Treatment Of Cervical Artery Dissection Research Articles

Hálsæðaflysjun á Íslandi: faraldsfræði, meðferð og horfur

Background: Cervical artery dissection is a common cause of ischemic stroke in young adults and middle-aged individuals. Due to advances in imaging techniques and increased knowledge, dissections are now diagnosed much more frequently than before. This study aimed to investigate the incidence of cervical artery dissection in Iceland from 2005 to 2023. Methods: A retrospective study was conducted using medical records of individuals diagnosed with cervical artery dissection in Iceland between January 1, 2005, and December 31, 2023. The factors examined included gender, year of diagnosis, age at diagnosis, symptoms, risk factors, treatment, and prognosis. Data processing was performed using Excel® and Rstudio. Results: The study sample consisted of 107 individuals, including 37 women and 70 men. The average incidence was 1.62 per 100,000 people per year. The incidence increased over the period, being 2.7 times higher in the latter half compared to the former. The average age of diagnosis was 50 years (range 18-101 years). The most common symptom was pain (72%), followed by sensory disturbances (67%), motor disturbances (49%), and Horner's syndrome (36%). Half of the patients experienced an ischemic stroke (51%). Five individuals (4.6%) had a recurrent dissection during the follow-up period. Dissections occurred in the internal carotid artery in 56% of cases and the vertebral artery in 44% of cases. All patients received antiplatelet and/or anticoagulant therapy. After 3-6 months, 77% had no or mild disability (0-2 on the modified Rankin scale). Discussion: The incidence of cervical artery dissection in Iceland is consistent with findings from other studies. Diagnoses have increased in recent years, and the average incidence has risen. The majority of patients achieved good recovery, indicating effective diagnosis and treatment of cervical artery dissection in Iceland.

Surgical treatment of one traumatic carotid artery dissection: A case report and review of the literature.

Dissection of the cervical arteries is the most commonly identified cause of stroke in young patients. This report helps to investigate the etiology, diagnosis, and treatment of cervical artery dissection (CAD). A 40-year-old female presented with a 3-week history of right carotid artery dissection due to a fall. The patient was admitted to the local hospital 3 weeks ago with a right neck impingement after a fall, and presented with right neck pain. The local hospital CT scan showed a dissection of the middle segment of the right common carotid artery. The patient clinical manifestations and imaging tests confirmed that right carotid artery dissection. Medical treatment with antiplatelet failed, and the CT scan showed progression of dissection. Carotid endarterectomy (CEA) was performed, and the prognosis is good. This patient was followed up at 1 and 6 months after the operation, CT scan showed the original stenotic vessels returned to standard diameter. Diagnosis of CAD mainly depends on clinical manifestations and imaging. we recommend that clinicians can prescribe either anticoagulants or antiplatelet therapy. CAD can be effectively treated by surgical reconstruction, if medical treatment with anticoagulation or antiplatelet fails or if carotid aneurysms and/or high-grade carotid stenosis persisted or have newly developed.

Advances in Management of the Stroke Etiology One-Percenters.

Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.

Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial

Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines-based on available evidence from mostly observational studies-suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection. We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0-3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460. Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI -4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group. Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection. Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.

Treatment of Cervical Artery Dissection: Antithrombotics, Thrombolysis, and Endovascular Therapy.

Cervical artery dissection (CAD) is an important cause of stroke for young patients, accounting for 5–22% of strokes in patients <45 years of age, which presents not only a great burden to the stroke victims but also a financial burden to the family and society. Because CAD can lead to different clinical lesions, including neuropathy, acute ischemic stroke, and subarachnoid hemorrhage, and is an arterial dissection with a self-healing tendency, the treatment options depend on the clinical manifestations. The main purpose of the treatment is to control CAD-induced neuronal damage and to restore blood flow. The treatment programs include drug treatment and endovascular treatment. However, antithrombotic treatment is crucial. Both antiplatelet drugs and anticoagulant drugs are used to reduce the risk of stroke, but whether one treatment strategy is more effective than the other is unknown. The efficacy and timing of the endovascular treatment of CAD remain controversial.

Abstract W P223: Treatment of Cervical Artery Dissection with Different Antithrombotic Agents

Background and Purpose: Antiplatelet agents and anticoagulants are both accepted and commonly used agents for treatment of cervical artery dissection (CAD), though randomized clinical trials are lacking. We report on the use of novel oral anticoagulants for CAD and compared their efficacy and safety to traditional anticoagulants. Methods: We retrospectively identified patients diagnosed with CAD at a single academic center between July 2010 and December 2012. Patients treated with novel anticoagulants (NOAC: dabigatran or rivaroxaban), other anticoagulants (AC: warfarin, heparin, or low molecular weight heparin), or antiplatelet agents (AP: aspirin, clopidogrel, or aspirin-dypyridamole) were compared for baseline characteristics, recurrent stroke, vessel recanalization on follow-up, and bleeding complications using Fisher’s exact and student t-tests. Results: During the study period, 110 patients with CAD were included, of whom 20 (18%), 61 (55%), and 29 (26%) were treated initially with a NOAC, AC, and AP, respectively. Clinical follow-up was available in 98 (89.1%) patients while radiographic follow-up was available in 88 (80%) patients. NOAC-treated patients were more likely to have presented with ischemic stroke symptoms (90% vs. 55.7%, p=0.007) but had similar rates of severe stenosis (60% vs. 53.3%, p=0.522) and intraluminal/intramural thrombus (70% vs. 57.6%, p=0.327) on initial vascular imaging compared to AC patients. There was 1 recurrent stroke in the NOAC group and 1 in the AC group. Similar proportions of patients had resolved or improved stenosis on follow-up imaging (NOAC: 66.7 vs. AC: 63.3%, p=0.217). Hemorrhagic complications were more likely to occur in AC compared to NOAC patients (17.0% vs. 0%, p=0.019). Conclusion: In this retrospective study, use of novel oral anticoagulants for CAD was associated with similar rates of recurrent stroke and vessel recanalization on follow-up imaging but with fewer hemorrhagic complications. Given their safety profile, NOACs may be a reasonable alternative to traditional anticoagulants in CAD. Prospective validation of these findings is needed.

