Antti J. Metso, Tiina M. Metso and Turgut Tatlisumak
Local Symptoms and Recanalization in Spontaneous Carotid Artery Dissection
Copyright © 2009 American Heart Association. All rights reserved. Print ISSN: 0039-2499. Online
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Local Symptoms and Recanalization in
Spontaneous Carotid Artery Dissection
To the Editor:
We congratulate Nedeltchev and coworkers for their merito-
rious report1on recanalization of spontaneous internal carotid
artery dissection. The strengths of this work are a fairly large
patient population compared with most previous reports and the
repeated ultrasound examinations of the vasculature at 1, 3, 6,
and 12 months. Recanalization always occurred within 6 months,
but not later. We, having similar experience, currently repeat
vascular imaging only at 6 months.
Nedeltchev et al discuss that they did not detect any beneficial
effect of complete recanalization and refer to 2 articles that do not
directly support their view; of these, one is a small study on 60
cervical artery dissection patients treated with anticoagulants2and
the second3is a review in Spanish that discusses the merits of
thrombolysis in acute ischemic stroke. In patients with carotid artery
dissection, ischemic stroke may occur either by artery-to-artery
embolism or by hemodynamic mechanisms. The risk for embolism
is substantially reduced with timely anticoagulation, and prevention
of hemodynamic infarction may not require complete recanaliza-
tion, but modest recanalization may establish enough blood flow.
Although most of their patients may have had late recanalization,
still it would be interesting to see if different levels of recanalization
correlated with clinical outcome. We recently showed that patients
in whom complete recanalization occurred within 6 months from
symptom onset returned to work more often.4
Nedeltchev et al state in their “Results” that presentation with
local symptoms and signs only increased the likelihood of
recanalization. Local symptoms included headache, neck pain,
pulsatile tinnitus, Horner syndrome, and cranial nerve palsy, all
ipsilateral to the spontaneous internal carotid artery dissection.
They suggest that an outward-expanding hematoma could ex-
plain the association of local symptoms and the tendency to
recanalize, whereas inward expansion of the artery wall would
cause less local symptoms and a tendency not to recanalize. This
interpretation about the location of the hematoma versus recan-
alization is logical but speculative and requires confirmation by
imaging data. Their series and others indicate that initial stenosis
compared with initial occlusion. Emphasizing the presence of local
symptoms and signs may lead to false conclusions about their
prognostic significance. Patients who sustain less severe strokes,
or no brain ischemia at all, are more likely to spontaneously
report these minor symptoms and most of them, indeed, arrive to
medical attention particularly with those complaints. On the
other hand, local symptoms such as pain and tinnitus experienced
by patients with more severe strokes are more likely to be
overlooked and underestimated or cannot be reported at all due to
barriers such as aphasia, inattention, or depressed consciousness.
In the “Results,” the authors write that there were 79 patients
who presented with local symptoms only that were associated
with a high rate of complete recanalization. However, several
typographic errors in Table 3 obscure this finding, and the patient
numbers used for statistical analysis may be erroneous. Surpris-
ingly, migraine was found in 30 patients, a figure much lower
than expected. On the other hand, we fully agree with the authors
on the use of Rankin 0 to 1 as a favorable outcome.5A patient
with a Rankin score of 2 will be independent in daily life but will
not return to his or her work. Patients with carotid artery
dissection are mostly young to middle-aged adults and working
ability after carotid artery dissection is critical for most of them.
Regarding the risks and benefits of anticoagulation and anti-
platelet therapies6and for many other unanswered questions in
the carotid artery dissection field, multicenter collaborations with
large numbers of patients such as the Cervical Artery Dissection
in Ischemic Stroke Patients (CADISP) network7are needed
instead of overinterpreting results from small patient series.
Antti J. Metso, MD, PhD
Tiina M. Metso, MD
Turgut Tatlisumak, MD, PhD
Department of Neurology
Helsinki University Central Hospital
1. Nedeltchev N, Bickel S, Arnold M, Sarikaya H, Georgiadis D, Stur-
zenegger M, Mattle HP, Baumgartner RW. Recanalization of spontaneous
carotid artery dissection. Stroke. 2009;40:499–504.
2. Desfontaines P, Despland PA. Dissection of the internal carotid artery:
aetiology, symptomatology, clinical and neurosonological follow-up, and
treatment in 60 consecutive cases. Acta Neurol Belg. 1995;95:226–234.
therapeutic option at our disposal [in Spanish]. Rev Neurol. 2007;45:42–52.
4. Metso TM, Metso AJ, Salonen O, Haapaniemi E, Putaala J, Artto V, Helenius
J, Kaste M, Tatlisumak T. Adult cervicocerebral artery dissection: a single-
center study of 301 Finnish patients. Eur J Neurol. 2009;16:656–661.
5. Putaala J, Metso AJ, Metso TM, Konkola N, Kraemer Y, Haapaniemi E,
Kaste M, Tatlisumak T. Analysis of 1008 consecutive patients aged 15 to
49 with first-ever ischemic stroke. The Helsinki Young Stroke Registry.
6. Engelter ST, Brandt T, Debette S, Caso V, Lichy C, Pezzini A, Abboud S,
Bersano A, Dittrich R, Grond-Ginsbach C, Hausser I, Kloss M, Grau AJ,
Tatlisumak T, Leys D, Lyrer PA. Antiplatelets versus anticoagulation in
cervical artery dissection. Stroke. 2007;38:2605–2611.
7. Debette S, Metso TM, Pezzini A, Engelter ST, Leys D, Lyrer P, Metso AJ,
V, Bersano A, Grau A, Altintas A, Amouyel P, Tatlisumak T, Dallongeville J,
Grond-Ginsbach C; on behalf of the CADISP-group. CADISP-genetics: an
international project searching for genetic risk factors of cervical artery dis-
sections. Int J Stroke. 2009;3:224–230.
KEY WORDS: carotid artery?dissection?embolism?stroke in young adults
© 2009 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.109.552463
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