Vertebral Artery Dissection Patients Research Articles

Clinical characteristics and management of vertebral artery dissection without definitive imaging features: A single center cohort study

BackgroundManagement of vertebral artery dissection (VAD), which is difficult to diagnose definitively on imaging, is a clinical concern. The aim of this study was to clarify the clinical characteristics of VAD without definitive imaging features and evaluate our clinical decisions and their consequences. MethodsWe searched our database to identify patients with VAD registered between January 2008 and December 2021. We performed a retrospective chart review to obtain detailed clinical information and compared the clinical characteristics and radiological findings between patients with definitive VAD and those with non-definitive VAD by radiological findings at the initial evaluation. ResultsOf 188 patients (mean age 52.7 ± 12.3 years, 121 male), 127 had definitive VAD. Patients in the definitive group had a younger average age and a high rate of intramural hematoma, while those in the non-definitive group were more likely to have a history of hypertension. Overall, the prognosis was good for the majority (n = 163), and there was no significant difference in the prognosis between two groups. Especially, the prognosis of non-definitive VAD patients without stroke was favorable. ConclusionsCases of non-definitive VAD are likely to be complicated by atherosclerotic changes. Therefore, clinicians should carefully evaluate the potential etiologies based on the clinical history and imaging data to provide patients with the optimal treatment options. Identification of IMH was an important factor to make a definitive diagnosis, and the vessel wall imaging is a useful imaging modality for the purpose.

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.

Clinical Characteristics, Course, and Outcomes of Vertebral Artery Dissections in the Postpartum Period; a Pooled Analysis of Published Case Reports.

Vertebral artery dissection (VAD) is a rare, but life-threatening condition. Compared to the general population, pregnant and postpartum women are more likely to develop VAD. Spontaneous arterial dissections have an ambiguous pathophysiology and may be difficult to manage. This study aimed to pool and analyze the data of published cases in this regard. We conducted a literature search on February 24, 2022, using MeSH terms of interest in PubMed, Google Scholar, Ovid, Web of Science, and Scopus databases to find studies on VAD following childbirth. A total of 28 studies were included in this review based on a database search. In the studies, 44 postpartum VAD (PPVAD) patients with a mean age of 34.26 ± 3.5 years were included. It took an average of 24.37± 13.7 days from delivery to dissection. 64% of the patients had developed unilateral dissection and 36% had developed bilateral dissection; 70% reported full recovery, and 9% did not achieve full recovery. The most common symptoms were headaches (89%), neck pain (64%), and hypertension (52%). The most common methods of diagnosis were magnetic resonance imaging (MRI) (64%) and computed tomography (CT) angiography (CTA) scan (66%). Only 8 (18%) cases reported the use of electrocardiography (ECG). The recorded outcomes of the patients with unilateral and bilateral postpartum VAD showed no statistical difference. Most of the included studies recommend early suspension and management for a better prognosis and prevention of complications. PPVAD is a severe medical condition but most cases were fully recovered after an early and proper antithrombotic plan for each case scenario.

Headache characteristics and frequency of migraine in patients with cervical artery dissections.

Headache is a common symptom of cervical artery dissections (CAD). Sometimes, it can be the only symptom and mimic migraine. We aimed to investigate headache characteristics and previous history of migraine in CAD patients, and to compare headache features between patients with internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD). We investigated 53 CAD patients (n = 28 with ICAD, n = 25 with VAD). Demographic and clinical data were evaluated retrospectively. Headache information was obtained from the patient interviews with a structured questionnaire (based on the International Headache Society criteria). The patients withheadache were assessed by headache specialist with a face-to-face interview. Headache was evaluated according to International Classification Committee of the International Headache Society ICHD. Headache (n = 38, 71.7%) was the most common symptom in CAD patients, which was mostly thunderclap, throbbing, intense and ipsilateral to dissection. Headache frequency and neck pain were significantly higher in VAD patients (p = 0.002, p < 0.001, respectively). Photophobia and phonophobia were also more common in patients with VAD (p < 0.001, p < 0.001, respectively). 29 (54.7%) of CAD patients had a prior history of headache, that 20 (37.7%) of them met the migraine criteria. CAD should be considered in patients with severe unilateral throbbingheadache with phonophobia and photophobia,even inpatients witha history of migraine. Phonophobia andphotophobia may be more common symptoms in VAD patients.Because headache commonly precedes the development of cerebral ischemic events, it needs prompt and accurate diagnosis and treatment.

