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Carotid and Vertebral Artery Dissection

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INTRODUCTIONCarotid and vertebral artery dissections are potentially disabling and yet probably under-diagnosed, and mainly seem to affect young and middle-aged people (Bogousslavsky et al. 1987). Our review focuses on the mechanisms, possible underlying causes, clinical manifestations, diagnostic tools, treatment and prognosis of both carotid and vertebral dissection.EPIDEMIOLOGYCervical artery dissection accounts for up to 20% of strokes in patients under 30 years of age (Bogousslavsky et al. 1987). The incidence of carotid dissection is about 2–3 per 100 000 per year (Schievink et al. 1993; Giroud et al. 1995); the incidence of cervical dissection must be higher because these figures do not take into account vertebral dissection (about 25% of all dissections), dissections without ischaemic events (20% of extracranial dissections) or asymptomatic dissections. Furthermore, dissections may be overlooked because the clinical manifestations resolve spontaneously and are not necessarily familiar to many emergency physicians. Most studies report either

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... The following risk factors are associated with an increased risk of either internal carotid or vertebrobasilar arterial pathology and should be thoroughly assessed during the patient history (Arnold and Bousser, 2005;Kerry et al, 2008): ...
... The following information is provided to assist in the differential diagnosis of musculoskeletal dysfunction from serious pathologies which commonly manifest as musculoskeletal dysfunction (Arnold and Bousser, 2005;Arnold et al, 2006;Kerry et al, 2008;Kerry, 2011): It is important to consider the above information in the context of the aforementioned risk factors. ...
... Further examples of similar cases can be found in the literature (Biousse et al, 1994;Lemesle et al, 1998;Crum et al, 2000;Zetterling et al, 2000;Chan et al, 2001;Caplan and Biousse, 2004;Arnold and Bousser, 2005;Asavasopon et al, 2005;Rogalewski and Evers, 2005;Taylor and Kerry, 2005;Thanvi et al, 2005;Arnold et al, 2006;Debette and Leys, 2009;Kerry and Taylor, 2009). Planning the physical examination ...
... 25,26 The non-ischemic presentation of vertebral dissection is typically ipsilateral posterior neck pain and/or occipital headache alone e Figure 3 (e.g. 2,8,15,59,71 ) Very rarely cervical root impairment (usually C5/6) can be present as a result of local neural ischemia. 18 These clinical features may then be followed by the ischemic events associated with vertebrobasilar dysfunction. ...
... These may also include some of the classic 5Ds and 3Ns as stated above, but may also include many other symptoms (see Table 2). 2,55,59 It is rare for posterior dysfunction to manifest in only one sign or symptom, and isolated dizziness or transient loss of consciousness are often misattributed to posterior circulation ischemia. 59 Dizziness is often reported as being one of the most common symptoms of VBI. 17 However, there have been cases reported when dizziness has not been present. ...
... The fronto-temporal headaches are often described as cluster-like, thunder-clap, migraine without aura, hemicrania continua, or simply "different from previous headaches". 2,13,56,63,69 The upper cervical or antero-lateral neck pain, facial pain and/or facial sensitivity are described in medical literature as "carotidynia". ...
Article
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This paper presents a clinical overview and update of cervical arterial dysfunction (CAD) for osteopaths and other clinicians who treat patients presenting with cervical pain and headache syndromes. An overview of a ‘system based’ approach to the concept of vertebrobasilar arterial insufficiency (VBI) is covered, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice remains limited and present a more holistic approach to considering cervical arterial dysfunction. This ‘system based’ approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors, pathomechanics and haemodynamics of arterial dysfunction is also given. We suggest that consideration of the information provided in this updated ‘Masterclass’ will enhance clinical reasoning with regard to differential diagnosis of cervical pain syndromes and prediction of serious adverse reactions to treatment.
... The following risk factors are associated with an increased risk of either internal carotid or vertebrobasilar arterial pathology and should be thoroughly assessed during the patient history (Arnold and Bousser, 2005;Kerry et al, 2008): ...
... The following information is provided to assist in the differential diagnosis of musculoskeletal dysfunction from serious pathologies which commonly manifest as musculoskeletal dysfunction (Arnold and Bousser, 2005;Arnold et al, 2006;Kerry et al, 2008;Kerry, 2011): It is important to consider the above information in the context of the aforementioned risk factors. ...
... Further examples of similar cases can be found in the literature (Biousse et al, 1994;Lemesle et al, 1998;Crum et al, 2000;Zetterling et al, 2000;Chan et al, 2001;Caplan and Biousse, 2004;Arnold and Bousser, 2005;Asavasopon et al, 2005;Rogalewski and Evers, 2005;Taylor and Kerry, 2005;Thanvi et al, 2005;Arnold et al, 2006;Debette and Leys, 2009;Kerry and Taylor, 2009). Planning the physical examination ...
Chapter
In dit hoofdstuk worden de hoogcervicale wervelkolom (C0-C3) en het kaakgewricht besproken. Er is aandacht voor het screeningsproces, de risicofactoren, de verschillende behandelprofielen en de verschillende graden van nekpijn conform de KNGFAQ-richtlijn Nekpijn. Het belang van een professioneel klinisch redeneerproces voor deze regio is evident. Daarom zijn er vaker momenten van overweging tijdens de screening en het onderzoek om uiteindelijk te komen tot een ‘pluis’-gevoel, de juiste werkdiagnose en de keuze voor de juiste behandeling: preventief, curatief of palliatief. Ook het ‘pluis’-gevoel van de patiënt, het hebben van een diagnose en de instemming met de voorgestelde aanpak zijn hier van extra groot belang. Bij het bespreken van de anatomie van de hoogcervicale regio is er aandacht voor het bijzondere verloop van bloedvaten, zoals de arteria vertebralis. Speciale paragrafen zijn er over duizeligheid en hoofdpijn. Kennis over de ingenieuze hoogcervicale osteo- en artrokinematica is natuurlijk van groot belang voor de manueeltherapeut om de functiestoornissen te kunnen diagnosticeren, analyseren en ontrafelen. Het theoriegedeelte wordt afgesloten met de bouw en functie van het temporomandibulaire gewricht en de nomenclatuur van alle tanden en kiezen. Kaakbewegingen als depressie (elevatie), occlusie (detractie), protractie (protrusie), retractie (retrusie), laterotrusie en circumductie worden toegelicht en duidelijk geïllustreerd. Het hoofdstuk wordt afgesloten met de uitgebreide beschrijving van 33 technieken. Aan de hand van instructieve video’s, duidelijke foto’s en helder geformuleerde opmerkingen wordt duidelijk gemaakt hoe de manueeltherapeut klachten aan de hoogcervicale wervelkolom en het kaakgewricht kan onderzoeken en behandelen.
... Ischaemic strokes (as opposed to hemorrhagic strokes) account for around 80% of all young to middle-aged strokes. The majority of these strokes arise from the internal carotid artery whilst around 20% arise from the posterior system (Arnold & Bousser, 2005;Savitz & Caplan, 2005;Thanvi et al, 2005). These figures relate specifically to dissection events. ...
... There is potential for the resultant thrombus (haematoma) formation to either enlarge to the point of clinically significant stenosis or to embolize (also referred to as dissecting of the thrombus). A widened vessel, and the associated inflammation in its proximity, can also compress or stretch local C H A P T E R 6 Haemodynamics structures resulting in a variety of symptoms, including somatic pain from non-vascular structures (Arnold & Bousser, 2005) or cranial nerve dysfunction/palsy (Leys et al, 1997). Vasculogenic pain may also arise from the deformation of nociceptive nerve endings in the adventitia of the vessel, as a result of vessel widening (Nichols et al, 1993). ...
... local, somatic causes) and ischaemic (i.e. brain, or retinal) manifestations (Arnold & Bousser, 2005). The non-ischaemic presentation of vertebral dissection is typically ipsilateral posterior neck pain and/or occipital headache alone (e.g. . ...
Chapter
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... Patients with VAD commonly present with posterior neck pain or occipital headache on the side of the dissection. The presentation is less distinct than for ICAD and more likely to be interpreted as musculoskeletal in origin (Arnold and Bousser, 2005a). ICAD presents with unilateral frontal or retro-orbital pain. ...
... In contrast to cervicogenic headache and migraine, this is usually the first episode of headache. Similarly if neck pain and headache precede any ischaemic features, this is strongly suggestive of dissection (Arnold and Bousser, 2005a;Debette, 2014). Notably, some patients present with mild or no pain and only neurological features. ...
... There may be a slightly increased frequency of smoking in CAD patients but is inconsistent (Arnold and Bousser, 2005a;Thomas et al., 2011). Even though migraine without aura has been linked with CAD, it is only present in 8% of patients . ...
Article
Cervical arterial dissection (CAD) is a common cause of stroke in young people under 55 years. It can occur spontaneously or subsequent to minor trauma or infection. The incidence is difficult to determine accurately as not all CAD progress to stroke. CAD is the most catastrophic adverse event associated with cervical manipulative therapy but it is rare. Early features of CAD can mimic a painful musculoskeletal presentation and a patient may present for treatment of neck pain and headache with a dissection in progress. Whether the manipulative technique is responsible for dissection or whether the diagnosis of CAD has been missed is unclear. Identification of individuals at risk, or early recognition of CAD could help expedite medical intervention and avoid inappropriate treatment. The aims of this masterclass are to outline current research into the pathophysiology, aetiology and clinical presentation of CAD, to place the risk in context in a manipulative therapy setting and to discuss its possible clinical recognition. For those patients presenting with recent onset, moderate to severe unusual headache or neck pain, clinicians should perform a careful history, in particular questioning about recent exposure to head/neck trauma or neck strain. Cardiovascular factors may not be particularly useful indicators of risk of dissection. Clinicians should also be alert to reports of transient neurological dysfunction such as visual disturbance and balance deficits, arm paraesthesia and speech deficits, as these may be subtle. If clinicians suspect arterial dissection is in progress patients should be urgently referred for medical evaluation. Copyright © 2015 Elsevier Ltd. All rights reserved.
... It is therefore important that the subtle symptoms of these pathologies are recognised in the patient history. It is also important to recognise risk factors indicating a potential for neuro-vascular pathology, and these should be thoroughly assessed during the patient history (Arnold and Bousser, 2005; Kerry et al, 2008). Additionally, a history of trauma (e.g. ...
... whiplash, rugby neck injury) and congenital collagenous disorders are associated with the potential for bony or ligamentous compromise of the upper cervical spine (Cook et al 2005). The patient history is therefore an opportunity for the astute clinician to observe signs and symptoms of serious pathology and contraindications or precautions to treatment early in the clinical encounter.Table 1 provides key information to assist in the differential diagnosis of musculoskeletal dysfunction from more sinister pathologies masquerading as musculoskeletal dysfunction (Arnold and Bousser, 2005; Arnold et al, 2006; Kerry et al, 2008; Kerry, 2011); enabling their consideration in the context of known risk factors. ...
