–9.24), but these results were not statistically significant, due to limited instances of confirmed influenza. Conclusions ILI may increase risk of CeAD for 15 days, and possibly up to three months.

Beauty Parlor Stroke Syndrome in A 32 Year-Old Female: A Case Report

Purpose To describe a case report of the beauty parlor stroke syndrome in a 32 year old patient Summary: Beauty parlor stroke syndrome, otherwise known as a Hairdresser-related ischemic cerebrovascular event (HICE) or vertebral-basilar ischemia (VBI), is a rare phenomenon caused by either cerebral artery dissection or vertebral artery compression due to neck positioning and manipulation at the hair salon sink bowl. Majority of the cases previously reported occurred in elderly women, rather than younger patients. We describe a case of beauty stroke syndrome in a 32 year-old patient with no prior medical history or risk factors such as atherosclerotic disease, diabetes, hypertension and hyperlipidemia. Conclusion: The 2014 Stroke guidelines issued a warning to healthcare professionals regarding the risk of cervical artery dissections following cervical manipulative therapy in young and middle-aged adults. However, the risk of cervical artery dissection following manipulation at the shampoo bowl was not specifically mentioned. Practitioners must be cognizant of the various symptoms of beauty salon syndrome, and intervene in a timely manner to prevent potential ongoing issues.

Chapter 22 - Cerebral aneurysms and cervical artery dissection: Neurological complications and genetic associations

Dissections and aneurysms are two of the more common nonatherosclerotic arteriopathies of the cerebrovascular system and a significant contributor to neurovascular complications, particularly in the young. Specifically, ruptured intracranial aneurysms (IA) account for nearly 500,000 cases of subarachnoid hemorrhage annually with a 30-day mortality approaching 40% and survivors suffering often permanent neurologic deficits and disability. Unruptured IAs require dedicated assessment of risk and often warrant serial radiologic monitoring. Cervical artery dissection, affecting the carotid and vertebral arteries, accounts for nearly 20% of strokes in young and middle-aged adults. While approximately 70% of cervical artery dissection (CeAD) cases present with stroke or TIA, additional neurologic complications include severe headache and neck pain, oculosympathetic defect (i.e., partial Horner's syndrome), acute vestibular syndrome, and rarely lower cranial nerve palsies. Both aneurysms and dissections of the cerebrovascular system may occur frequently in patients with syndromic connective tissue disorders; however, the majority of cases are spontaneously occurring or mildly heritable with both polygenic and environmental associations. Fibromuscular dysplasia, in particular, is commonly associated with both risk of CeAD and IA formation. Further research is needed to better understand the pathophysiology of both IA and CeAD to better understand risk, improve treatments, and prevent devastating neurologic complications.

Influenza-Like Illness is Associated with Increased Short-Term Risk of Cervical Artery Dissection

IntroductionNon-traumatic Cervical Artery Dissection (CeAD) is a leading cause of ischemic stroke in the young. Influenza-like illnesses (ILI) trigger ischemic strokes. We hypothesized that influenza and ILI are associated with CeAD. MethodsIn a case-crossover study within the New York State (NYS) Department of Health Statewide Planning and Research Cooperative System (2006–2014), we used ICD-9 codes to exclude major trauma and to define CeAD, influenza, and the Centers for Disease Control defined ILI. We estimated the association of ILI and influenza with CeAD by comparing their prevalence in intervals immediately prior (0–30,0–90,0–180, and 0–365 days) to CeAD (case period) to their prevalence exactly one and two years earlier (control periods). Conditional logistic regression models generated odds ratios and 95% confidence intervals (OR, 95% CI). Models were adjusted for NYS estimates of influenza prevalence rates. ResultsOur sample included 3,610 cases of CeAD (mean age 52±16 years, 54.7% male, 6.2% Hispanic, 9.9% Black, 68.7% White). During case periods, 7.3% had one or more ILI. ILI was more likely within 90 days of CeAD compared to the same time interval one and two years before (0–15 days: adjusted OR 1.88, 95%CI 1.20–2.94; 0-30 days: adjusted OR 1.74, 95%CI 1.22–2.46; 0–90 days: adjusted OR 1.35, 95%CI 1.00–1.81). Influenza trended with CeAD (adjusted OR 1.86, 95%CI 0.37–9.24), but these results were not statistically significant, due to limited instances of confirmed influenza. ConclusionsILI may increase risk of CeAD for 15 days, and possibly up to three months.

Association between Pregnancy and Cervical Artery Dissection.