351 The Diagnosis of Carotid and Vertebral Artery Dissections by Emergency Physicians is Rare

Carotid and vertebral artery dissections are rare events. The most frequent symptoms are head and neck pain and neurological deficits, but these are common emergency department (ED) chief complaints and other diseases causing these occur much more often. Furthermore, about one-third of patients have no headache, one-third have no neck pain and over 10% have no neurologic deficits. For these reasons, diagnosing dissections is challenging. We wished to quantify the magnitude of this problem in a large ED database. Our goal was to determine the number of total ED visits for every carotid and vertebral artery dissection diagnosed by ED physicians. Design: Multicenter retrospective cohort. Setting: 27 suburban and urban New York and New Jersey EDs with annual visits between 20,000 and 119,000. Participants: Patients seen by ED physicians in the four-year period from 11-1-2015 through 10-31-2019. Observations: We identified carotid and vertebral artery dissections using ICD-10 codes. We then calculated the number of ED visits for every carotid and vertebral artery dissection, along with 95% confidence intervals (CIs). From a database of 6,223,499 ED visits, we identified 115 carotid artery dissections and 97 vertebral artery dissections. The median ages (with interquartile ranges) and percent female of carotid and vertebral artery dissection patients were 54 years (41, 64), 47 years (38, 63), 55% and 51%, respectively. Of the total ED visits there was one carotid artery dissection for every 54,117 (95% CI 45,089 to 64,953) visits and one vertebral artery dissection for every 64,160 (95% CI 52,599 to 78,261) visits. The diagnosis of carotid and vertebral artery dissections by ED physicians is rare. An ED physician seeing 3,000-4000 patients a year would diagnose one carotid artery dissection every 13 to18 years and one vertebral artery dissection every 16 to 21 years.Tabled 1Row LabelsCount of Billed ICD DescriptionNumber of visits for each diagnosisDissection of carotid artery11554117.38Dissection of renal artery23111750Dissection of vertebral artery9764159.78Extradural and subdural abscess, unspecified7286437.49Intraspinal abscess and granuloma12649392.85total visits622349927 hospitals Open table in a new tab

Genetic analysis of ring finger protein 213 (RNF213) c.14576G>A polymorphism in patients with vertebral artery dissection: a comparative study with moyamoya disease

ABSTRACTBackground: Intracranial vertebral artery dissection (VAD) and moyamoya disease (MMD) are rare cerebrovascular diseases, both of which have an ethnic predominance in the East Asian population. Disruption of the internal elastic lamina and subsequent rupture of the medial layer result in intracranial VAD. MMD is a chronic occlusive cerebrovascular disease of unknown etiology, in which the medial layer and internal elastic lamina of the intracranial arteries are significantly compromised. Recent genetic studies found ring finger protein 213 (RNF213) to be an important susceptibility gene for MMD in East Asian patients, but the association between VAD and RNF213 has not been investigated. .Methods: We investigated polymorphism of the RNF213 gene (c.14576G>A) in genomic DNA of 24 patients with intracranial VAD in comparison with 58 patients with definitive MMD and 48 healthy controls.Results: Although RNF213 gene polymorphism (c.14576G>A) was evident in 69% of the MMD patients (40/58), none of the patients with intracranial VAD had this characteristic polymorphism (0/24, p < 0.001). The incidence of RNF213 c.14576G>A polymorphism was 4.2% in healthy controls (2/48). After adjustment by age and sex, the incidence of RNF213 c.14576G>A was significantly lower in intracranial VAD patients (p = 0.021) than that in MMD patients.Conclusions: In contrast to MMD patients, the prevalence of RNF213 c.14576G>A polymorphism was significantly lower in patients with intracranial VAD. The RNF213 gene polymorphism may preferentially affect the cerebrovascular lesion in the anterior circulation, which is originated from the primitive internal carotid arteries. The genetic background underlying intracranial VAD should be elucidated in future studies.Abbreviations: VAD: vertebral artery dissection; MMD: moyamoya disease; RNF213: ring finger protein 213; CAD: carotid artery dissection