Article
A consensus clinical reasoning framework for best practice for the examination of the cervical spine region has been developed through an iterative consultative process with experts and manual physical therapy organisations. The framework was approved by the 22 member countries of the International Federation of Orthopaedic Manipulative Physical Therapists (October 2012). The purpose of the framework is to provide guidance to clinicians for the assessment of the cervical region for potential of Cervical Arterial Dysfunction in advance of planned management (inclusive of manual therapy and exercise interventions). The best, most recent scientific evidence is combined with international expert opinion, and is presented with the intention to be informative, but not prescriptive; and therefore as an aid to the clinician's clinical reasoning. Important underlying principles of the framework are that 1] although presentations and adverse events of Cervical Arterial Dysfunction are rare, it is a potentially serious condition and needs to be considered in musculoskeletal assessment; 2] manual therapists cannot rely on the results of one clinical test to draw conclusions as to the presence or risk of Cervical Arterial Dysfunction; and 3] a clinically reasoned understanding of the patient’s presentation, including a risk:benefit analysis, following an informed, planned and individualised assessment, is essential for recognition of this condition and for safe manual therapy practice in the cervical region. Clinicians should also be cognisant of jurisdictionally specific requirements and obligations, particularly related to patient informed consent, when intending to use manual therapy in the cervical region.
... Many clinicians feel that antithrombotic therapy is no longer necessary once the flow in the dissected artery is reestablished. 8 Combined extracranial and transcranial ultrasound is useful, particularly in patients presenting with carotid territory ischemia for assessing carotid stenosis and occlusion in patients with SICAD, both in the acute phase and during recanalization. 9, 10 We undertook this study to investigate the predictors and the time course of recanalization of the cervical internal carotid artery using ultrasound in patients with SICAD. ...
... 13 Ultrasound studies were performed with the same equipment (for extracranial and transcranial color duplex studies, Acuson XP 10 or Sequoia; for transorbital Doppler studies, EME; and since October 1997, Acuson XP 10 or Sequoia). Extracranial color duplex sonography of the ICA at the origin, the external carotid artery, and common carotid artery was performed with linear probes (5)(6)(7)(8), and of the cervical ICA with sector probes (2.0 -3.5 MHz). Transorbital insonation of the ophthalmic arteries and the carotid siphon was performed with pulsed-wave Doppler probes (2 MHz) or color Doppler sector probes (2.0 -3.5 MHz). ...
Article
We set out to investigate the predictors and time course for recanalization of spontaneous dissection of the cervical internal carotid artery (SICAD). We prospectively included 249 consecutive patients (mean age, 45+/-11 years) with 268 SICAD. Ultrasound examinations were performed at presentation, during the first month, and then at 3, 6, and 12 months, and clinical follow-ups after 3, 6, and 12 months. Of 268 SICADs, 20 (7.5%) presented with <or=50% stenosis, 31 (11.6%) with 51% to 80% stenosis, 92 (34.3%) with 81% to 99% stenosis, and 125 (46.6%) with an occlusion. Antithrombotic treatment included anticoagulation in 174 (67%) patients, aspirin in 64 (24%) patients, and aspirin followed by anticoagulation or vice versa in 22 (8%) patients. Follow-up ultrasound showed normal findings in 160 (60%), <or=50% stenosis in 27 (10%), 51% to 80% stenosis in 4 (1%), 81% to 99% stenosis in 26 (10%), and occlusion in 51 (19%) vessels. The rate of complete recanalization was 16% at 1 month, 50% at 3 months, and 60% at 6 and 12 months. Initial occlusion of the dissected vessels reduced the odds of recanalization (OR, 4.0; 95% CI, 2.2-7.3; P<0.001), whereas the occurrence of local symptoms and signs only at presentation were independently associated with complete recanalization (OR, 0.4; 95% CI, 0.2-0.8; P=0.048). These results suggest that recanalization of SICAD occurs mainly within the first 6 months after the onset of symptoms. Initial occlusion reduces the likelihood of complete recanalization, whereas presentation with local symptoms and signs only increases it.
... In most cases, headache and neck pain may be the initial symptom before the ischemic stroke [7]. However, due to the fact that early features of CAD can mimic a painful musculoskeletal presentation, trigeminal neuralgia-like pain or migraine, the clinical diagnosis may be difficult when clear neurological features are not present [6,[8][9][10]. Our aim of this study was to analyze the characteristics and relative factors of headache and neck pain in CAD patients. ...
... But the pain is not always located in the typical pain area. For example, some patients with vertebral artery dissection present with pain in the orbital part, and others with internal carotid artery may be suffering from occipital pain [8,17,[23][24][25]. In this study, 41.2% of patients had the temporal pain when the dissection was in anterior circulation, and 46.5% of the patients had occipital pain when the dissection was in posterior circulation. ...
Article
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Objective To analyze the characteristics and relative factors of headache and neck pain due to cervicocerebral artery dissection (CAD). Methods A total of 146 consecutive patients with CAD in Zhengzhou, China (2010–2017) were observed and registered prospectively. There were 60 (60/146) cases who complained of headache and neck pain, and we analyzed the characteristics of pain according to their clinical features. For the 130 (130/146) patients with complete clinical laboratory data, they were divided into two groups according to pain, and the relative factors of pain were analyzed. Results The headache and neck pain in 60 CAD patients was mostly acute onset (98.3%), 70.6% (12/17) of patients with anterior circulation dissection and 88.4% (38/43) of patients with posterior circulation dissection complained of moderate to severe pain. 41.2% (7/17) of patients with anterior circulation dissection had temporal pain, while 46.5% (20/43) of the patients with posterior circulation dissection had occipital pain. There were 23.5% (4/17) and 32.6% (14/43) of patients with anterior and posterior circulation dissection complained of throbbing pain, respectively, 23.5% (4/17) and 20.9% (9/43) of patients with anterior and posterior circulation dissection complained of pulsating pain. The pain could occur in the ipsilateral (40.0%), bilateral (52.7%), or contralateral (7.3%) sites of the dissection. In the 130 patients, there were 56 cases (43.1%) in the pain group, and 74 cases (56.9%) in the non-pain group. Multivariate logistic regression analysis showed that female gender (OR 4.01, 95% CI 1.63–9.85, P = 0.002), posterior circulation (OR 3.18, 95% CI 1.39–7.28, P = 0.006), history of headache (OR 4.72, 95% CI 1.08–20.52, P = 0.039), and low-density lipoprotein less than 1.8 mmol/L (OR 2.90, 95% CI 1.15–7.34, P = 0.025) were risk factors of the occurrence of the pain related to CAD. Conclusion The headache and neck pain caused by CAD is a moderate to severe pain occurring suddenly. The pain nature may be diverse but mostly like throbbing and pulsating. When the dissected artery is located in the posterior circulation, the pain is mostly in the occipital region, and mostly in the temporal region when the dissected artery is located in the anterior circulation. The pain can occur in ipsilateral, bilateral, or contralateral of the dissection. In addition, several factors might contribute to the occurrence of headache and neck pain.
... Therefore if, as suggested by both ourselves and Professor Rivett, the therapist is to cultivate a high index of suspicion of arterial dissection, failure to consider carotid pathology would potentially lead to grave error, as numerous case series suggest (Biousse et al., 1994). Particularly as head and neck pain are frequently cited as the only early presenting symptoms (Arnold and Bousser, 2005). ...
... Functional positional tests (FPT) as part of clinical guidelines for assessing vertebrobasilar insufficiency (VBI) are advocated to screen those likely to be at risk of stroke or other adverse effects as a result of cervical manipulation (Australian Physiotherapy Association (APA), 2006). The diagnostic utility of FPT in relation to assessment of blood flow in the vertebral arteries have shown mixed results (Refshauge, 1994; Mitchell et al., 2004; Arnold and Bousser, 2005), and the sensitivity and specificity of the tests has been questioned (Richter and Reinking, 2005). In addition to physical testing, APA (2006) guidelines recommend subjective questioning of patients with upper quadrant dysfunction for symptoms of VBI and emphasis has been placed on physiotherapist's clinical reasoning skills. ...
Article
The aim of this study was to investigate the clinical reasoning processes of physiotherapists in relation to the assessment of vertebrobasilar insufficiency (VBI). Using a qualitative multiple case studies design 12 physiotherapists (mean=12.89 years clinical experience, SD=3.44) with an MSc in Manipulative Physiotherapy were shown 2 patient vignettes of a cervical spine disorder and associated symptoms of VBI sequentially in 4 sections and questioned as to their clinical reasoning processes via audio taped semi-structured interviews. Transcripts of the interviews were analysed for common themes. The therapists' hypothesis generation in relation to VBI was mainly based on the subjective examination (SE) with no new patho-anatomic hypotheses being generated in the physical examination. The major indicators of VBI involvement were dizziness particularly if associated with other symptoms (visual disturbances, history of trauma and headache) and if exacerbated by cervical spine movements. Therapists demonstrated a lack of confidence in functional positional testing (FPT) and based decisions on the use of high velocity thrust techniques on subjective findings. The results of this study emphasise the importance of physiotherapists' clinical reasoning process during the SE particularly in view of the questionable diagnostic utility of FPT.
... 9 The etiology is not well understood but is thought to involve an underlying intrinsic susceptibility coupled with exposure to an external trigger. 1,9,11 Cervical spine manipulation has been implicated as one such trigger. 28 The critical question for clinicians is whether the manipulative technique is responsible for reported cases of CAD or the adverse event occurs because the differential diagnosis of CAD has been missed. ...
Article
Craniocervical arterial dissection is one of the most common causes of ischaemic stroke in young people and is occasionally associated with neck manipulation. Identification of individuals at risk will guide risk management. Early recognition of dissection in progress will expedite medical intervention. Study aims were to identify risk factors and presenting features of craniocervical arterial dissection. Medical records of patients from the Hunter region of New South Wales, Australia aged ≤ 55 years with radiographically confirmed or suspected vertebral or internal carotid artery dissection, were retrospectively compared with matched controls with stroke from some other cause. Records were inspected for details of clinical features, presenting signs and symptoms and preceding events. Records of 47 dissection patients (27 males, mean age 37.6 years) and 43 controls (22 males, mean age 42.6 years) were inspected. Thirty (64%) dissection patients but only three (7%) controls reported an episode of mild mechanical trauma, including manual therapy, to the cervical spine within the preceding three weeks. Mild mechanical trauma to the head and neck was significantly associated with craniocervical arterial dissection (OR 23.53). Cardiovascular risk factors for stroke were less evident in the dissection group (<1 factor per case) compared to the controls (>3).
... The strength of possible risk factors for neuro-vascular pathology such as CAD is largely unknown (Arnold and Bousser, 2005;Kerry et al., 2008). It is important here to realize that the limited available data concern risk factors for CAD in general, and not for CAD as a possible consequence of cervical manipulation. ...
... The strength of possible risk factors for neuro-vascular pathology such as CAD is largely unknown (Arnold and Bousser, 2005;Kerry et al., 2008). It is important here to realize that the limited available data concern risk factors for CAD in general, and not for CAD as a possible consequence of cervical manipulation. ...
... Cervical arterial dissection (CeAD) is a rare adverse outcome of cervical manipulation but may be catastrophic (Albuquerque et al., 2011;Arnold and Bousser, 2005;Paciaroni and Bogousslavsky, 2009). It is also a common cause of stroke in people under 55 years who are usually otherwise healthy, although it can occur at any age with an estimated incidence of 2.6-3/100,000 (Debette, 2014;Metso et al., 2012). ...