Correction: Antiplatelets versus Anticoagulants for the Treatment of Cervical Artery Dissection: Bayesian Meta-Analysis

Correction: Antiplatelets versus Anticoagulants for the Treatment of Cervical Artery Dissection: Bayesian Meta-Analysis

Antiplatelets versus anticoagulants for the treatment of cervical artery dissection: Bayesian meta-analysis.

ObjectiveTo compare the effects of antiplatelets and anticoagulants on stroke and death in patients with acute cervical artery dissection.DesignSystematic review with Bayesian meta-analysis.Data SourcesThe reviewers searched MEDLINE and EMBASE from inception to November 2012, checked reference lists, and contacted authors.Study SelectionStudies were eligible if they were randomised, quasi-randomised or observational comparisons of antiplatelets and anticoagulants in patients with cervical artery dissection.Data ExtractionData were extracted by one reviewer and checked by another. Bayesian techniques were used to appropriately account for studies with scarce event data and imbalances in the size of comparison groups.Data SynthesisThirty-seven studies (1991 patients) were included. We found no randomised trial. The primary analysis revealed a large treatment effect in favour of antiplatelets for preventing the primary composite outcome of ischaemic stroke, intracranial haemorrhage or death within the first 3 months after treatment initiation (relative risk 0.32, 95% credibility interval 0.12 to 0.63), while the degree of between-study heterogeneity was moderate (τ2 = 0.18). In an analysis restricted to studies of higher methodological quality, the possible advantage of antiplatelets over anticoagulants was less obvious than in the main analysis (relative risk 0.73, 95% credibility interval 0.17 to 2.30).ConclusionIn view of these results and the safety advantages, easier usage and lower cost of antiplatelets, we conclude that antiplatelets should be given precedence over anticoagulants as a first line treatment in patients with cervical artery dissection unless results of an adequately powered randomised trial suggest the opposite.

Correction

HomeCirculationVol. 124, No. 4Correction Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection Originally published26 Jul 2011https://doi.org/10.1161/CIR.0b013e31822771a4Circulation. 2011;124:e145This article corrects the following2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive SummaryIn the article by Brott et al, “2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery,” which published ahead of print on January 31, 2011, and appeared in the July 26, 2011, issue of the journal (Circulation. 2011;124:489–532), several corrections were needed.On page 489, in the footnotes, the web links have been updated in paragraphs 7, 8, and 9.On page 505, the footnote to Table 3, last paragraph, read “Reprinted with permission from Sacco et al.4” It should read “Modified with permission from Sacco et al.4”On page 500, in the left column, “Section 18. Recommendations for Management of Patients With Cervical Artery Dissection,” the Class IIa Recommendation 1 read:For patients with symptomatic cervical artery dissection, anticoagulation with intravenous heparin (dose adjusted to prolong the partial thromboplastin time to 1.5 to 2.0 times the control value) followed by warfarin (dose-adjusted to achieve a target INR of 2.5 [range 2.0 to 3.0]), low-molecular-weight heparin (in the dose recommended for treatment of venous thromboembolism with the selected agent) followed by warfarin (dose-adjusted to achieve a target INR of 2.5 [range 2.0 to 3.0]), or oral anticoagulation without antecedent heparin can be beneficial for 3 to 6 months, followed by antiplatelet therapy with aspirin (81 to 325 mg daily) or clopidogrel (75 mg daily).(Level of Evidence: C)It should read:Antithrombotic treatment with either an anticoagulant (heparin, low-molecular-weight heparin, or warfarin*) or a platelet inhibitor (aspirin, clopidogrel, or the combination of extended-release dipyridamole plus aspirin*) for at least 3 to 6 months is reasonable for patients with extracranial carotid or vertebral arterial dissection associated with ischemic stroke or TIA.72a–72d(Level of Evidence: B)*Drugs are not listed in order of preference.On page 519, in the References, the following were added:72a. Metso TM, Metso AJ, Helenius J, et al. Prognosis and safety of anticoagulation in intracranial artery dissections in adults. Stroke. 2007;38:1837–42.72b. Engelter ST, Brandt T, Debette S, et al, for the Cervical Artery Dissection in Ischemic Stroke Patients (CADISP) Study Group. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke. 2007;38:2605–11.72c. Menon R, Kerry S, Norris JW, Markus HS. Treatment of cervical artery dissection: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2008;79:1122–7.72d. Georgiadis D, Arnold M, von Buedingen HC, et al. Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients. Neurology. 2009;72:1810–5.These corrections have been made to the print version and to the current online version of the article, which is available at http://circ.ahajournals.org/cgi/reprint/124/4/489. Previous Back to top Next FiguresReferencesRelatedDetailsRelated articles2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive SummaryThomas G. Brott, et al. Circulation. 2011;124:489-532 July 26, 2011Vol 124, Issue 4 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIR.0b013e31822771a4 Originally publishedJuly 26, 2011 PDF download Advertisement

Treatment of cervical artery dissection: a systematic review and meta-analysis

Background and purpose:Cervical dissection is an important cause of stroke in the young. This paper presents a systematic review and a meta-analysis to assess the effectiveness of different treatment approaches:...