We wanted to determine whether pregnancy is associated with cervical artery dissection. We performed a case-control study using claims data from all nonfederal emergency departments and acute care hospitals in New York and Florida between 2005 and 2015. Cases were women 12-42 years of age hospitalized with cervical artery dissection, defined using validated diagnosis codes for carotid/vertebral artery dissection. Controls were women 12-42 years of age with a primary diagnosis of renal colic. Cases and controls were matched 1:1 on age, race, insurance, income, state, and visit year. The exposure variable was pregnancy, defined as labor and delivery within 90 days before or 6 months after the index visit. Logistic regression was used to compare the odds of pregnancy between cases and controls. We performed a secondary cohort-crossover study comparing the risk of cervical artery dissection during pregnancy versus the same time period 1 year later. Pregnancy was twice as common among 826 women with cervical artery dissection compared with the 826 matched controls with renal colic (odds ratio, 2.5; 95% confidence interval [CI], 1.3-4.7). In our secondary analysis, pregnancy was associated with a higher risk of cervical artery dissection (incidence rate ratio [IRR], 2.2; 95% CI, 1.3-3.5), with the heightened risk limited to the postpartum period (IRR, 5.5; 95% CI, 2.6-11.7). Pregnancy, specifically the postpartum period, was associated with hospitalization for cervical artery dissection. Although these findings might in part reflect ascertainment bias, our results suggest that arterial dissection is one mechanism by which pregnancy can lead to stroke. ANN NEUROL 2020;88:596-602.

Serum-Based Proteomics Reveals Lipid Metabolic and Immunoregulatory Dysregulation in Cervical Artery Dissection With Stroke.

Cervical artery dissection (CAD) is an important causal factor for stroke in young and middle-aged individuals and presents a great burden to the individual stroke victim. However, the pathophysiological mechanisms underlying CAD remain unknown. Here, an iTRAQ (isobaric tagging for relative and absolute quantitation)–based quantitative proteomic approach was performed, to identify differentially expressed proteins in serum samples obtained from spontaneous CAD and non-CAD ischemic stroke subjects. Differential protein expression was analyzed for Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway overrepresentation, and six differential proteins were selected for enzyme-linked immunosorbent assay validation. Through KEGG analysis, the significantly differentiated proteins were primarily involved in immunoregulation, blood coagulation, and lipid metabolism. For the first time, differential expressions of apolipoprotein B, apolipoprotein C-I, lipopolysaccharide-binding protein, vascular cell adhesion molecule 1, fibulin-1, and ficolin-2 were confirmed as being significantly upregulated in CAD as compared to non-CAD ischemic stroke subjects. In conclusion, proteomic analysis reveals that early perturbation of immunoregulation and lipid metabolism may be involved in the pathophysiology of CAD. Specifically, the panel of six proteins identified is promising as serum-based biomarkers for the detection of increased CAD risk in stroke subjects.

Abstract TMP60: Association Between Pregnancy and Cervical Artery Dissection

Background and Purpose: Pregnancy is a risk factor for stroke. The mechanisms of stroke in pregnancy have not been well established. Cervical artery dissection may be one such mechanism, but it is unclear whether pregnancy is a risk factor for cervical artery dissection. Methods: We performed a cohort-crossover analysis using administrative claims data from all hospitalizations and emergency department visits involving nonfederal acute care hospitals in NY and FL between 2005-2015. We identified women ≥12 years old who were hospitalized for labor and delivery. Our outcome was cervical artery dissection, defined as carotid or vertebral artery dissection. We defined the period of risk as 6 months antepartum through 3 months postpartum. We compared each patient’s risk of dissection during this time period versus the corresponding 270-day period exactly 1 year later. Conditional Poisson models with robust standard errors were used to calculate incidence risk ratios (IRRs). Results: We identified 4,193,417 pregnancies among 3,061,413 women during our study period. There were 52 cases of cervical artery dissection during the peripartum period and 24 cases during the control period 1 year later. The incidence of cervical artery dissection was 12 (95% CI, 10-17) per million pregnancies versus 6 (95% CI, 4-9) per million patients during the control period 1 year later (IRR, 2.2; 95% CI, 1.3-3.5). Our findings were similar when we limited our outcome to cervical artery dissections complicated by ischemic stroke (IRR, 2.3; 95% CI, 1.1-5.1). Secondary analyses suggested that the heightened risk occurred in the peripartum and postpartum period (IRR,5.5; 95% CI, 2.6-11.7), not the antepartum period (IRR, 0.5; 95% CI, 0.2-1.2). Conclusions: In a large, population-based sample of women, pregnancy was associated with an increased risk of cervical artery dissection. This increased risk appeared to be limited to the peripartum and postpartum period.