Article
Background: Cervical arterial dissection (CeAD) is a serious condition that can mimic a musculoskeletal condition. A diagnostic tool using five key criteria could help prompt early medical referral, but these criteria may occur in healthy people or benign neck pain/headache. Objective: To determine the frequency of CeAD criteria in healthy individuals and those with neck pain/headache, and identify refinements needed to improve specificity. Methods: An interview and neurological screen to identify the presence of the five criteria was conducted. Definitions were refined and the frequency of the modified criteria in each individual was determined. The criteria were re-administered using data from 37 CeAD cases of the derivation cohort, to examine how the modifications impact sensitivity of the tool. Results: One hundred healthy and 20 participants with neck pain/headache were interviewed. Most participants had ≤ 2 criteria, mainly age or trauma, 3% had 3 criteria, but had migraine or resolving symptoms. None had >3. Modifications to definitions were needed to improve potential specificity of the tool (96.7%). Changes did not impact sensitivity of the tool (81%). Further refinements may be required. Conclusions: Strictly defined CeAD criteria may assist in identifying when to refer, when to wait and monitor, or when management can proceed. Trialing the tool in those with migraine and in emergency departments to calculate risk scores is recommended.
... 9 The etiology is not well understood but is thought to involve an underlying intrinsic susceptibility coupled with exposure to an external trigger. 1,9,11 Cervical spine manipulation has been implicated as one such trigger. 28 The critical question for clinicians is whether the manipulative technique is responsible for reported cases of CAD or the adverse event occurs because the differential diagnosis of CAD has been missed. ...
Article
Study design: Cross-sectional case-control study. Objectives: To identify risk factors and clinical presentation of individuals with cervical arterial dissection. Background: Cervical arterial dissection is a common cause of stroke in young people and has in rare cases been associated with cervical manipulative therapy. The mechanism is considered to involve pre-existing arterial susceptibility and a precipitating event, such as minor trauma. Identification of individuals at risk or early recognition of a dissection in progress could help expedite medical intervention and avoid inappropriate treatment. Methods: Participants were individuals 55 years of age or younger from the Hunter region of New South Wales, Australia with radiologically confirmed vertebral or internal carotid artery dissection and an age- and sex-matched comparison group. Participants were interviewed about risk factors, preceding events, and clinical features of their stroke. Physical examination of joint mobility and soft tissue compliance was undertaken. Results: Twenty-four participants with cervical arterial dissection and 21 matched comparisons with ischemic stroke but not dissection were included in the study. Seventeen (71%) of the 24 participants with dissection reported a recent history of minor mechanical neck trauma or strain, with 4 of these 17 reporting recent neck manipulative therapy treatment. Cardiovascular risk factors were uncommon, with the exception of diagnosed migraine. Among the participants with dissection, 67% reported transient ischemic features in the month prior to their admission for dissection. Conclusion: Recent minor mechanical trauma or strain to the head or neck appears to be associated with cervical arterial dissection. General cardiovascular risk factors, with the exception of migraine, were not important risk factors for dissection in this cohort. Preceding transient neurological symptoms appear to occur commonly and may assist in the identification of this serious pathology. Level of evidence: Prognosis, level 4.
... 9 The etiology is not well understood but is thought to involve an underlying intrinsic susceptibility coupled with exposure to an external trigger. 1,9,11 Cervical spine manipulation has been implicated as one such trigger. 28 The critical question for clinicians is whether the manipulative technique is responsible for reported cases of CAD or the adverse event occurs because the differential diagnosis of CAD has been missed. ...
... 1,2 Loss of the flow void usually indicates vertebral artery dissection or occlusion in acute trauma, particularly with cervical spine fractures extending to the foramen transversarium or with facet fracture/subluxation. 3 The most feared complication is posterior circulation ischemia from vertebral artery occlusion or artery-to-artery embolism, and cerebral ischemia can be seen in up to 77% of patients with vertebral artery dissection. 4 Additional confirmatory tests such as computed tomography (CT), MRI or conventional angiography are typically performed prior to instituting antithrombotic therapy. However, the significance of an absent vertebral artery flow void on cervical spine MRI is less clear when incidentally discovered on imaging performed for other reasons. ...
Article
Purpose: Loss of the T2 vertebral artery flow void can be an ominous sign in patients with trauma. However, the significance of an absent vertebral artery flow void is less clear when discovered incidentally in patients without trauma or acute neurological symptoms. The purpose of this study was to review retrospectively the results of additional imaging and clinical evaluation in atraumatic patients without acute neurological symptoms found to have an incidentally discovered absent vertebral artery flow void on magnetic resonance imaging. Materials and methods: An imaging database was reviewed for absent vertebral artery flow voids in atraumatic cervical spine magnetic resonance images. Imaging and long-term clinical follow-up were recorded. Results: Fifty-four patients were included in the study. All patients had clinical follow-up and 22 patients (40% of cases) had vascular imaging follow-up. Nine patients had a hypoplastic but patent vertebral artery on follow-up vascular imaging, and no further action was taken. Ten patients had evidence of stenosis or occlusion of the vertebral artery on follow-up imaging, none with acute neurological symptoms or new symptoms/subsequent change in management during follow-up. Three additional patients had vertebral artery dissections on follow-up imaging, but all of them had acute neurological symptoms at the time of imaging and acute infarcts on current or subsequent magnetic resonance imaging. The other 32 patients had clinical follow-up and remained asymptomatic throughout the study period, without change in management. Conclusion: In the absence of trauma or acute neurological symptoms an absent vertebral artery flow void has a low likelihood of altering patient management.
Article
The aim of this study was t survey the current practice of cervical spine pain assessment in relation to vertebrobasilar artery insufficiency (VBI), attitudes toward guidelines, and the practice of achieving informed consent in advance of planned orthopaedic manual therapy interventions. A self-administered postal survey was validated and sent to 325 physiotherapists working in the National Health Service (NHS) and private musculoskeletal practices in the Dorset and Hampshire region. The response rate was 53% from NHS physiotherapists and 20% from private practice, overall 34% (n = 111). Compliance rates with published guidelines were 50.4%; the sample holds them in neutral opinion (51.4%), and also holds cervical manipulation in neutral opinion (n = 50; 45.5%). Of these, 30.4% of respondents use cervical manipulation; a practice more closely associated with male practitioners (Φ = 0.35 P < 0.001), most use non-manipulative techniques such as manual traction (86.3%) or mobilizations (96.1%) with exercise (99%) as these are believed to be just as effective.
Article
Completely updated edition, written by a close-knit author team. Presents a unique approach to stroke - integrated clinical management that weaves together causation, presentation, diagnosis, management and rehabilitation. Includes increased coverage of the statins due to clearer evidence of their effectiveness in preventing stroke. Features important new evidence on the preventive effect of lowering blood pressure. Contains a completely revised section on imaging. Covers new advances in interventional radiology. © 2007 C. Warlow, J. van Gijn, M. Dennis, J. Wardlaw, J. Bamford, G. Hankey, P. Sandercock, G. Rinkel, P. Langhorne, C. Sudlow, P. Rothwell.
Article
In this paper, we present a clinical overview of cervical arterial dysfunction (CAD) for manual therapists who treat patients presenting with cervical pain and headache syndromes. An overview of vertebrobasilar arterial insufficiency (VBI) is given, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice is limited and present a more holistic, evidence-based approach to considering CAD. This approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors and pathomechanics of arterial dysfunction is also given. We suggest that consideration of the information provided in this Masterclass will enhance the manual therapist's clinical reasoning with regard to differential diagnosis of cervical pain syndromes, and prediction of serious adverse reactions to treatment.
Article
Background Standard‐of‐care time‐of‐flight (TOF) techniques for nonenhanced magnetic resonance angiography (NEMRA) of the carotid bifurcation and other cervical arteries often provide nondiagnostic image quality due to motion and flow artifacts. Purpose To perform an initial evaluation of an ungated radial quiescent‐interval slice‐selective (QISS) technique for NEMRA of the neck, in comparison with 2D TOF and contrast‐enhanced magnetic resonance angiography (CEMRA). Study Type Retrospective. Population Sixty patients referred for neck MR angiography. Field Strength/Sequence Ungated radial QISS at 3T. Assessment Three radiologists scored image quality of 18 arterial segments using a 4‐point scale (1, nondiagnostic; 2, fair; 3, good; 4, excellent), and two radiologists graded proximal internal carotid stenosis using five categories (<50%, 50–69%, 70–99%, occlusion, nondiagnostic). Statistical Tests Friedman tests with post‐hoc Wilcoxon signed‐rank tests; unweighted Gwet's AC1 statistic; tests for equality of proportions. Results Ungated radial QISS provided image quality that significantly exceeded 2D TOF (mean scores of 2.7 vs. 2.0, 2.7 vs. 2.2, and 2.9 vs. 2.3; P < 0.001, all comparisons), while CEMRA provided the best image quality (mean scores of 3.6, 3.7, and 3.5 for the three reviewers). Interrater agreement of image quality scores was substantial for CEMRA (AC1 = 0.70, P < 0.001), and moderate for QISS (AC1 = 0.43, P < 0.001) and TOF (AC1 = 0.41, P < 0.001). Compared with TOF, QISS NEMRA provided a significantly higher percentage of diagnostic segments for all three reviewers (91.0% vs. 71.7%, 93.5% vs. 72.9%, 95.5% vs. 85.2%; P < 0.0001) and demonstrated better agreement with CEMRA for grading of proximal internal carotid stenosis (AC1 = 0.94 vs. 0.73 for reviewer 1, P < 0.05; AC1 = 0.89 vs. 0.68 for reviewer 2, P < 0.05). Data Conclusion In this initial study, ungated radial QISS significantly outperformed 2D TOF for the evaluation of the neck arteries, with overall better image quality and more diagnostic arterial segments, and improved agreement with CEMRA for grading stenosis of the proximal internal carotid artery. Level of Evidence: 3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019.
Article
Clinical, pathological and radiological advances in recent years have considerably advanced our understanding of the incidence and underlying mechanisms producing dissection of the cervical arteries, which should have implications for medical and, surgical therapy in the near future. This review is a summary of progress to date. Numerous published studies, primarily over the last decade, have generated a rapidly evolving data base especially in the areas of etiology, neuroimaging and more recently, arterial pathology and its genetic basis. Dissection of the carotid and vertebral arteries, both intracranially and extracranially, is a major and frequently underdiagnosed cause of stroke, especially in the young. These advances in clinical epidemiological observations, and new radiological and pathological data, are gradually providing an evidence-based rationale for future trials of therapeutic interventions, using both drugs and devices.
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This paper offers a contemporary, evidence-based perspective on the issue of adverse neurovascular events related to cervical spine manual therapy. The purpose of this perspective is to challenge traditional thought and practice and to recognize areas where practice and research should develop. By considering the themes presented in this paper, the clinician can broaden his or her approach to neurovascular assessment in line with contemporary evidence and thought. We present information based on clinically relevant questions. The nature of vertebrobasilar insufficiency and the utility of pre-treatment testing are examined in light of contemporary evidence. In addition, we report on internal carotid artery pathology, and the significance of appreciating atherosclerosis in clinical decision-making. These later two areas are not commonly recognized within manual therapy literature, and we suggest that their importance to differential diagnosis of head and neck pain, as well as estimating treatment related risk, is paramount. We propose that the term cervical arterial dysfunction is more appropriate than classically used nomenclature. This term refers more accurately and completely to the range of pathologies at different anatomical sites that manual therapists treating patients with head and neck pain are likely to encounter. Finally, we present a brief review of the medico-legal status pertaining to this area. Although this is English law-related, the themes derived from this section are of interest to all manual therapists.
