Literature Review and Case Report of Intravenous Thrombolysis in Acute Cerebral Infarction Attributed to Cervical Arterial Dissection.

Acute cerebral infarction (ACI) caused by cervical arterial dissection (CAD) is a rare clinical disease. Therapeutic approaches include anticoagulant therapy, antiplatelet aggregation, and thrombolytic therapy. Currently, anticoagulant therapy or antiplatelet aggregation is the primary choice, whereas the thrombolytic therapy is still controversial. In this article, we report a patient with ACI caused by right CAD, which led to a compensatory increase in blood supply to the right middle cerebral artery through the anterior communicating artery. After treatment with intravenous thrombolysis, the clinical symptoms of the patient improved, and the National Institutes of Health Stroke Scale (NIHSS) score declined to 2 points from the initial 14 points. In addition, cranial computed tomography scans showed that there were no signs of intracranial or extracranial hemorrhage, but that the vessel occlusion was still uncured. After 17 days of antiplatelet aggregation treatment, a cranial magnetic resonance angiography scan showed complete recanalization of the right internal carotid artery. Furthermore, the NIHSS score was reduced to 1 point when the patient discharged, and for 3 months of follow-up.

Unilateral posterior cervical spinal cord infarction due to spontaneous vertebral artery dissection.

CONTEXT: Ischemia of the cervical spinal cord is a rare complication of spontaneous vertebral artery dissection (VAD) and usually involves the ventral portion. We describe a less evocative clinical presentation and images of unilateral posterior spinal cord infarction due to spontaneous VAD in order to facilitate early diagnosis. FINDINGS: A previously fit 30-year-old man presented with persistent headaches and proximal motor deficit of the right arm. He was diagnosed with spontaneous dissection of both vertebral arteries, with occlusion of the right one, and the right carotid artery. Neurological examination also revealed a right C2-C3 tactile sensory loss, with unilateral proprioceptive deficit below. Brain images revealed small bilateral cerebellar infarcts which could not be responsible for the clinical symptoms. Magnetic resonance imaging of the spinal cord showed a right posterior cervical spinal cord infarction. The patient achieved nearly complete recovery after several weeks of anticoagulation and rehabilitation. CONCLUSION AND CLINICAL RELEVANCE: Infarction of the caudal portion of the cervical spinal cord, especially unilateral, caused by spontaneous VAD, has rarely been described and is certainly under-diagnosed due to less suggestive symptoms, like unilateral and mainly sensory deficit. Nevertheless, early diagnosis of this condition is important to guide patient management and rehabilitation.

A Sudden Unilateral Visual Field Loss in a Recreational Tennis Player: Cervical Internal Carotid Artery Dissection Associated With Low-Impact Sports.

Traumatic cervical internal carotid artery dissection (CICAD) is a rare condition caused by blunt trauma to the neck, often through automobile- or sports-related collisions, assaults, or falls. Herein, we report an unusual case in which engaging in a low-impact sport (tennis) caused CICAD, without a direct injury. A 56-year-old man with hypertension suddenly experienced a visual field loss in his right eye while playing tennis. Carotid echocardiography revealed severe stenosis of the right internal carotid artery (ICA). Angiography revealed severe and irregular stenosis of the right ICA from the bifurcation to the petrous portion, suggesting CICAD. Upon admission, the patient had left upper visual field defects in his right eye and neck pain. Antiplatelet therapy was initiated with prasugrel (3.75 mg/day), with the intent to treat surgically if the stenosis or symptoms progressed. Follow-up angiography and magnetic resonance imaging showed gradual resolution of the stenosis, and the patient was discharged on day 28 with a modified Rankin Scale score of 1. The CICAD should be considered as a diagnosis for neurological symptoms, even in the context of low-impact sports such as tennis. Antithrombotic therapy is a reasonable first-line treatment for stable CICAD.

The Clinical Utility of High-Resolution Vessel Wall Imaging in Screening for Meningovascular Neurosyphilis.

Meningovascular neurosyphilis is a common cause of stroke in young adults, particularly when HIV co-infection is present. Contemporary screening for neurosyphilis relies on invasive testing. High resolution vessel wall imaging (HR-VW) is an emerging non-invasive tool to detect intracranial vessel wall inflammation. We report a case of multifocal acute cerebral infarctions from meningovascular neurosyphillis in which HR-VWI was instrumental in leading to the etiological diagnosis. A 32-year-old man with history of untreated HIV and polysubstance abuse presented with sudden onset vertigo. CT angiogram of the head and neck showed non-dominant left extracranial vertebral artery occlusion in the V1 segment, and multifocal areas of stenoses in V2 through V4 segments. Non-contrast brain MRI demonstrated multiple small acute infarcts in the left cerebellum, left brachium pontis, medulla and occipital lobe. Rapid plasma reagin was reactive. 3D whole-brain HR-VWI revealed concentric vessel wall contrast enhancement in the left V4 segment, suggestive of inflammation. This HR-VWI finding prompted further investigation with cerebrospinal fluid analysis that revealed reactive fluorescent treponemal antibody absorption test. The patient received high-dose intravenous Penicillin G, was restarted on highly active antiretroviral therapy, and remained neurologically stable to-date. With high spatial resolution and signal-to-noise ratio, HR-VWI allows for visualization of vessel wall inflammation in co-morbid HIV and neurosyphilis.