Complementary and Integrative Medicine for Episodic Migraine: an Update of Evidence from the Last 3 Years.

The purpose of this review is to evaluate evidence from the last 3years on complementary and integrative medicine treatment options for episodic migraine. Using Pubmed, Embase, and Cochrane databases, research published from 2015-2018 evaluating the modalities of mind/body therapies, supplements, and manual therapies for treatment of migraine were assessed. Although many studies had major methodological challenges that limit interpretation, several studies reported decreased headache frequency, improved quality of life, or less affective responses to pain. The evidence is currently most promising for the mind/body treatment options of mindfulness, yoga, and tai chi. Mindfulness meditation may be as effective as pharmacological treatment for medication-overuse headache after the offending medication is withdrawn. While older research has shown magnesium, riboflavin, feverfew, and butterbur to be helpful in migraine treatment, new research is promising to suggest potential benefit with melatonin, vitamin D, higher dosages of vitamin B6 (80mg)/folic acid 5mg combinations, and the combination of magnesium 112.5mg/CoQ10 100mg/feverfew 100mg. Omega 3s have limited evidence of efficacy in migraine. Butterbur needs to be free of pyrrolizidine alkaloids (PA) to ensure safety given their hepatotoxicity. Physical therapy (PT) continues to have strong evidence of support, and acupuncture is superior to sham acupuncture and placebo. Side effects and risks reported were minimal and well tolerated overall, with the exception of the life-threatening risk of cervical artery dissection with high-velocity chiropractic manipulation and hepatotoxicity with the PAs in butterbur. Several studies are ongoing to further evaluate mindfulness, melatonin, PT, exercise, chiropractic manipulation, and acupuncture. The American Academy of Neurology (AAN) and American Headache Society (AHS) are currently updating the guidelines for integrative treatment options for migraine, so additional recommendations may be available soon. In conclusion, many complementary and integrative treatment options may be helpful for patients with migraines, and understanding potential efficacy, benefits, and risks can help providers discuss these modalities with their patients. Such a conversation can empower patients, build the therapeutic relationship, and increase self-efficacy, thus improving outcomes and patient-centered care.

Abstract WMP49: Influenza-Like Illness May Trigger Cervical Artery Dissection

Background and Purpose: Non-traumatic Cervical Artery Dissection (CeAD) is a leading cause of ischemic stroke in patients 15 to 45 years old. Influenza-like illnesses (ILI) have been found to trigger ischemic stroke, but ILI has not been investigated in relation to CeAD. We hypothesized that ILI and influenza would be associated with CeAD. Methods: We used a case-crossover design among patients > 18 years old at time of first non-traumatic CeAD within the New York State (NYS) Department of Health Statewide Planning and Research Cooperative System (2006-2014). We used ICD-9 codes to define CeAD (443.21, 443.24) excluding individuals with major trauma (integer values 800-804 and 850-854), confirmed influenza (480, 487.0, 487.1, 487.8), and a broader influenza definition endorsed by the CDC for ILI surveillance. We compared ILI and influenza in sequential, mutually exclusive intervals preceding CeAD (0-15, 16-30, 31-90, 91-180, and 181-365 days prior to CeAD: case period) and overlapping intervals (0-30, 0-90, 0-180, and 0-365 days prior to CeAD: alternate case period) to ILI and influenza exactly one and two years earlier (control periods). Conditional logistic regression models were used to calculate odds ratios and 95% confidence intervals (OR, 95% CI) before and after adjusting for annual NYS population estimates of influenza prevalence rate. Results: Our final sample included 3,861 cases of CeAD (mean age 52±16 and 55.5% of male). We found 1,736 instances of ILI and 113 of influenza during the 3 years preceding CeAD. Patients were more likely to have ILI within 30 days of CeAD compared to the same time one and two years before (0-15 days: adjusted OR 1.53, 95% CI 1.02 - 2.30; 0-30 days: adjusted OR 1.60, 95% CI 1.14 - 2.23). ILI during later overlapping or sequential intervals was not associated with CeAD in adjusted models. Influenza was associated with CeAD between 31 and 90 days after CeAD, but this effect was no longer significant after adjusting for prevalence rate of influenza, perhaps due the small number of patients with confirmed influenza. Conclusions: ILI may increase risk of CeAD for up to one month. Further research on mechanisms by which ILI and influenza may trigger dissection are warranted.

Migraine and cerebrovascular diseases: Epidemiology, pathophysiological, and clinical considerations.