Article
To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery. Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible. A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma. Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.
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Synopsis: This clinical commentary provides evidence-based information regarding adverse cerebrovascular events in the context of manual therapy assessment and management of the cervical spine. Its aim is to facilitate clinical decision making during diagnosis and treatment of patients presenting to the therapist with cervicocranial pain. Rather than focusing on a traditional view of premanipulative testing as the cornerstone for decision making, we present information concerning the clinical presentation of specific vascular conditions. Additionally, we discuss the assessment and management of musculoskeletal pain in the presence of risk factors for cerebrovascular accident. It is proposed that vascular "red flag" presentations mimic neuromusculoskeletal cervicocranial syndromes. Invariably, the 2 conditions coexist. This reasoning presupposes that some patients who have poor clinical outcomes, or a serious adverse response to treatment, may be those who actually present with undiagnosed vascular pathology. We use 2 case reports to demonstrate how incorporating vascular knowledge into clinical reasoning processes may influence clinical decision making. Level of evidence: Level 5.
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Cite this article: Clarke R, Bagchi A, Rana A, Tyagi V, Reid JM. Three cases of vomiting-associated cervical artery dissection. Abstract Extracranial Cervical Arterial Dissection (CAD) affects 10-25% of young onset Acute Ischaemic Stroke (AIS) patients. We report three cases of CAD in young AIS patients (ages 14, 18 and 49) associated with prior vomiting. All three cases presented within five weeks of each other at a single centre , lived in a specific region in Northeast Scotland suffering an outbreak of winter vomiting and were treated with IV thrombolysis. These cases are noteworthy for several reasons ; reports of stroke in children treated with thrombolysis are rare, and new UK guidelines for stroke thrombolysis in children have been published; secondly we speculate that infective gastroenteritis triggered CAD, and thirdly the two younger cases developed vertebral artery pseudoaneu-rysms which are rare in CAD. In one case the presence of an anomalous vertebral artery course between the first and second cervical vertebrae may have predisposed to dissec-tion.
Article
Two cases of ischemic infarction from the vertebrobasilar part are analyzed. Both patients were young, they did not present any vascular risk but pain at cervical level. The angiographic study showed a vertebral artery dissection. Some considerations are being made regarding the clinic, pathogenesis and the treatment.
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Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened.
Article
First patient, presented with sudden onset of headache, left hypoacusia and right hemiparesis, posteriorly developing gaze-evoked nystagmus and worsening right-sided weakness. Diagnosis of vertebral artery dissection and Foville Syndrome were made through clinical assessment and CT-carotid angiogram-MR angiography. Second patient, presented with four episodes of pain over left side of the nose and left eye pain over 1 month; admitted for acute facial pain without limb weakness. During admission, tingling over V1/V2 facial territory, vertigo, hypotension, uvula deviation and right lower limb numbness. CT-carotid angiogram confirmed vertebral artery with dissection. MRI revealed left lateral medullary infarct. Third patient, presented with sudden onset of left facial numbness and right upper limb weakness; 1 day after, right arm and leg hypoesthesia with hoarseness. MRA revealed dissection of left distal vertebral artery and MRI showed infarction in lower medulla oblongata.
Article
Internal carotid dissection most commonly presents as headache, focal neurological deficits or stroke. Rarely it can manifest itself by causing a palsy of the lower cranial nerves (IX, X, XI, XII). The reported incidence of isolated cranial nerve palsies is rare. We report a case of an internal carotid artery dissection manifesting as isolated XII (hypoglossal) cranial nerve palsy.
Article
Carotid artery dissections are potentially disabling, probably underdiagnosed, and mainly affect young-aged and middle-aged people. We present three consecutive cases illustrating different clinical presentations and thereby emphasizing the diagnostic challenge of carotid artery dissections for the emergency physician. Neck and facial pain, headache, unilateral pulsatile tinnitus, partial Horner's syndrome (or oculosympathetic palsy), amaurosis fugax, retinal infarction, and anterior circulation brain ischemia may all occur in isolation or in various combinations. Medical imaging plays a pivotal role in making the right diagnosis. Clinical vigilance is of utmost importance as early diagnosis and timely treatment favor long-term prognosis and even prevent ischemic complications. We review the literature and discuss the pathophysiology, etiology, clinical presentation, diagnosis, imaging techniques, treatment, and prognosis of carotid dissections.
Article
A 38 year old woman presented with one day history of acute onset frontal headache which progressively generalised over a few hours. The headache was dull in nature and did not respond to analgesics. A day prior to the onset of headache her family members and the patient had noticed a distinct change in the appearance of her eyes. The headache was not associated with symptoms of meningism, vomiting, seizures, syncope or loss of consciousness. She did not report any weakness in her extremities. There was no recent history of neck trauma or neck pain and no other systemic symptoms.
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This article reviews vascular causes of head and neck pain with regard to the current available evidence. It considers the overall assessment of the patient's suitability to undergo any form of manual therapy intervention ranging from simple exercise-based prescription, through to mobilisation and/or manipulative therapies. A brief review of regional anatomy combined with potential complications of system failure is presented. This is linked to an overview of the key signs for the alert practitioner to look for, together with some consideration of underlying risk factors (with regard to vascular pathology).
Article
Background: Intra- and extracranial internal carotid artery dissections (ICD) are two different pathological conditions. Extracranial dissection is considered to be among the most frequent causes of stroke in the young and the segment generally reopens in 2 out of 3 cases, completely or partially, within 6 months. Intracranial ICD (IICD) is considered a rare occurrence in stroke and, accordingly, there are few systematic published data. However, it is a clinically significant condition that may cause severely disabling ischemic stroke or subarachnoid hemorrhage. In the past, sole availability of invasive imaging methods for its detection may have induced an underreporting. The aim of the study was to analyze ultrasound findings, timing and predictors of recanalization in patients with IICD. Methods: IICD acute patients admitted to our Stroke Unit were submitted to carotid sonographic seriated monitoring, daily for the 1st week after symptom onset, at day 14, at month 1 and every 3 months thereafter up to a follow-up of 4 years. Contrast carotid ultrasound was performed in patients with persistent occlusion after month 1. Results: Fourteen acute patients with IICD were enrolled. Extracranial internal carotid patency was observed in 8 patients at first ultrasound scans; all of these showed complete intracranial recanalization within the 1st week and oral anticoagulants were withdrawn after 6 months. Conversely, in 6 patients retrograde extracranial internal carotid thrombosis was immediately observed, since the first ultrasound scans. In 4 of these the occlusion persisted after 4 years while 2 of them had only a partial recanalization, with evidence at contrast ultrasound of still late remodeling processes in the extracranial thrombus up to 2 years after the first observation; for this reason, in these 2 patients anticoagulation was not discontinued, while in the 4 patients with persistent, stable, occlusion, therapy was suspended 1 year after the diagnosis. Conclusions: Identification of the site of dissection - i.e. extra- versus intracranial - is fundamental in clinical studies for outcome and prognosis evaluation. Carotid ultrasound strict surveillance is important to monitor eventual recanalization in patients with ICD, even in a late phase. Retrograde internal carotid thrombosis seems to be correlated with persistent occlusion and partial recanalization. Remodeling of thrombotic material in the internal carotid artery may, however, continue for up to 2 years. In these cases, contrast ultrasound evidence of thrombus morphological changes may support the decision to continue anticoagulation.
Article
Carotid artery dissection is an uncommon entity associated with head and neck pain, partial Horner’s syndrome, amaurosis fugax, and brain ischemia, which may all occur in isolation or in combination. Herein, we report a rare case of cervical artery dissection in which pulsatile tinnitus was the only reported symptom. A 38-years-old man attended our hospital with a 4-days history of left side pulsatile tinnitus which began after stumbling. He had no other symptom. MRA showed luminal stenosis with pseudo lumen of the internal carotid artery. The patient was diagnosed with left internal carotid artery dissection and treated with antihypertensive therapy accordingly. After 2 months, the stenosis and tinnitus spontaneously resolved.
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Clinical data and neuroradiological findings of 19 patients with 20 vertebral artery dissections were analysed to describe the features of time of flight magnetic resonance angiography (MRA) for the diagnosis and follow up of this vascular disorder. All patients underwent a combined MRI and MRA protocol with 1.5 T scanners, using a three dimensional flow compensated gradient echo sequence for MRA. Duplex sonography was performed on all patients and selective angiography was available from 17 vertebral artery dissections. MRI showed ischaemic lesions of the brain in 18 of 19 patients (95%). In the acute and subacute stage, MRA detected signal abnormalities within the dissected vertebral artery in 94% (16/17) and MRI was specific for a dissection in 29% (5/17). Sensitivity of selective angiography was 100% and specificity was 35% (6/17). Combination of the results of both methods increased the specificity to 50%. Duplex sonography was sensitive in 79% (15/19), but lacked specific results. Follow up magnetic resonance in 16 patients showed recanalisation of the dissected vessel in 10 (63%), persistent occlusion in five (31%), and a dissecting aneurysm in one (6%) patient. Magnetic resonance improves the triage for selective angiography and discloses complementary information for the diagnosis of vertebral artery dissection. If magnetic resonance identifies a double lumen or a mural haematoma with a stenosis or aneurysmal dilatation, invasive procedures can be omitted.
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Since the advent of advanced radiological modalities such as MRI and magnetic resonance angiography (MRA), dissections of cervical arteries are increasingly recognised as a common cause of stroke in young adults. Auer et al 1recently advocated MRA as the initial diagnostic tool for vertebral artery dissection. Conventional angiography might be avoided altogether in subjects with a suspicious history and MRA images suggestive of a dissection (double lumen or mural haematoma).1 The sensitivity of MRA for the diagnosis of vertebral artery dissection was only 20% in one study, but the specificity was excellent (100%).2 The sensitivity was considerably better in the hands of Auer et al ,1 but in this study the specificity (true negative rate in subjects free of disease) was not considered because all patients had vertebral artery dissection. The following case report illustrates that care must be taken to avoid false positive results when using MRA for the diagnosis of vertebral artery dissection. A 47 year old male pilot suddenly experienced clumsiness and slight loss of strength in the right arm and leg during a long distance flight, while he stooped forward. During the following hours, he developed a global headache without irradiation to the neck, but the other symptoms gradually diminished. Prior history was unremarkable, except for a 3 hour period of horizontal diplopia which suddenly developed 3 months earlier. He had never smoked. Family history was negative for cardiovascular disorders. The patient later confessed that he had recently picked up the habit of gargling his throat with toothpaste twice a day, always with his …
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Several reports have linked chiropractic manipulation of the neck to dissection or occlusion of the vertebral artery. However, previous studies linking such strokes to neck manipulation consist primarily of uncontrolled case series. We designed a population-based nested case-control study to test the association. Hospitalization records were used to identify vertebrobasilar accidents (VBAs) in Ontario, Canada, during 1993-1998. Each of 582 cases was age and sex matched to 4 controls from the Ontario population with no history of stroke at the event date. Public health insurance billing records were used to document use of chiropractic services before the event date. Results for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had >/=3 visits with a cervical diagnosis in the month before the case's VBA date (95% CI from bootstrapping, 1.34 to 18.57). No significant associations were found for those aged >/=45 years. While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment. Because of the popularity of spinal manipulation, high-quality research on both its risks and benefits is recommended.