The Comparison of Clinical Findings and Treatment Between Unilateral and Bilateral Vertebral Artery Dissection

Background: There are limited clinical studies of bilateral vertebral artery dissection (VAD). Objective: To compare the characteristics, imaging findings, and treatments between patients with bilateral and unilateral VAD. Methods: Between February 2007 and May 2017, 31 (mean age: 53.0 years; 23 men, 8 women) out of 171 VAD patients were hospitalized because of bilateral VAD. Onset type, dissection site, dominant side of the VA, imaging features, treatments, and outcomes were investigated based on medical records. The dominant side of the VA was determined by basi-parallel anatomical scanning. Results: Twenty (64.5%) of 31 patients exhibited bilateral VAD on both sides of V4. The dominant side of the VA was right in 16 patients and left in 15 patients. The pearl and string sign (an angiographical finding with both dilatation and stenosis) was frequently observed on the dominant VAD side, while a tapered occlusion and string sign were most common on the nondominant side. For clinical subtype of VAD, 6 (19.4%) patients had subarachnoid hemorrhage, 10 (32.3%) ischemic stroke, 3 (9.7%) infarction plus subarachnoid hemorrhage, and 12 (38.7%) only headache. The frequency of infarction was increased in bilateral VAD compared with unilateral (P < .05). Surgical intervention was performed in 3 cases, while 14 patients received endovascular intervention. Conclusions: Infarction occurred frequently in bilateral VAD patients, and 17 patients required an intervention (mainly endovascular) for VA. The treatment strategy varied depending on the clinical subtype, imaging findings of VAD, and morphology of the dominant VAD side.

Spontaneous intracranial vertebral artery dissection with acute ischemic stroke: High-resolution magnetic resonance imaging findings.

Background Acute ischemic stroke (AIS) more frequently develops in patients with intracranial vertebral artery dissection (VAD) than extracranial VAD, and is associated with possible poor clinical outcomes. The aim of this study is to compare high-resolution magnetic resonance imaging (HR-MRI) findings and clinical features of VAD with and without AIS. Methods Twenty-nine lesions from 27 patients (15 male and 12 female patients; age range = 28-73 years) who underwent diffusion MRI and 3T HR-MRI within seven days were included. We classified VAD according to the presence of AIS lesions on diffusion MRI. Clinical features and HR-MRI findings (angiographic patterns, presence of double lumen sign, dissecting flap, posterior inferior cerebellar artery involvement, remodeling index, length of affected vessels, T1-signal intensity, area of intramural hematoma, and grades and patterns of vessel wall enhancement) were evaluated. Results Thirteen VADs with AIS and 16 without AIS were included. There were no significant differences in the clinical parameters (sex, age, risk factors, symptoms). More VADs with AIS presented as a steno-occlusive pattern than VADs without AIS. More VADs without AIS presented with aneurysmal dilation, larger mean remodeling index and longer mean length than VADs with AIS. Presence of intramural hematoma, T1-iso-signal intensity of intramural hematoma and contrast enhancement were significantly more common in VADs with AIS than without AIS. Conclusions Our study showed some differences in HR-MRI comparing intracranial VAD patients with and without AIS. Differing findings may facilitate a better understanding of intracranial VAD and risk assessment of AIS in these patients.