Migraine and cerebrovascular diseases are disabling disorders, which are possibly closely interrelated. Heterogeneous and scattered evidence in literature remains a challenge. We searched for systematic reviews including diverse cerebrovascular events in migraineurs and reported relevant original studies to update the evidence when necessary. The studies show that migraine is associated with increased risk of transient ischemic attacks, any stroke, and possibly hemorrhagic stroke. In addition, migraine with aura increases the risk of ischemic stroke and white matter abnormalities. Migraine without aura increases the risk of cervical artery dissection as a cause of ischemic stroke. Groups with specific risk profiles are women, young people, smokers, and oral contraceptive users. The pathophysiology of the association remains uncertain. However, genetic and environmental factors may be involved in intricate mechanisms responsible for oxidative stress, vascular dysfunction and, ultimately, vascular events. In conclusion, migraine is a potential risk factor for cerebrovascular diseases. Migraineurs should be carefully evaluated considering their vascular risk assessment based on current evidence, so that healthcare professionals can provide appropriate and individualized management of other cardiovascular risk factors, notably quitting smoking and restricting use of oral contraceptives.

Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study

Chiropractic manipulation is a popular treatment for neck pain and headache, but may increase the risk of cervical artery dissection and stroke. Patients with carotid artery dissection can present with neck pain and/or headache before experiencing a stroke. These are common symptoms seen by both chiropractors and primary care physicians (PCPs). We aimed to assess the risk of carotid artery stroke after chiropractic care by comparing association between chiropractic and PCP visits and subsequent stroke. A population-based, case-crossover study was undertaken in Ontario, Canada. All incident cases of carotid artery stroke admitted to hospitals over a 9-year period were identified. Cases served as their own controls. Exposures to chiropractic and PCP services were determined from health billing records. We compared 15,523 cases to 62,092 control periods using exposure windows of 1, 3, 7, and 14 days prior to the stroke. Positive associations were found for both chiropractic and PCP visits and subsequent stroke in patients less than 45 years of age. These associations tended to increase when analyses were limited to visits for neck pain and headache-related diagnoses. There was no significant difference between chiropractic and PCP risk estimates. We found no association between chiropractic visits and stroke in those 45 years of age or older. We found no excess risk of carotid artery stroke after chiropractic care. Associations between chiropractic and PCP visits and stroke were similar and likely due to patients with early dissection-related symptoms seeking care prior to developing their strokes.

Risk of recurrent cervical artery dissection during pregnancy, childbirth and puerperium.

Hormonal and mechanical factors might increase the risk for cervical artery dissection (CAD) during pregnancy and the puerperium. There is uncertainty how to counsel women with a previous CAD regarding the risk of CAD recurrence during pregnancy and the puerperium. In an observational study of four stroke centers, all women aged 16-45years with primary CAD in the previous decade were asked to participate in a standardized assessment on long-term follow-up with a special focus on pregnancies and recurrent CAD. Ninety-two women were identified and 53 of them were included in the analysis (60%). Eleven women declined to participate, 28 were untraceable. The 39 non-participants did not differ from participants regarding key baseline characteristics. Average follow-up time was 72months. Nine women (17%) had recurrent CAD after a median of 14days (range 2days to 117months). Eleven women (20%) had a total of 13 completed pregnancies at a median of 44months (range 12-84months) after index CAD. Two of the pregnant women (18%) had suffered recurrent CAD ≥18months prior to the pregnancy. All 13 pregnancies and puerperia went without recurrent CADs or cerebrovascular events. This includes giving birth by vaginal delivery (n=6) and caesarean section (n=7). None of the five women with typical connective tissue disease became pregnant. Our observation suggests that the risk of recurrent CAD may not be greatly increased with pregnancies starting at least 12months after CAD in women without typical connective tissue disease.

Hyperhomocysteinemia and Methylenetetrahydrofolate Reductase Polymorphism in Cervical Artery Dissection: A Meta-Analysis