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Multisection CT angiography is a minimally invasive technique that can provide high-resolution and high-contrast images of the arterial lumen and wall. To our knowledge, the ability of multisection CT angiography in detecting vertebral artery (VA) dissection has never been evaluated. We assessed the sensitivity and specificity of a routine, standardized, multisection CT angiographic protocol for the detection of VA dissection. We retrospectively reviewed multisection CT angiograms of 17 patients with VA dissection and 17 control subjects. The acquisition protocol for multisection CT angiography was 1.25-mm nominal section thickness, a table speed of 7.5 mm per rotation (9.4 mm/s), and a 0.8-second gantry rotation period. Two radiologists assessed the maximum intensity projection and axial source images. The sensitivity and specificity of this technique in depicting VA dissection were determined. Conventional angiography depicted 15 normal and 19 dissected VAs (including five stenotic, seven occlusive, and seven aneurysmal dissections) in the patient group and 28 normal and six atherosclerotic VAs in the control group. Multisection CT angiography enabled successful diagnosis of all 19 dissected VAs and 48 (98%) of 49 nondissected VAs but misidentified a severe atherosclerotic lesion as an aneurysmal-type dissection. The sensitivity, specificity, accuracy, and positive and negative predictive values of multisection CT angiography in diagnosing VA dissection were 100%, 98%, 98.5%, 95%, and 100%, respectively. Multisection CT angiography was a sensitive and accurate technique for the diagnosis of VA dissection.
Article
A patient with spontaneous intracranial dissection in the carotid system and fatal outcome is presented. A review of 59 patients reported in the literature shows that this condition has different epidemiological, clinical, pathological and prognostic features compared to other craniocerebral dissections. The disorder usually affects healthy subjects below 30 years with no underlying vasculopathy. The middle cerebral artery is most commonly involved, often in combination with the intracranial carotid artery. The plane of dissection is subintimal in 80% of the cases, leading to stenosis or occlusion of the vessel. These patients present with sudden headache, focal neurologic deficits, syncope, seizures and early alterations of consciousness. Twenty percent of the patients have a subadventitial dissection and present with subarachnoid bleeding. Angiography is rarely pathognomonic, showing usually a nonspecific intracranial arterial stenosis or occlusion. Diagnosis in vivo is difficult and must be based on both clinical and radiological features. No treatment has proved its efficacy: anticoagulation and surgery should be proposed only on an individual basis. Prognosis is usually poor with a fatal outcome in three quarters of the patients and neurologic sequelae in half of the survivors. However, recent reports suggest the possibility of intracranial dissections of the carotid system with less dramatic presentations and more favorable outcomes. The use of MRI studies may lead to earlier and better recognition of this condition, improving so its management and prognosis.
Article
Seventy patients with spontaneous and 21 with traumatic extracranial internal carotid artery dissections were studied clinically and angiographically with mean follow-ups of 64 (spontaneous group) and 40 months (traumatic group). Sixty percent of the patients in the spontaneous group and 71% in the traumatic group also had follow-up angiograms. In traumatic dissections aneurysms were common, significantly fewer aneurysms resolved or became smaller and fewer stenoses resolved or improved, whereas more stenoses progressed to occlusion. Traumatic dissections were more likely to leave the patients with neurological deficits. A significantly higher percentage of the patients with spontaneous dissections were asymptomatic at follow-up compared with the traumatic group. Although both spontaneous and traumatic dissections of extracranial internal carotid arteries mostly carry a good prognosis, the outcome may be somewhat less favorable for the traumatic group.
Article
SYNOPSIS A case control study technique was employed to test for an association between non-traumatic cervical artery dissection and several possible risk factors. A significant positive association was shown with migraine, independent of type and treatment regimen. No such relationship was found with smoking history, hypertension or past oral contraceptive use. There was, however a significant and independent association with current oral contraceptive use.
Article
A 35-year-old woman with 3 weeks of cervical pain developed ischemia in the basilar artery territory following cervical manipulation. At autopsy, there was a dissecting aneurysm within the third segment of the right vertebral artery. The pathologic changes in the lower and the upper part of the dissecting aneurysm were different, indicating recurring bleeding. Cervical manipulation could have accounted for one recent dissection, but not for another, which was a few weeks old. This suggests that cervical pain, which prompted the manipulation, may have been the first symptom of the dissection, and manipulation of the neck precipitated the stroke by inducing bleeding within the dissecting aneurysm.
Article
Clinical and angiographic features and outcome in 25 patients with spontaneous dissections of the vertebral arteries are described. Most patients were in their fourth or fifth decade of life, and women predominated. Forty-eight percent of the patients were hypertensive. Angiographic evidence of fibromuscular dysplasia was noted in one only. Brainstem ischemic symptoms (usually a lateral medullary syndrome) and ipsilateral occipital headache and neck pain (often preceding but sometimes associated with or following the brainstem ischemic event) were the most common clinical findings. The angiographic features in decreasing order of frequency were luminal stenosis (often irregular and tapered), aneurysm, occlusion, and intimal flap. On follow-up, most of the patients (88%) made complete or very good recoveries. Angiographic abnormalities either subsided or improved in 76%. Multivessel dissection (involvement of both vertebral arteries or one or both vertebral arteries and one or both internal carotid arteries) was noted in about two-thirds of the patients. This tendency of vertebral artery dissections to involve multiple cervicocephalic vessels concurrently, if not simultaneously, implies that four-vessel angiography should be attempted if a vertebral artery dissection is visualized. It also raises the possibility of an underlying arteriopathy that predisposes the vessel to dissection.
Article
We describe four patients and review prior reports to clarify the clinical, radiographic, and pathologic findings of intracranial vertebral artery (VA) dissection. A 43-year-old man and a 33-year-old woman had chronic bilateral VA dissecting aneurysms. The man had multiple episodes of subarachnoid hemorrhage (SAH) and necropsy showed multiple dissections and defects in the internal elastica. The woman had many brainstem TIAs and strokes during 3 years. Two other patients had SAH and unilateral dissections. Intracranial VA dissection causes four overlapping syndromes: (1) brainstem infarcts are usually due to subintimal dissection extending into the basilar artery, affect younger patients, and often are single fatal events; (2) SAH is due to subadventitial or transmural dissection; (3) aneurysms cause mass effect on the brainstem and lower cranial nerves; and (4) chronic dissections due to connective tissue defects cause extensive bilateral aneurysms and repeated TIAs, small strokes, and SAH.
Article
Thirty (2.5%) of 1200 consecutive patients with a first stroke had a spontaneous dissection with occlusion of the cervical internal carotid artery (ICA). A suggestive picture with ipsilateral headache and oculosympathetic paresis was uncommon (17%), so that diagnosis was uncertain before angiography. Seven patients died within one week. During follow-up (mean, 3.2 years) with sequential Doppler ultrasonographic testing, 12 survivors had a good recovery and early reopening of the occluded ICA, and 11 had a poor recovery usually without reopening of the ICA. Recurrence of a dissection occurred in only one patient. Large infarcts causing death or a severe disability were associated with an ICA thrombus and distal emboli; the organization of this intraluminal thrombosis may explain the absence of reopening in these cases while resorption of the intramural hematoma developed. Early heparin sodium therapy may help prevent intraluminal clotting without carrying an important risk of extending the dissection, but its clinical benefit remains unproven. Contrary to current opinions, ICA dissection with occlusion causing cerebral infarction may often carry a severe prognosis.
Article
Two patients had acute spontaneous dissection of both internal carotid arteries and of one or both vertebral arteries. One had angiographic signs suggestive of fibro-muscular dysplasia and both were on oral contraceptives. They were treated with high dose heparin and made a good clinical recovery. A digital intravenous angiography performed two to three months later showed a complete recanalization of arteries involved. These patients are similar to those reported as "idiopathic regressing arteriopathy" and "reversible angiopathy" which probably correspond to the same entity.
Article
Though the syndrome of carotid artery dissection is well known, "spontaneous" vertebral artery dissection is rarely recognized. We now report clinical and radiologic findings in five patients with presumed vertebral dissection, one pathologically confirmed. Mean age was 35.2 years (range 27-41). Two were men; three women. None had hypertension, vascular disease, or trauma. Headache and neck or occipital pain was prominent in all, often preceding other symptoms. Four of five patients had unilateral partial alteral medullary syndromes, in one accompanied by medial medullary signs. One patient had a cerebellar infarct. Angiography in four patients showed severe irregular stenosis of the distal extracranial vertebral artery (three bilaterally). A fifth patient with irregular stenosis above the vertebral origin had verified extensive dissection in the resected segment. No patient developed late ischemia. Repeat angiography in three showed healing. We conclude that spontaneous vertebral artery dissection, though rare, has recognizable clinical and radiologic features.
Article
Dissections have been reported with increasing frequency in recent years. The authors discuss dissection of extracranial carotid, intracranial cerebral, and vertebrobasilar arteries and consider differences in clinical features and in pathophysiologic and therapeutic considerations.
Article
We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For patients with internal carotid artery dissection (ICAD), the mean age was 47 years and for those with vertebral artery dissection (VAD), 40.7 years. A history of migraine was present in 18% of the ICAD group and in 23% of the VAD group. Headache was reported by 68% of the patients with ICAD and by 69% of those with VAD, and, when present, it was the initial manifestation in 47% of those with ICAD and in 33% of those with VAD. Ten percent of patients with ICAD had eye, facial, or ear pain without headache. The median interval from onset of headache to development of other neurologic manifestations was 4 days for the ICAD group and 14.5 hours for the VAD group. For all dissections, headaches typically were ipsilateral to the side of dissection. In the ICAD group, headaches were limited to the anterior head in 60% of patients and were steady in 73% and pulsating in 25%. In the VAD group, headaches were distributed posteriorly in 83% of patients and were steady in 56% and pulsating in 44%. Neck pain was present in 26% of patients with ICAD (anterolateral) and in 46% of those with VAD (posterior). The median duration of the headache in patients with VAD and ICAD was 72 hours, but headaches became prolonged, persisting for months to years, in four patients with ICAD.
Article
Cerebral infarction is the most frequent and severe manifestation of extracranial internal carotid artery dissection. However, few data exist on the precise time course of symptoms preceding the onset of stroke. We studied 80 consecutive patients (29 retrospectively, 51 prospectively) with angiographically diagnosed extracranial internal carotid artery dissection and, during a 6-month follow-up, recorded the time elapsed between the onset of the first symptoms and the onset of any ischemic event (transient ischemic attack or stroke). We compared patients with and without ischemic events, with and without completed stroke, and, among patients who had local signs at onset, those with and without subsequent ischemic events. Cerebral or retinal infarction occurred in 42 patients. It was inaugural in 9 patients. In the 33 others, the time interval between the first symptoms (local signs and/or transient ischemic attacks) and the onset of stroke ranged from a few minutes to 31 days; it was < or = 7 days in 82% of the patients. No significant difference in the baseline characteristics of the patients or in the angiographic pattern of dissection was found based on the presence or absence of ischemic signs or of completed stroke. In carotid artery dissections, completed stroke usually occurs in the first few days after the onset of the first symptoms, whether local or ischemic, but it can occur as much as 1 month later. This suggests that any potential preventive treatment should be initiated as early as possible after the onset of the first symptoms but might also be worth initiating even 1 month later.