Abstract TP283: Nationwide Trends of Thirty Day Readmissions : Carotid Versus Vertebral Artery Dissections

Introduction: Carotid and vertebral artery dissection significantly increases risk of ischemic stroke. Due to variability in treatment for stroke prevention and different mechanisms of dissection-related stroke, it is important to understand differences in 30 day unplanned readmission rates (30RR) and related causes of readmission in this population. Methods: We used the year 2014 NRD (Nationwide Readmission Database) which is designed to generate national estimates of readmission. The patients with carotid and vertebral dissections were identified by primary discharge diagnosis with ICD9-CM code 443.21 and 443.24. All causes of 30RR were calculated for patients admitted between January and November 2014 by excluding elective readmissions. Differences in readmission rates due to different causes were examined with univariate analysis. Results: The NRD contained 1164 (Weighted N = 2550) admissions due to carotid dissection (CD), and 1244 (Weighted N = 2644) admissions due to vertebral dissections (VD). There was no significant difference for comparing average age of readmitted patients [57.5 years (CD) Vs. 56.74 years (VD), p=0.49]. 30RR for CD (15.45%) was higher compared to VD (13.43%) (p=0.037). Major cause specific 30RR in CD and VD included acute cerebrovascular event (4.54% vs 6.43%, p=0.004), sepsis (0.07% vs 0.06%, p= 0.78) and TIA (0.07% vs 0.04%, p=0.09). Conclusion: The 30RR for acute cerebrovascular events was elevated in carotid and vertebral dissection patients in a nationally representative readmission database. Although the 30RR is higher for carotid compared to vertebral artery dissection, acute cerebrovascular event related readmissions remains significantly high in vertebral artery dissection patients. Further investigations are necessary to explore these differences, including analysis of the various treatments and the specific anatomic features of these dissections.

The comparative study of CT angiography with DSA in vertebral artery dissection

Objective To explore the diagnostic value of CT angiography (CTA) of vertebral artery dissection (VAD) value. Methods We retrospectively analysed vertebral artery dissection in 30 patients (32 branches) according to the results of DSA. Tow radiologists independently analyzed the CTA images, and the sensitivity, specificity and accuracy of CTA in VAD patients were determined. The consistency of DSA and CTA results were evaluated by Kappa test. Results Thirty two branches of 60 vertebral arteries were diagnosed as VAD by DSA, 31 branches were diagnosed as VAD by CTA, 1 branch was misdiagnosis. Eight branches with dissection aneurysm were all displayed by CTA and DSA. Eleven branches of 12 branches withstring of beads signwere diagnosed by CTA. Five branches of 6 branches withstring and pearl signwere diagnosed by CTA;CTA and DSA of 1 branch withdouble-lumen signwere all displayed. Six branches of 5 branch withlinear signwere diagnosed by CTA. One branch showedlinear sign, but was diagnosed thrombosis by CTA. Two branches were showedlinear sign, but were diagnosedstring of beads signandstring and pearl sign. The sensitivity, specificity, accuracy of CT angiography in diagnosing VA dissection were 96.8% (31/32) , 100% (28/28) , 98.3% (59/60) , respectively. The results made good agreement with DSA(Kappa=0.967, P<0.01). Conclusion Dual source CTA was a sensitive and accurate technique for the diagnosis of VAD. Key words: Vertebral artery dissection; Tomography, X-ray computed; Angiography

Cervical Artery Dissection in Young Adults in the Stroke in Young Fabry Patients (sifap1) Study