Background: Cervical artery dissection (CAD) is a recognized cause of ischemic stroke. Hyperhomocysteinemia (HHcy), i.e. an elevated concentration of plasma homocysteine, is identified as an independent risk factor for stroke prevalence. However, an association between HHcy and CAD has so far remained unknown. Methods: A meta-analysis was performed to analyze the association between HHcy and CAD as well as the relevance of the C677T polymorphism of methylenetetrahydrofolate reductase (MTHFR), the key enzyme in homocysteine metabolism during CAD. We searched PubMed and Embase for studies reporting homocysteine concentrations or MTHFR genotype frequencies in CAD patients from 1990 to 2013. Outcomes were extracted from studies meeting the inclusion criteria and were subjected to a meta-analysis by the random-effect model. Heterogeneity was assessed by the I² test. Results: Eight case-control studies with 2,146 individuals fulfilled the required criteria and were included in the meta-analysis. HHcy was found to be significantly associated with CAD (pooled standardized mean difference: 0.96; 95% confidence interval, CI: 0.42-1.49; p < 0.01). We also found a significantly increased risk of CAD in individuals with the MTHFR C677T polymorphism by both the recessive model (TT vs. CT+CC; odds ratio, OR = 1.81; 95% CI: 1.22-2.67; p = 0.003) and the dominant model (TT+CT vs. CC; OR = 1.47; 95% CI: 1.08-1.99; p = 0.014). Conclusion: Our data suggest positive correlations between HHcy and CAD and between the C677T polymorphism of MTHFR and CAD.

Migraine et risque vasculaire

Migraine with aura is well known to be associated with an increased risk of ischemic stroke. This risk dramatically increases in smokers and uses of oral contraceptives. Brain MRI studies suggest that migraine is associated with silent brain infarcts. Migraine is also established as a risk factor for significantly more cerebral white matter lesions. Recent data suggest that migraine is also associated with coronary artery disease. Data concerning an increase risk of mortality in migraine are controversial. The pathophysiology of the increased risk of ischemic events is unclear. Migrainous infarcts seem to be very rare. Migraine is associated with an increased risk of cervical artery dissection. Classical vascular risk factors are more common in migraineurs. Triptans are not associated with an increased risk of ischemic events. Another explanation is a probable endothelial dysfunction and a lower level of endothelial progenitor cells in migraine. A prothrombotic state in migraine is also another possible explanation due to genetic polymorphisms. Appropriate management for primary vascular prevention in migraineurs is not different from that proposed for the general population. Oral contraceptives should be avoided in migraineurs with aura, especially if they smoke.

Migraine, migraine aura, and cervical artery dissection: A systematic review and meta-analysis

We evaluated the current evidence on the association between migraine, including aura status, and cervical artery dissection. We performed a systematic review and meta-analysis of studies investigating the association between migraine or migraine subtypes (e.g. migraine with aura) and cervical artery dissection published through October 2010. We identified five case-control studies investigating the association between migraine and cervical artery dissection. In pooled analysis, migraine doubled the risk of cervical artery dissection (pooled odds ratio [OR]=2.06, 95% confidence interval [CI] 1.33-3.19). All studies allowed evaluation of migraine aura status. While the effect estimate for migraine without aura (pooled OR=1.94, 95% CI 1.21-3.10) was similar to overall migraine, the association was weaker for migraine with aura (pooled OR= 1.50, 95% CI 0.76-2.96). However, there is no evidence that aura status significantly modifies the association between migraine and cervical artery dissection (meta-regression on aura status p= .58). The risk does not appear to differ between women and men; however, only few studies presented gender-specific data. Heterogeneity among studies was low to moderate. In this meta-analysis migraine is associated with a two-fold increased risk of cervical artery dissection. This risk does not appear to significantly differ by migraine aura status or gender.

CADISP-Genetics: An International Project Searching for Genetic Risk Factors of Cervical Artery Dissections

Cervical artery dissection (CAD) is a frequent cause of ischemic stroke, and occasionally death, in young adults. Several lines of evidence suggest a genetic predisposition to CAD. However, previous genetic studies have been inconclusive mainly due to insufficient numbers of patients. Our hypothesis is that CAD is a multifactorial disease caused by yet largely unidentified genetic variants and environmental factors, which may interact. Our aim is to identify genetic variants associated with an increased risk of CAD and possibly gene-environment interactions. We organized a multinational European network, Cervical Artery Dissection and Ischemic Stroke Patients (CADISP), which aims at increasing our knowledge of the pathophysiological mechanisms of this disease in a large group of patients. Within this network, we are aiming to perform a de novo genetic association analysis using both a genome-wide and a candidate gene approach. For this purpose, DNA from approximately 1100 patients with CAD, and 2000 healthy controls is being collected. In addition, detailed clinical, laboratory, diagnostic, therapeutic, and outcome data are being collected from all participants applying predefined criteria and definitions in a standardized way. We are expecting to reach the above numbers of subjects by early 2009. We present the strategy of a collaborative project searching for the genetic risk factors of CAD. The CADISP network will provide detailed and novel data on environmental risk factors and genetic susceptibility to CAD.