Article
In this study we analyzed the value of ultrasound examination for diagnosis of vertebral artery dissection. The vertebrobasilar arterial system was assessed in 14 patients using transcranial and extracranial pulsed-wave Doppler and duplex sonography. The dissections were verified by angiography (in 1 patient), magnetic resonance imaging (in 5), or both (in 8). The dissected segments were atlantoaxial (V-3) in 6, V-3 and intertransverse (V-2) in 3, V-3 and intracranial (V-4) in 3, and V-2 in 2 patients. Extracranial and transcranial Doppler examination of the atlas loop, involved in 12 patients, showed absent flow signal in 5, low bidirectional flow signal in 1, and poststenotic low blood flow velocities in 3 patients. Seven of these patients had high-grade stenosis or occlusion. The stenotic segment with increased flow signal could be identified directly in 2 patients. Duplex examination of the intertransverse segment confirmed absent flow in 4 patients, making technically insufficient examination unlikely. In the 2 patients with directly detected stenosis, duplex examination showed low flow velocities before the stenosis. The combined use of extracranial and transcranial Doppler and duplex sonography increases the diagnostic yield to detect vertebral artery pathology. If any abnormal sonographic finding was considered, the yield was 86%; relying only on definitively abnormal findings (absent flow signal, severely reduced vertebral artery blood flow velocities, no diastolic flow, bidirectional flow, and a stenosis signal), the yield was 64%. In most cases, there is no pathognomonic ultrasound finding for vertebral artery dissection. However, if a patient presents with suggestive symptoms, ultrasound may corroborate the clinical suspicion and aid in the decision regarding early anticoagulant treatment. A definite diagnosis can be made noninvasively when magnetic resonance imaging demonstrates hematoma in the vessel wall. Angiography yields additional information such as nature of underlying vascular disease, site and extent of dissection, intracranial extension, and presence of pseudoaneurysm.
Article
Clinical features of carotid artery dissection include ipsilateral local signs, contralateral ischemic stroke, or both. We observed two patients in whom these features were associated with renal infarcts. A 57-year-old woman had painful Horner's syndrome caused by a right internal carotid artery dissection. On days 3 and 4 she had acute abdominal pain, first on the right side and later on the left. The computed tomographic (CT) scan showed a left renal infarct. No aortic dissection or cardiac source of embolism was found. Transesophageal echocardiography showed a mild dystrophy of the ascending aorta and of the mitral valve. Cerebral angiography showed irregularities of the V3 segment of the left vertebral artery compatible with fibromuscular dysplasia. Erythrocyte sedimentation rate was 100 mm/h, and she complained of intense fatigue. She fully recovered within 3 months. A 53-year-old man had sudden severe abdominal pain followed by headache and difficulty in swallowing. He had 9th, 10th, 11th, and 12th cranial nerve involvement on both sides due to bilateral internal carotid artery dissections and pseudoaneurysms. CT scan showed a left renal infarct. Angiography showed extensive signs of fibromuscular dysplasia involving carotid, vertebral, renal, iliac, and mesenteric arteries as well as a dissection of the left renal artery. Erythrocyte sedimentation rate was 65 mm/h, and he complained of severe fatigue. His neurological signs returned to normal in 6 months. Renal infarct due to renal artery dissection may occur together with cerebral artery dissection. Acute abdominal pain, increased erythrocyte sedimentation rate, and intense fatigue are the warning symptoms.
Article
SYNOPSIS The clinical features of headache and neck pain in 14 patients with extracranial vertebral artery dissection proven by angiography or magnetic resonance imaging are reported. Pain was always located on the side of the dissected vertebral artery. Whereas eleven patients had head and posterior neck pain, the others had either only posterior neck pain, no change of a chronic pre-existing headache or no pain at all. Pain started suddenly, was of sharp quality and severe intensity, different from any previously experienced headache. Following acute onset, the time course of pain was monophasic with gradual remission of a persistent headache lasting one to three weeks. A delay between onset of head or posterior neck pain and onset of neurologic dysfunction was noted in 12 patients and was less than one day and between one day and three weeks in six each. Report of this distinct type of pain, although non-specific as an isolated symptom, should raise suspicion of an underlying vertebral artery dissection. Early confirmation of this diagnosis and subsequent anticoagulation if dissection does not extend intracranially may help prevent vertebro-basilar ischemic deficits.
Article
Heritable disorders of connective tissue are recognized in a small minority of patients with neurovascular diseases. In this report, we review the neurovascular manifestations of four heritable connective tissue disorders: Ehlers-Danlos syndrome, Marfan's syndrome, osteogenesis imperfecta, and pseudoxanthoma elasticum, as well as two other systemic disorders with potential vascular manifestations: neurofibromatosis and polycystic kidney disease. Typical neurovascular complications of Ehlers-Danlos syndrome are carotid-cavernous fistulae, intracranial aneurysms, and cervical artery dissections. Arterial dissections and intracranial aneurysms cause the majority of neurovascular symptoms in Marfan's syndrome. Neurovascular disease is uncommon in osteogenesis imperfecta, although carotid-cavernous fistulae and vertebral artery dissections have been reported. Neurovascular disease in pseudoxanthoma elasticum is characterized by intracranial aneurysms and cerebral ischemia caused by premature arterial occlusive disease. Intracranial occlusive arterial disease is the most common neurovascular manifestation of neurofibromatosis, followed by cervical arteriovenous fistulae and aneurysms and intracranial aneurysms. Intracranial aneurysms are the hallmark of polycystic kidney disease. Recognition of an underlying generalized connective tissue disorder may be of considerable importance, although marked phenotypic heterogeneity often complicates the diagnosis of these disorders. Conversely, the association of certain neurovascular anomalies with generalized connective tissue disorders and recognition of their basic molecular defect may offer clues to the etiology and pathogenesis of these neurovascular diseases in general.
Article
In order to assess the prevalence and characteristics of cephalic pain in internal carotid artery (ICA) dissection, and to compare clinical and angiographic features of patients with painful and non-painful dissections, we observed 65 patients with angiographically diagnosed extracranial ICA dissection from 1972 to 1990. Forty-eight patients (74%) complained of a cephalic pain which was inaugural in 38 (58.5%). It was homolateral to the dissection in 79% of cases and lasted from 1 h to 30 days, with a median of 5 days. Signs of cerebral or retinal ischemia were observed in 79% of patients, often delayed and occurring up to 29 days after the onset of pain. A painful Horner's syndrome was present in 31% of patients, and was the only manifestation of dissection in 16%. The clinical presentation of the dissections and angiographic findings were similar in patients with and without pain except for a past history of migraine which was more frequent in patients with painful dissections. Cephalic pain is frequent and often inaugural in carotid dissection. Its recognition is important for early diagnosis and treatment.
Article
Cervical internal carotid artery dissections are diagnosed with an increasing frequency, but reliable epidemiologic data are not available. The aim of this study was to determine the incidence rate of spontaneous cervical internal carotid artery dissection in a defined population. Using the medical record linkage system used for epidemiologic studies in Rochester, Minn, all patients diagnosed with spontaneous cervical ICA dissection for 1987 through 1992 were identified. A total of 10 patients with spontaneous cervical internal carotid artery dissection (6 women and 4 men; mean age, 44 years) were identified. For the period 1987 through 1992, the average annual incidence rate for all ages was 2.6 per 100,000 (95% confidence intervals, 0.9 to 4.2). This study, for the first time, provides incidence rates for spontaneous cervical internal carotid artery dissections. No diagnoses were made before 1987, probably reflecting an increased awareness of the disorder among physicians.
Article
Spontaneous dissection of the internal carotid and vertebral arteries is increasingly recognized as a cause of ischemic stroke in young people. An underlying arteriopathy is often suspected in the pathogenesis of such dissection, but the frequency of recurrent dissection is unknown. We describe the long-term follow-up of 200 consecutive patients (104 women and 96 men) with spontaneous cervical-artery dissections evaluated at the Mayo Clinic between 1970 and 1990. All diagnoses were confirmed by angiography. The mean age of the patients was 44.9 years (range, 16 to 76). Internal carotid arteries were affected in 150 patients, vertebral arteries in 37, and both in 13. Multivessel dissections were present in 28 percent of the patients. The mean follow-up was 7.4 years. Recurrent dissection occurred only in arteries not previously involved by dissection. A recurrent arterial dissection developed in 16 patients (8 percent)--within a month after the initial dissection in 4 patients (2 percent) and between 1.4 and 8.6 years later in 12 patients (a rate of 1 percent per year). The cumulative rate of recurrent dissection among patients followed for 10 years was 11.9 percent. Younger patients had a greater risk of recurrent dissection. Although dissections in multiple cervical vessels are common at presentation, after the first month the risk of recurrent dissection is only about 1 percent per year.
Article
Fifteen consecutive patients with a diagnostic problem of ischaemia-induced migraine with aura (symptomatic migraine) or migraine-associated ischaemia (migrainous infarction) were studied in order to elucidate the mechanisms. Three had a 1 month flurry of daily attacks of migraine auras with or without headache. A severe internal carotid stenosis/occlusion and reduced regional cerebral blood flow (rCBF) was demonstrated. Borderline ischaemia may thus prime the brain for developing migrainous aura with or without migraine (symptomatic migraine). Four patients had a combination of permanent deficits after the very first migraine attack, severe atherosclerosis, risk factors for stroke, high age and no family history of migraine. In these cases the evidence indicates that thromboembolic ischaemia had triggered an attack of migraine with aura (likely symptomatic migraine). Three young females presented long-lasting typical and severe idiopathic migraine with aura. Attack-associated rCBF reduction was likely to have caused permanent, mild, visual or somatosensory deficits (migrainous infarction). In five patients the relationship between migraine and stroke remained unresolved. It seems that ischaemia-induced migraine attacks may be more frequent than migraine-induced ischaemic insults. Therefore, migraine is not as strong a risk factor for stroke as indicated by the mere coincidence of the two disorders.
Article
Among patients with spontaneous cervical artery dissections, the risk of recurrent arterial dissection is relatively low at 1% per year, but this risk may be higher for patients with a family history of arterial dissections. We compared the risk of a recurrent arterial dissection in patients with familial versus non familial disease. Long-term follow-up was established in 200 patients (104 women and 96 men with a mean age of 44.9 years) with spontaneous cervical artery dissections evaluated at a single institution between 1970 and 1990. Among the 200 patients, 10 (5%) were identified who had a family history of spontaneous arterial dissections. In a multivariate analysis, family history was the only significant variable associated with the risk of recurrent dissection (X2=15.51; P=.0001). A recurrent arterial dissection was identified in 5 (50%) of the 10 patients with familial disease compared with 11 (5.8%) of the 190 patients with nonfamilial disease, with an estimated relative risk of 6.3 (95% confidence interval, 2.2 to 18.3; P=.0007). Among patients with spontaneous cervical artery dissections, a family history of arterial dissection is an important risk factor for the development of a recurrent arterial dissection.