Background: Patients with carotid artery dissection (CAD) have been reported to have different vascular risk factor profiles and clinical outcomes to those with vertebral artery dissection (VAD). However, there are limited data from recent, large international studies comparing risk factors and clinical features in patients with cervical artery dissection (CeAD) with other TIA or ischemic stroke (IS) patients of similar age and sex. Methods: We analysed demographic, clinical and risk factor profiles in TIA and IS patients ≤55 years of age with and without CeAD in the large European, multi-centre, Stroke In young FAbry Patients 1 (sifap1) study. Patients were further categorised according to age (younger: 18-44 years; middle-aged: 45-55 years), sex, and site of dissection. Results: Data on the presence of dissection were available in 4,208 TIA and IS patients of whom 439 (10.4%) had CeAD: 196 (50.1%) had CAD, 195 (49.9%) had VAD, and 48 had multiple artery dissections or no information regarding the dissected artery. The prevalence of CAD was higher in women than in men (5.9 vs. 3.8%, p < 0.01), whereas the prevalence of VAD was similar in women and men (4.6 vs. 4.7%, n.s.). Patients with VAD were younger than patients with CAD (median = 41 years (IQR = 35-47 years) versus median = 45 years (IQR = 39-49 years); p < 0.01). At stroke onset, about twice as many patients with either CAD (54.0 vs. 23.1%, p < 0.001) or VAD (63.4 vs. 36.6%, p < 0.001) had headache than patients without CeAD and stroke in the anterior or posterior circulation, respectively. Compared to patients without CeAD, hypertension, concomitant cardiovascular diseases and a patent foramen ovale were significantly less prevalent in both CAD and VAD patients, whereas tobacco smoking, physical inactivity, obesity and a family history of cerebrovascular diseases were found less frequently in CAD patients, but not in VAD patients. A history of migraine was observed at a similar frequency in patients with CAD (31%), VAD (27.8%) and in those without CeAD (25.8%). Conclusions: We identified clinical features and risk factor profiles that are specific to young patients with CeAD, and to subgroups with either CAD or VAD compared to patients without CeAD. Therefore, our data support the concept that certain vascular risk factors differentially affect the risk of CAD and VAD.

Neck pain and headache as the only manifestation of cervical artery dissection

To analyze clinical and neuroimaging data in patients with neck pain and headache as the only manifestation of the internal carotid artery (ICA) dissection (ICAD) and vertebral artery (VA) dissection (VAD). One hundred and sixty-one patients (mean age - 37.4±4,99 years, 84 women, 52%) with cervical artery dissection (CAD) verified by magnetic resonance imaging (MRI) were enrolled. Neck pain and headache were the only CAD manifestation in 33 patients (mean age 37,3±7,4 yars, 28 women, 85%). The localization of the dissections in these patients was the following: one VA (15 patients), two VA (9), one ICA (7), two ICA (1), one ICA + two VA (1). The whole number of dissected arteries was 45: extracranial localization - 38, extra-intracranial - 6, intracranial - 1. Dissection led to stenosis of the arterial lumen in 41 arteries, to occlusion - in 2 and to dual lumen in 2 arteries. Small aneurism was found in 4 arteries. Combination of headache and the neck pain was observed in 26 out of 33 patients (79%), the only headache in 4 patients, the only neck pain in 3 patients. Along with this, 9 out of 24 VAD patients had the shoulder and/or arm pain. Headache in VAD patients was located more often in the occipital region (18 out of 24) that had never been observed in ICAD patients (p=0.0009). Fronto-temporal pain was observed more often in ICAD patients (5 out of 8 patients) than in VAD (2 out of 24 patients) (p=0.003). Neck pain in all VAD patients in comparison with 3 out ofI8 [CAD patients had posterior localization (p=0,007). Anterolateral neck pain was observed in 4 out ofI8 ICAD patients and in no patients with VAD (p=0.0009). The pain appearance was abrupt in all ICAD patients and most of the VAD patients. In 8 VAD patients the pain has been increasing during several hours. The pain intensity was severe in 19 patients, moderate in 12 and mild in 2. The characteristics of the pain were as following: constrictive/dull (26 patients), throbbing (1 patient) or combined (6 patients). Pain was increasing in a stepwise manner during the first days in 14 out of 24 VAD patients and in no one of ICAD patients (p=0.008). The mean pain duration period was 31 8 ± 15,7 days. Pain relief drugs were ineffective or had a short effect in 97% of patient. Isolated pain is more characteristic for women with VAD. Usually pain is presented as a combination of headache and neck pain. Pain localization, mode of appearance and the course are different in VAD and ICAD. The rarity of occlusion among patients with <<pain-only>> manifestation let to suggest that the intramural hematoma in this group of patients spreads to the adventitia that can reflect media weakness. Arterial wall changes underlying its weakness seem to be sex-hormone dependent taking into consideration the high predominace of women in cad manifested by isolated pain.