Shear wave elastography of the cervical arteries: A novel approach to the assessment of cervical arterial wall stiffness. An investigation of psychometric properties and intra-rater reliability.

BACKGROUND: Cervical arterial dissection, can occur spontaneously and is a rare but catastrophic adverse event associated with neck manipulation. Pathophysiology involves altered integrity of the arterial wall increasing its vulnerability to minor trauma. Those at risk are difficult to detect. Previous screening investigated blood flow but altered mechanical properties as stiffness of cervical arterial wall could provide a more valid indication of arterial integrity or even early dissection. OBJECTIVES: To investigate suitability and intra-rater reliability of shear wave ultrasound elastography to measure mechanical properties of the cervical arterial wall. Suitability was assessed by ability to track arteries along their length and measurement accuracy. DESIGN: Observational and intra-rater reliability study. METHODS: Internal carotid (ICA) and vertebral arteries (VA) of healthy participants were examined with shear wave elastography. Shear wave velocity (m/s) indicative of wall stiffness was measured with the head in the neutral position: proximally (C3-4) and distally (C1-2) where injuries have been more commonly reported. Proximal measures were repeated to assess intra-rater reliability. RESULTS: Thirty healthy participants (13 female), mean age of 29 (±12.8) years were imaged. Mean VA wall stiffness (3.4 m/s) was greater than ICA (2.3 m/s) (p < 0.000). Intra-rater reliability for ICA was ICC 0.81 (CI 0.52 to 0.92) and for VA ICC 0.76 (CI 0.38 to 0.9). Standard error of measurement was 0.16 for ICA and 0.34 for VA. CONCLUSIONS: Shear wave ultrasound elastography appears a suitable and reliable method to measure cervical arterial wall stiffness, justifying further research into its use for screening arterial integrity.

Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: A systematic review.

Cervical spinal manipulation (CSM) and cervical mobilization are frequently used in patients with neck pain and headache. Pre-manipulative cervical instability and arterial integrity tests appear to be unreliable in identifying patients at risk for adverse events. It would be valuable if patients at risk could be identified by specific characteristics during the preliminary screening. Objective was to identify characteristics of 1) patients, 2) practitioners, 3) treatment process and 4) adverse events (AE) occurring after CSM or cervical mobilization. A systematic search was performed in PubMed, Embase, CINAHL, Web-of-science, AMED, and ICL (Index Chiropractic Literature) up to December 2014. Of the initial 1043 studies, 144 studies were included, containing 227 cases. 117 cases described male patients with a mean age of 45 (SD 12) and a mean age of 39 (SD 11) for females. Most patients were treated by chiropractors (66%). Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication. Cervical arterial dissection (CAD) was reported in 57% (P = 0.21) of the cases and 45.8% had immediate onset symptoms. The overall distribution of gender for CAD is 55% (n = 71) for female and therefore opposite of the total AE. Patient characteristics were described poorly. No clear patient profile, related to the risk of AE after CSM, could be extracted. However, women seem more at risk for CAD. There seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AE using standardized terminology.

Helsinki experience on nonvitamin K oral anticoagulants for treating cervical artery dissection.

BACKGROUND: Cervical artery dissection (CeAD) patients with or without stroke are frequently treated with either antiplatelet agents or vitamin K antagonists (VKAs), but few data are reported on the use of nonvitamin K oral anticoagulants (NOACs). METHODS: Between November 2011 and January 2014, we recorded data from patients with a stroke due to vertebral (VAD) or internal carotid artery dissection (ICAD). Patients using oral anticoagulants were included in the study and were divided into two treatment groups: patients using NOACs and those using VKAs. Excellent outcome was defined on modified Rankin Scale (mRS) ≤1 at 6 months. RESULTS: Of 68 stroke patients (67% male; median age 45 [39-53]), six (8.8%; two with VAD and four with ICAD) were treated with NOACs: three with direct thrombin inhibitor dabigatran and three with direct factor Xa inhibitor rivaroxaban. National Institutes of Health Stroke Scale score at baseline was 4 (3-7) in the NOAC versus 2 (1-7) in the VKA groups. Complete recanalization at 6 months was seen in most patients in the NOAC (n = 5; 83%) and VKA (n = 34; 55%) groups. All the patients using NOACs had mRS ≤1 at 6 months and none had an intracerebral hemorrhage (ICH). In the VKA group most patients (n = 48; 77%) had mRS ≤1, one patient (1.7%) had an ICH and one died. CONCLUSIONS: In this small, consecutive single-center patient sample treating ischemic stroke patients with CeAD with NOACs did not bring up safety concerns and resulted in similar, good outcomes compared to patients using VKAs.