Article
Cranial nerve palsy was present in 23 of 190 consecutive adult patients (12%) with spontaneous dissection of the extracranial internal carotid artery. Ten patients (5.2%) had a syndrome of lower cranial nerve palsies (with invariable involvement of cranial nerve XII with or without additional involvement of cranial nerves XI, X, and IX), seven (3.7%) had palsy of cranial nerve V, and five (2.6%) had a syndrome of ocular motor palsies. Palsy of cranial nerve VIII and ischemic optic neuropathy occurred in one patient each. Three patients had dysgeusia without other cranial nerve involvement, presumably due to involvement of the chorda tympani nerve. Headache or face pain (often unilateral) was present in 83% of patients. Other associated manifestations were cerebral ischemic symptoms, bruits, or oculosympathetic palsy. In one patient, cranial nerve palsy was the only manifestation of internal carotid artery dissection, and in another patient, the disease presented only as a palsy of cranial nerve XII and oculosympathetic palsy. In six patients, a syndrome of hemicrania and ipsilateral cranial nerve palsy was the sole manifestation of internal carotid artery dissection. Cranial nerve palsy is not rare in internal carotid artery dissection. Compression or stretching of the nerve by the expanded artery may explain some but not all of the palsies. An alternative mechanism is likely interruption of the nutrient vessels supplying the nerve.
Article
The etiology of spontaneous cervical artery dissection is poorly understood; however, it may involve genetic and environmental factors. The purpose of this study was to determine whether seasonality of spontaneous cervical artery dissection exists. The seasonal pattern of spontaneous cervical artery dissection was analyzed in a group of 200 consecutive patients (104 females and 96 males with a mean age of 44.9 years) who were evaluated using the Rayleigh test during the period from 1970 to 1990. The majority of patients resided in the midwestern section of the United States, where large seasonal fluctuations in climate occur. A circannual periodicity was found in the frequency of spontaneous cervical artery dissections with a peak occurring in October (p < 0.02). The seasonal variation was substantial, with approximately 58% more patients suffering a cervical artery dissection during autumn than during other seasons. A seasonal pattern of spontaneous cervical artery dissection exists with a peak occurring in October. The cause of the seasonality remains to be explained; however, weather- or infectious disease-related factors may provide etiological leads.
Article
The cause of spontaneous cervicocerebral artery dissection is unknown. An underlying arteriopathy due to a connective tissue disorder has often been presumed. We studied 25 patients with proven nontraumatic dissections. The ultrastructural morphology of dermal connective tissue components was assessed by transmission electron microscopy of skin biopsies. Ultrastructural abnormalities were seen in 17 (68%) patients, resembling in some cases the aberrations found in Ehlers-Danlos syndrome type II or III. These observations indicate a correlation of cervical artery dissections with connective tissue abnormalities. A structural abnormality in the extracellular matrix potentially caused by basic molecular defects is suggested and warrants further exploration.
Article
To report the ophthalmologic symptoms and signs associated with extracranial internal carotid artery dissection. One hundred forty-six consecutive patients with extracranial internal carotid artery dissection were evaluted; 29 were studied retrospectively from 1972 to 1984 and 117 prospectively from 1985 to 1997. Sixty-two percent of patients (91/146) with extracranial internal carotid artery dissection had ophthalmologic symptoms or signs that were the presenting symptoms or signs of dissection in 52% (76/146). Forty-four percent (65/146) had painful Horner syndrome, which remained isolated in half the cases (32/65). Twenty-eight percent (41/146) had transient monocular visual loss, which was painful in 31 cases, associated with Horner syndrome in 13 cases, and described as "scintillations" or "flashing lights"-often related to postural changes or exposure to bright lights-suggesting acute choroidal hypoperfusion in 23 cases. Four patients had ischemic optic neuropathy; one had diplopia. Among the 76 patients with ophthalmologic symptoms or signs as the presenting features of carotid dissection, a nonreversible ocular or hemispheric stroke later occurred in 27, within a mean of 6.2 days (range, 1 hour to 31 days). Eighteen patients had a stroke within the first week after the onset of neuro-ophthalmic symptoms and signs, and 24 had a stroke within the first 2 weeks. Ophthalmologic symptoms or signs are frequently associated with and are often the presenting features in internal carotid artery dissection. Painful Horner syndrome or transient monocular visual loss should prompt investigations to diagnose carotid artery dissection and begin early treatment to prevent a devastating ocular or hemispheric stroke.
Article
We sought to determine the clinical and neuroradiological features of intracranial vertebrobasilar artery dissection. The clinical features and MR findings of 31 patients (20 men and 11 women) with intracranial vertebrobasilar artery dissections confirmed by vertebral angiography were analyzed retrospectively. The vertebral angiography revealed the double lumen sign in 11 patients (13 arteries) and the pearl and string sign in 20 patients (28 arteries). The patients ranged in age from 25 to 82 years (mean, 54.8 years). Clinical symptoms due to ischemic cerebellar and/or brain stem lesions were common, but in 3 cases the dissections were discovered incidentally while an unrelated disorder was investigated. Headache, which has been emphasized as the only specific clinical sign of vertebrobasilar artery dissection, was found in 55% of the patients. Intramural hematoma on T1-weighted images has been emphasized as a specific MR finding. The positive rate of intramural hematoma was 32%. Double lumen on 3-dimensional (3-D) spoiled gradient-recalled acquisition (SPGR) images after the injection of contrast medium was identified in 87% of the patients. The 3-D SPGR imaging method is considered useful for the screening of vertebrobasilar artery dissection. Intracranial vertebrobasilar artery dissection is probably much more frequent than previously considered. Such patients may present no or only minor symptoms. Neuroradiological screening for posterior circulation requires MR examinations, including contrast-enhanced 3-D SPGR. Angiography may be necessary for the definite diagnosis of intracranial vertebrobasilar artery dissection because the sensitivity of the finding of intramural hematoma is not satisfactory.
Article
To evaluate the clinical course of aneurysms developed during extracranial internal carotid artery (ICA) dissection. Aneurysms developed during extracranial ICA dissection are detected angiographically in 5 to 40% of cervical artery dissections. The clinical and radiologic course of these aneurysms is not known, and it is not known how they should be treated. Fifty-eight consecutive patients with extracranial ICA dissection were reviewed, and those with radiographically detectable dissecting aneurysm at the acute stage or during early follow-up were included in this study. All patients had regular clinical and MR angiography examinations. Sixteen patients (27.5%) with a total of 20 ICA dissecting aneurysms were followed for a mean period of 36.9+/-21 months (range, 10 to 93 months). No clinical symptoms suggestive of aneurysmal rupture or embolization from the aneurysm were identified. Extracranial ICA aneurysms remained unchanged in 65% of patients, were resolved in 5% of patients, and decreased in size in 30% of patients. The clinical course of dissecting aneurysms was benign, although spontaneous radiologic resolution occurred rarely. Medical management with antiplatelet therapy alone (after early anticoagulation) is generally sufficient, and surgical management was seldom required.
Article
The dermal connective tissue of most patients with spontaneous cervical artery dissections (sCAD) contains abnormal collagen fibers. This suggests a predisposing connective tissue defect. The ultrastructural abnormalities in the skin of patients with sCAD have similarity with the morphological alterations in patients with Ehlers-Danlos syndrome type II, a dominant hereditary disorder that has been correlated in some patients to mutations within the genes encoding type V collagen. The aim of this study was to assess the alpha 1 chain of type V collagen (COL5A1) as a candidate gene for sCAD. We searched for mutations in the COL5A1 gene in cDNA from cultured fibroblasts of 19 patients with sCAD using single-strand conformational polymorphism analysis and nucleotide sequence analysis of polymerase chain reaction-amplified fragments of the whole COL5A1 coding sequence. We detected 1 missense mutation leading to a predicted amino acid (192D/N) substitution within the N-terminal propeptide in 2 siblings. All other patients showed regular COL5A1 sequences with some silent polymorphisms. Mutations in the COL5A1 gene do not appear to be a major factor in the etiology of sCAD.
Article
Migraine has been associated with diseases considered to be related to extracellular matrix disorders--in particular, cervical artery dissection. In this population-based study, we found a highly significant association between migraine and the activity of serum elastase, a metalloendopeptidase degrading specific elastin-type amino acid sequences. Such enzymes are involved in matrix degradation. This association was seen in both sexes and was stronger for migraine with aura. These findings could help in the understanding of why patients with migraine are at higher risk of stroke. Further study is needed to establish whether extracellular matrix abnormalities play a broader role in the pathophysiology of migraine.
Article
Among 111 patients with vertebral artery dissection (VAD), two presented with spinal manifestations: one with a C5-C6 radiculopathy and the other with a cervical myelopathy. Of 13 previously reported cases of spinal manifestations of VAD (mean age 37 years), ischemic cervical myelopathy was noted in seven; cervical radiculopathy, often at C5-C6 and primarily motor, in five; and hemorrhagic complications in one, with chest pain being part of the presentation.
Article
The pathogenesis of cervical artery dissection (CAD) remains unknown in most cases. Hyperhomocyst(e)inemia [hyperH(e)], an independent risk factor for cerebrovascular disease, induces damage in endothelial cells in animal cell culture. Consecutive patients with CAD and age-matched control subjects have been studied by serum levels of homocyst(e)ine and the genotype of 5,10-methylenetetrahydrofolate reductase (MTHFR). Twenty-six patients with CAD, admitted to our Stroke Unit (15 men and 11 women; 16 vertebral arteries, 10 internal carotid arteries), were compared with age-matched control subjects. All patients underwent duplex ultrasound, MR angiography, and/or conventional angiography. Mean plasma homocyst(e)ine level was 17.88 micromol/L (range 5.95 to 40.0 micromol/L) for patients with CAD and 6.0+/-0.99 micromol/L for controls (P:<0.001). The genetic analysis for the thermolabile form of MTHFR in CAD patients showed heterozygosity in 54% and homozygosity in 27%; comparable figures for controls were 40% (P:=0.4) and 10% (P:=0.1), respectively. Mild hyperH(e) might represent a risk factor for cervical artery dissection. The MTHFR mutation is not significantly associated with CAD. An interaction between different genetic and environmental factors probably takes place in the cascade of pathogenetic events leading to arterial wall damage.
Article
When a tear occurs in one of the major arteries in the neck and allows blood to enter the wall of the artery and split its layers, the result is either stenosis or aneurysmal dilatation of the vessel. This process was long thought to be a rare cause of stroke, particularly in the absence of trauma, and the diagnosis was usually not made until the postmortem examination.1–3 It was not until the late 1970s, when Fisher et al.1 and Mokri et al.2 described dissections of carotid and vertebral arteries as detected by modern diagnostic approaches, that dissections began to . . .