Clinical import of Horner syndrome in internal carotid and vertebral artery dissection.

To study the prognostic importance of Horner syndrome (HS) in patients with internal carotid artery dissection (ICAD) or vertebral artery dissection (VAD). In this observational study, characteristics and outcome of patients with ICAD or VAD from the CADISP (Cervical Artery Dissection and Ischemic Stroke Patients) database were analyzed. The presence of HS was systematically assessed using a standardized questionnaire. Patients with HS (HS+) were compared with HS- patients. Crude odds ratios (ORs) with 95% confidence intervals and ORs adjusted for age, sex, center, arterial occlusion, bilateral dissection, stroke severity, and type of antithrombotic treatment were calculated. We analyzed 765 patients (n = 496 with ICAD, n = 269 with VAD, n = 303 prospective, n = 462 retrospective). HS was present in 191 (38.5%) of the patients with ICAD and 36 (13.4%) of the patients with VAD (p < 0.001). HS+ ICAD patients presented less often with stroke or TIA (p < 0.001), less often had bilateral (p = 0.019) or occlusive (p = 0.001) dissections, and had fewer severe strokes (p = 0.041) than HS- ICAD patients. HS+ ICAD patients had a better functional 3-month outcome than those without HS (ORcrude = 4.0 [2.4-6.7]), and also after adjustment for outcome-relevant covariates (ORadjusted = 2.0 [1.1-4.0]). HS+ ICAD patients were less likely to have new strokes than HS- ICAD patients (p = 0.039). HS+ VAD patients more often had vessel occlusion (p = 0.014) than HS- patients but did not differ in any of the other aforementioned variables. In patients with ICAD, HS is an easily assessable marker that might indicate a more benign clinical course. HS had no prognostic meaning in patients with VAD.

Comparison of Potential Risks between Intracranial and Extracranial Vertebral Artery Dissections

Background/Aims: To better understand potential risks for vertebral artery (VA) dissection (VAD), we compared intracranial and extracranial VADs. Methods: We analyzed consecutively admitted VAD patients over a 9-year period in whom VAD was confirmed by angiography. All patients were categorized as having intracranial or extracranial VAD, and demographic and radiological characteristics of VAD were compared. We used multivariate analysis to predict the risks for intracranial and extracranial VADs. Results: The study population (n = 74) had a mean age of 46.0 ± 10.3 years. VAD was more frequent in the nondominant VA (n = 49, 66.2%). Vertical nidus of VAD was more common in the intracranial segment (81.1%), and more particularly it was most frequently located within a 2-mm perimeter of the posterior inferior cerebellar artery (PICA) orifice (60.0%). Absence of traumatic history (OR 13.1, 95% CI 1.6-107.4; p = 0.016), history of hypertension (OR 14.1, 95% CI 1.1-184.6; p = 0.043) and aging (OR 1.1 per 1-year increase, 95% CI 1.0-1.2; p = 0.038) were independent predictors of intracranial VAD. Conclusion: As compared to extracranial VAD, intracranial VAD was particularly frequent and particularly vulnerable at the perimeters of the PICA and nondominant VA and was associated with an absent trauma history, hypertension and aging. Formation of VAD appeared to be different according to intracranial or extracranial involvement.

Incidence and Outcome of Vertebral Artery Dissection in Trauma Setting: Analysis of National Trauma Data Base

The natural history and epidemiological aspects of traumatic vertebral artery dissection (VAD) are not fully understood. We determined the prevalence of VAD and impact on outcome of patients with head and neck trauma. All the patients who were admitted with traumatic brain injury or head and neck trauma were identified by ICD-9-CM codes from the National Trauma Data Bank (NTDB), using data files from 2009 to 2010. NTDB represents one of the largest trauma databases and contains data from over 900 trauma centers across the United States. Presence of VAD was identified in these patients by using ICD-9-CM codes. Admission Glasgow Coma Scale (GCS) score, injury severity score (ISS), in-hospital complications, and treatment outcome were compared between patients with and without VAD. A total of 84 VAD patients were identified which comprised 0.01 % of all patients admitted with head and neck trauma. The mean age (in years) for patients with VAD was significantly higher than patients without dissection [46 (95 % CI 41-50) vs. 41.3 (95 % CI 41.2-41.4); p = 0.003]. The proportion of patients presenting with GCS score <9 was significantly higher in patients with VAD (31 vs. 12 %, p < 0.0001). The rate of cervical vertebral fracture was significantly higher in patients with VAD (71 vs. 11 %, p < 0.0001). Patients with VAD had higher rates of in-hospital stroke than patients without dissection (5 vs. 0.2 %, p < 0.0001). Numbers of ICU days, ventilator days, and hospital length of stays were all significantly higher in patients with VAD. These differences remained significant after adjusting for the demographics, admission GCS score, and ISS (p < 0.0001). A total of 7 % (N = 6) of the patients with VAD received endovascular treatment and there was no in-hospital stroke in these patients. Patients with VAD had a higher chance of discharge to nursing facilities in comparison to head trauma patients without VAD (OR: 2.1; 95 % CI 1.4-3.5; p < 0.0001). Although infrequent, VAD in head and neck trauma is associated with higher rates of in-hospital stroke and longer length of ICU stay and total hospital stay. Early diagnosis and endovascular treatment may be an alternative option to reduce the rate of in-hospital stroke in these patients.

Abstract WMP45: Incidence and Outcome of Vertebral Artery Dissection in Trauma Setting: Analysis from National Trauma Data Base (NTDB)

Background: Vertebral artery dissection (VAD) is an important cause of stroke in young adults. The natural history and epidemiological aspects of traumatic VAD are not fully understood. We determined the prevalence and outcome of dissection of the vertebral artery in a trauma setting. Methods: All patients who were admitted with traumatic brain injury or head and neck injury were identified by ICD-9-CM codes from the National Trauma Data Bank (NTDB), using data files from 2009 to 2010. NTDB represents one of the largest trauma databases and contains data from over 900 trauma centers across the United States. Presence of VAD was identified in these patients by using ICD-9-CM codes. Admission Glasgow Coma Scale (GCS), Injury Severity Score (ISS), in-hospital complications and treatment outcomes were compared between patients with VAD to patients without vascular dissection. Results: A total of 84 VAD patients were identified which comprised 0.1% of all patients admitted with head and neck injury. The mean age for patients with VAD was significantly higher than patients without dissection [46 (95% CI: 41-50) versus 41.3 (95% CI: 41.2-41.4); p= 0.003]. The admission GCS score was significantly lower in patients with VAD with 31% of these patients presenting with GCS&lt;9 (p=&lt;.0001). Patients with VAD had higher rate of in-hospital stroke than the patients without dissection (5% versus 0.2%; p=&lt;.0001). Numbers of ICU days, ventilator days, and hospital length of stays were all significantly higher in patients with VAD. These differences remained significant after adjusting for the demographics, admission GCS and ISS (p=&lt;.0001). Only 8% of the patients with VAD received endovascular treatment and there was no in-hospital stroke in these patients. Discharge destination and in-hospital mortality was not different in patients with VAD compared with other patients with head and neck injury. Conclusion: Although infrequent, vertebral artery dissection in head and neck trauma is associated with higher rates of in-hospital stroke and greater length of ICU and hospital stay. Considering the risks associated with anticoagulation in trauma setting, endovascular treatment may be an alternate option to reduce in-hospital complications in these patients.