Article
The etiology of spontaneous cervical artery dissection (CAD) is largely unknown. An underlying connective tissue disorder has often been postulated. To further assess the association of CAD with ultrastructural abnormalities of the dermal connective tissue. In a multicenter study, skin biopsies of 65 patients with proven nontraumatic CAD and 10 control subjects were evaluated. The ultrastructural morphology of the dermal connective tissue components was assessed by transmission electron microscopy. Only three patients (5%) had clinical manifestations of skin, joint, or skeletal abnormalities. Ultrastructural aberrations were seen in 36 of 65 patients (55%), consisting of the regular occurrence of composite fibrils within collagen bundles that in some cases resembled the aberrations found in Ehlers-Danlos syndrome type II or III and elastic fiber abnormalities with minicalcifications and fragmentation. A grading scale according to the severity of the findings is introduced. Intraindividual variability over time was excluded by a second biopsy of the skin in eight patients with pronounced aberrations. Recurrent CAD correlated with connective tissue aberrations. In addition, similar connective tissue abnormalities were detected in four first-degree relatives with familial CAD. CAD is associated with ultrastructural connective tissue abnormalities, mostly without other clinical manifestations of a connective tissue disease. A structural defect in the extracellular matrix of the arterial wall leading to a genetic predisposition is suggested. The dermal connective tissue abnormalities detected can serve as a phenotypic marker for further genetic studies in patients with CAD and large families to possibly identify the underlying basic molecular defect(s).
Article
To study whether spontaneous dissections of the cervical internal carotid artery dissection (ICAD) with and without ischemia of the brain or retina differ in the prevalence of vascular risk factors, local neurologic signs and symptoms, and stenoses and occlusions of the cerebral arteries. The authors prospectively studied 181 consecutive patients with 200 ICAD. Diagnosis was based on ultrasonography and MRI or catheter angiography. Vascular risk factors, presenting local (headache, neck pain, Horner syndrome, pulsatile tinnitus, cranial nerve palsy on the side of the ICAD) and ischemic signs and symptoms, and ultrasonographic findings in the carotid and basal cerebral arteries were evaluated. ICAD with ischemic events (n = 145) had a higher prevalence of hypercholesterolemia (p < 0.05), >80% stenoses and occlusions of the ICA (p < 0.0001), and intracranial obstructions (p < 0.001). ICAD without ischemic events (n = 55) had a higher prevalence of Horner syndrome (p < 0.001), cranial nerve palsy (p < 0.01), and normal ICA findings (p < 0.0001). These data suggest that ICAD causing high-grade stenosis and occlusion are more likely to lead to intracranial obstructions and cerebral or retinal ischemic events. Conversely, ICAD without luminal narrowing cause more local signs and symptoms.
Article
Results of recently published studies suggest that intravenous thrombolysis (IVT) and local intra-arterial thrombolysis (LIT) are feasible procedures in acute stroke after cervical artery dissection (CAD). To describe 9 patients with acute stroke caused by CAD who were treated by LIT (n = 7) or IVT (n = 2) and to review the literature. Retrospective analysis of clinical and neuroradiological findings; literature review from 1980 to present. Modified Rankin Scale (mRS) score. Of 7 patients treated with LIT, 3 had good outcomes (mRS score of 0-2) and 4 had bad outcomes (mRS score of 3-6) at 3 months. The 2 patients who had received IVT recovered to mRS scores of 0 and 3. Twenty-one patients were identified in the literature. Overall (N = 30), in the IVT group (n = 19), the outcome was good in 8 patients (42%) and bad in 11 (58%); in the LIT group (n = 11), 6 patients (55%) had a good outcome and 5 (45%) had a bad outcome. Overall, 47% (14/30) of the patients (IVT and LIT groups) had a good outcome. Total mortality was 13% (4/30). There were no secondary complications due to extension of wall hematoma or angiography. One symptomatic hemorrhage occurred. Thrombolysis is feasible in acute stroke caused by CAD. Local complications from extension of wall hematoma did not occur. Further prospective studies are needed to determine the safety and efficacy of thrombolysis in the special circumstance of acute stroke caused by CAD.
Article
The association between migraine and cervical artery dissection (CAD) was explored in a hospital-based case-control study. Migraine was present in 49.1% (23/47) of patients with CAD and in 21% (11/52) of patients hospitalized for a cerebral ischemic event not related to a CAD (adjusted odds ratio = 3.6; 1.5 to 8.6, p = 0.005). This result supports the hypothesis that an underlying arterial wall disease could be a predisposing condition for migraine.
Article
To compare the rate of ischemic events and intracranial hemorrhage in the long-term follow-up of patients with persistent and transient severe stenosis or occlusion of the internal carotid artery (ICA) due to spontaneous dissection (ICAD). One hundred and sixty-one consecutive patients with unilateral ICAD causing severe stenosis or occlusion were examined clinically and by ultrasound 1 year after symptom onset. Forty-six cases with persistent and 46 age- and latency-matched cases with transient (recanalization complete or less than 50% stenosis) severe stenosis or occlusion of the ICA were enrolled. Nine patients with surgical, endovascular, or fibrinolytic therapy for ICAD or associated stroke were excluded. Antithrombotic therapy was given at the discretion of the treating physician. Clinical follow-ups were done annually. Antithrombotic therapy and follow-up were similar in patients with permanent (6.2 +/- 3.4 years) and transient (7.2 +/- 4.3 years) severe stenosis or occlusion of the ICA. Cases with permanent carotid stenosis or occlusion showed annual rates of 0.7% for ipsilateral carotid territory stroke and of 1.4% for any stroke. Cases with transient carotid stenosis or occlusion showed annual rates of 0.3% for ipsilateral carotid territory stroke and of 0.6% for any stroke. This study suggests that ICAD has a benign long-term prognosis with low rates of ipsilateral carotid territory and any stroke and that the stroke rate in ICAD is not related to the persistence of severe carotid stenosis or occlusion. These results question the rationale of surgical or catheter-based revascularization in patients with ICAD.
Article
We reviewed the clinical and radiological findings of 93 consecutive patients with 111 extracranial internal carotid (ICAD) and vertebral artery (VAD) dissections and one concomitant intracranial VAD; 83% of the patients had unilateral and 17% multiple vessel dissections. The diagnosis was made by intra-arterial digital subtraction angiography in 92 patients and MR angiography in one. Follow-up angiography was performed in 77 cases (83%): of 49 initially stenotic arteries, 40 became completely or almost completely normal, while three showed slight improvement. Of 30 initially occluded arteries, nine had completely or partly recanalised. Of 12 pseudoaneurysms eight were unchanged at follow-up. The proximal vertebral artery was involved as often as the C1-C2 level. Recurrences were rare: a new dissection in another vessel was found in three patients. Kinking or coiling was found in 23% of the dissected internal carotid arteries.
Article
Several constitutional and environmental risk factors may be involved in the occurrence of spontaneous cervical artery dissection (SCAD). This work explored the association between recent infection and SCAD in an hospital-based case-control study. Forty-seven patients with SCAD and 52 with ischemic stroke from another cause were prospectively and consecutively recruited by 2 neurology departments. A specially designed questionnaire was used to assess the history of an acute infection that could have occurred within a month before the vascular event. Acute infection was more frequent in patients with SCAD (31.9%) than in control subjects (13.5%) (crude odds ratio, 3.0; 95% confidence interval, 1.1 to 8.2; P=0.032). This association was stronger in patients with multiple (odds ratio, 6.4) than single artery (odds ratio, 2.1) dissection. Recent infection is a risk factor and could be a trigger for SCAD.
Article
Carotid artery dissection (CAD) is a common cause of stroke in young patients. Clots formed at the low-flow zone in the false arterial lumen may give rise to distal emboli, and the mural hematoma may eventually occlude the artery. Anticoagulation is currently the accepted treatment, but it is unknown which patients will improve spontaneously, which will respond to anticoagulation, and which will have an exacerbation of ischemic symptoms despite therapy. Endovascular treatment of CAD may be an attractive alternative to anticoagulation, and methods of identifying patients who stand to benefit from such therapy need to be established. We present here 3 cases of spontaneous symptomatic CAD in which endovascular stenting procedures were performed on the basis of a paradigm aimed at identifying potentially salvageable but at-risk brain tissue by combining clinical with MRI (diffusion and perfusion) and angiographic data. Diffusion-perfusion MRI mismatches and/or evidence of cerebral ischemia on angiographic parenchymography were identified in all patients. They did not respond to anticoagulation, were therefore treated with endovascular stents, and had excellent outcomes. Endovascular stent placement may be an immediate, effective, and safe method of restoring vessel lumen integrity. It may be considered for selected patients who are clinically symptomatic despite anticoagulant treatment and in whom neuroimaging methods suggest that the neurological signs originate from a viable, hypoperfused, ischemic penumbra.
Article
To assess the risk of stroke, TIA, or dissection recurrence after a first event of cervical artery dissection (CAD). The authors undertook a historical cohort study of consecutive patients with a first event of CAD who were admitted in 24 departments of neurology within a period of at least 1 year. Patients were retrospectively selected from a stroke data bank or from the local administrative data bank using the 10th revision of the International Statistical Classification of Diseases. A neurologist and a radiologist reviewed all charts to validate diagnosis and collect data. In 2002, patients were interviewed by phone or during a visit by the local investigators. Four hundred fifty-nine patients (mean age 44.0 +/- 9.7 years) were included in the study. Among the 457 survivors, 25 (5.5%) could not be contacted in 2002 because they had moved. After a mean follow-up of 31 months, four (0.9%) patients presented a recurrent ischemic stroke attributable to either not yet completely recovered initial CAD (n = 2) or a recurrent CAD (n = 2). Eight (1.8%) patients had a TIA without CAD recurrence. Two TIA occurred at the acute stage of CAD. Of the six remaining TIA, only one was associated with chronic arterial stenosis. In addition, two patients had recurrent CAD without stroke, giving a total of four (0.9%) CAD recurrences. Patients with a first event of CAD have a very low risk of ischemic events or dissection recurrences. Ischemic events seem rarely to be in relation with chronic arterial lesions.
Article
It is unclear whether stroke in patients with spontaneous dissection of the cervical internal carotid artery (ICAD) is due to thromboembolism or impaired hemodynamics. This study investigated the mechanism of stroke in ICAD by examining brain imaging and cerebrovascular findings of such patients. We retrospectively evaluated the prospectively collected brain CT, MR, and ultrasound findings of 141 consecutive patients with 143 ICADs causing ischemic stroke. Eleven patients were not included because they had an inappropriate temporal bone window (n=6) or were treated with thrombolysis (n=5). Thus, the data of 130 patients (76 men, 54 women) with 131 ICADs were analyzed. All patients had territorial infarcts; 6 patients (5%) also had border-zone infarct patterns. Territorial infarcts affected the middle cerebral artery (MCA) in 130 of 131 cases (99%) and the anterior cerebral artery (ACA) in 1 case (1%). Additional vascular territories were affected in 8 patients with MCA infarcts (ACA, n=5 [4%]; posterior cerebral artery, n=3 [2%]). The pattern (hemodynamic versus thromboembolic) and extent of infarction were not influenced by vascular findings (MCA stenosis or occlusion, ACA occlusion, degree of obstruction in the dissected ICA, pattern of cross-flow in 115 patients with >80% ICA stenosis or occlusion). This study suggests that thromboembolism, not hemodynamic infarction, is the essential stroke mechanism in ICAD.