A Novel Method for Transcranial Doppler Microembolic Signal Monitoring at the Vertebrobasilar Junction in Vertebral Artery Dissection Patients

Vertebral artery dissection (VAD) is one of the most important etiologies in young stroke patients. VAD causes ischemic stroke by embolism and transcranial Doppler (TCD) monitoring can detect microemboli originating from the dissection point as high intensity transient signals (HITS). We developed a simple but novel method of TCD monitoring at the vertebrobasilar junction in VAD patients. We placed a Welder TCD headband upside down on the patient's head and rotated it by 90°. Then we fixed a pulsed-wave 2-MHz TCD probe to the headband and put it on the suboccipital paramedian area of the patient. With a patient in the lateral decubitus position, the vertebrobasilar junction was identified at a depth of approximately 80 mm. We examined 11 patients with VAD and detected HITS in 2 patients (18%). In 1 patient HITS disappeared after heparinization, and in the other patient HITS disappeared after treatment with aspirin. All of 9 HITS-negative patients and 1 of 2 HITS-positive patients experienced no ischemic recurrence during hospitalization. We successfully detected HITS at the vertebrobasilar junction in VAD patients, which may lead not only to an appropriate choice of antithrombotic drugs but also to individual evaluation of early risk of ischemic recurrence.

Imaging Characteristics of Symptomatic Vertebral Artery Dissection

Vertebral artery dissection (VAD) is an important cause of stroke in the young. VAD can present with a range of imaging findings. We sought to summarize the diagnostic value of various imaging findings in patients with symptomatic VAD. We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality and imaging data were abstracted. Pooled proportions were calculated. Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. Most studies utilized conventional angiography or magnetic resonance angiography (MRA) to diagnose VAD; computed tomographic angiography (CTA) and Doppler ultrasonography were described less frequently. Imaging findings reported were vertebral artery stenosis (51%), string and pearls (48%), arterial dilation (37%), arterial occlusion (36%), and pseudoaneurysm, double lumen, and intimal flap (22% each). In cases where conventional angiography was the reference standard, CTA was more sensitive (100%) than either MRA (77%) or Doppler ultrasonography (71%) (P=0.001). Imaging findings vary widely in patients with VAD, with no single radiographic sign present in the majority of VAD patients. Nonspecific radiographic signs predominate. CTA probably has greater sensitivity for dissection than MRA or ultrasound relative to conventional angiography. Higher quality studies on imaging techniques and radiographic criteria in subjects with VAD are needed. Future studies should compare imaging techniques in well-defined, undifferentiated populations of clinical VAD suspects.

Clinical Characteristics of Symptomatic Vertebral Artery Dissection

Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed with adverse consequences. We assessed the frequency of head/neck pain, other neurological symptoms, and cerebrovascular events in symptomatic VAD. We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality, and clinical data were abstracted. Pooled proportions were calculated. Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. The most common symptoms were dizziness/vertigo (58%), headache (51%), and neck pain (46%). Stroke was common (63%), especially with extracranial dissections (66% vs. 32%, P<0.0001), whereas transient ischemic attack (14%) and subarachnoid hemorrhage (10%) were uncommon. Subarachnoid hemorrhage was seen only with intracranial dissections (57% vs. 0%, P=0.003). Fewer than half of the patients had obvious trauma, and only 7.9% had a known connective tissue disease. Outcome was good (modified Rankin scale 0 to 1) in 67% and poor (modified Rankin scale 5 to 6) in 10% of patients. VAD is associated with nonspecific symptoms such as dizziness, vertigo, headache, or neck pain. Ischemic stroke is the most common reported cerebrovascular complication. VAD should be considered in the diagnostic assessment of patients presenting with dizziness or craniocervical pain, even in the absence of other risk factors. Future studies should compare clinical findings as predictors in well-defined, undifferentiated populations of clinical VAD suspects.