Long-term outcome of cervical artery dissection.

OBJECTIVE: The aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches. METHODS: A retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022. RESULTS: Thirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner's syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days. CONCLUSIONS: The majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.

Bow Hunter's syndrome combined with ipsilateral vertebral artery dissection/pseudoaneurysm: case study and literature review.

BACKGROUND: Bow hunter's syndrome (BHS), also known as rotational vertebral artery occlusion syndrome, is rare. Occasionally, it combines with dissection/pseudoaneurysm of the ipsilateral VA. METHODS: We report a case of BHS combined with ipsilateral VA dissection/pseudoaneurysm and review eight similar cases reported in the literature. Their aetiology, clinical and imaging features, treatment, and prognosis were analysed. RESULTS: Nine patients (seven male, two female; average age 22.0 ± 4.5 years) were enrolled. Visual symptoms comprised the most common clinical finding (66.7%, 7/9). Clinical symptoms were not related to neck rotation in seven patients (77.8%). Eight patients (88.9%) had multiple, scattered, new and old infarctions of the posterior circulation revealed on computed tomography/magnetic resonance imaging (CT/MRI) scans. Dissection/pseudoaneurysm was found in the ipsilateral VA - usually subtle and localised in the atlas, axis, and occipital bone - in all nine patients. Seven patients (66.7%) had special causes for the syndrome (i.e. congenital bone dysplasia). Altogether, 87.5% (7/8) experienced recurrence with cerebral infarction after antithrombotic therapy alone. Aetiologically targeted treatment, including surgical decompression or vertebral fixation, was performed in seven patients (77.8%). CONCLUSION: Young patients presenting with cryptogenic stroke in the posterior circulation and localised, subtle dissection/pseudoaneurysm of the ipsilateral VA around the atlanto-axial joint should undergo carotid ultrasonography with a neck rotation test or dynamic CT angiography/MR angiography/digital subtraction angiography, if necessary, to rule out/diagnose BHS.

Morphological characteristics associated with ruptured intracranial vertebral artery dissecting aneurysms.

OBJECTIVE: Morphological risk factors for the rupture of intracranial vertebral artery dissecting aneurysms (IVADAs) have not been well characterized. In this study, we aim to identify morphological characteristics associated with IVADA rupture. METHODS: We conducted a retrospective study of 249 consecutive patients with single IVADAs (31 ruptured and 218 unruptured) admitted to Beijing Tiantan Hospital between January 2016 and December 2020. Various morphological parameters were measured using three-dimensional digital subtraction angiography images. Univariate and multivariate logistic regression analyses were performed to identify morphological characteristics associated with IVADA rupture. RESULTS: Univariate regression analysis revealed that the coexistence of significant proximal and distal stenosis and posterior inferior cerebellar artery (PICA) involvement were associated with IVADA rupture, while the origin from the dominant vertebral artery was inversely associated with the rupture. Multivariate regression analysis demonstrated that the coexistence of significant proximal and distal stenosis (OR 22.00, 95% CI 5.60 to 86.70, p<0.001) and PICA involvement (OR 4.55, 95% CI 1.36 to 15.20, p=0.014) were independently associated with IVADA rupture. CONCLUSION: The coexistence of significant proximal and distal stenosis and PICA involvement were independently associated with IVADA rupture. These morphological characteristics may facilitate the assessment of rupture risk in patients with IVADAs.

Vertebral arteriovenous fistulae (AVF) and vertebral artery aneurysms in neurofibromatosis type 1: A case report and a systematic review.

BACKGROUND: Neurofibromatosis type 1 (NF1) is caused by mutations in the NF1 gene on the long arm of chromosome 17, which affects the skin, nervous system, eyes, and skeleton system. Vertebral arteriovenous fistula (AVF) associated with neurofibromatosis type I (NF-1) is rare. CASE PRESENTATION: We report a 31-year-old postpartum woman with NF1 with vertebral arteriovenous fistulae (AVFs). She presented to our hospital because of neck pain, intracranial hypotension headache, and right upper limb weakness. She had a family history of NF1. After endovascular intervention, the AVF disappeared. However, a new aneurysm appeared on the right vertebral artery V5 dissection after 6 months of follow-up. CONCLUSIONS: The presence of NF1 in patients who present with neurologic signs should prompt further angiography. Awareness of the coexistence between NF1 and AVF or aneurysm is crucial to avoiding diagnostic delays. Endovascular occlusion of VV-AVF in NF-1 patients is effective and safe.

Cervical Artery Dissections: Etiopathogenesis and Management.

Cervical Artery Dissection (CeAD) is a frequent stroke etiology for patients younger than 50 years old. The most common immediate complications related to CeAD are headache and neck pain (65-95%), TIA/ischemic stroke (>50%), and partial Horner's syndrome (25%). The prevailing hypothesis regarding the pathogenesis of sCeAD is that the underlying constitutional vessel wall weakness of patients with sCeAD is genetically determined and that environmental factors could act as triggers. The stroke prevention treatment of CeAD remains controversial, involving anticoagulation or antiplatelet therapy and potentially emergent stenting and/or thrombectomy or angioplasty for selected cases of carotid artery dissection with occlusion. The treatment of headache associated with CeAD depends on the headache phenotype and comorbidities. Radiographically, more than 75% of CeAD cases present with occlusion or non-occlusive stenosis. Many patients demonstrate partial and complete healing, more commonly in the carotid arteries. One-fifth of the patients develop dissecting pseudoaneurysm, but this is a benign clinical entity with an extremely low rupture and stroke recurrence risk. Good recovery is achieved in many CeAD cases, and mortality remains low. Family history of CeAD, connective tissue disorders like Ehlers-Danlos syndrome type IV, and fibromuscular dysplasia are risk factors for recurrent CeAD, which can occur in 3-9% of the cases. This review serves as a comprehensive, updated overview of CeAD, emphasizing etiopathogenesis and management.

"Incidence, characteristics and prognosis of cervical artery dissection-induced ischemic stroke in central Iran".

OBJECTIVES: Ischemic stroke is the most common presentation of cervical artery dissection (CAD). Information regarding CAD-induced stroke is scarce, especially in the Middle East. Here we investigated the incidence of CAD-induced stroke, its characteristics, and the clinical course in central Iran. METHODS: This is an observational study conducted in the city of Isfahan, Iran. We recruited patients with ischemic stroke during 2017-2019. We analyzed characteristics of the CAD-induced stroke patients with regards to the involved vessel (internal carotid artery dissection (ICAD) or vertebral artery dissection (VAD)). We assessed functional outcome (modified Rankin Scale [mRS]) and recanalization status after 1 year of follow-up. RESULTS: Among 3630 ischemic stroke patients, 51(1.4%) had CAD-induced stroke (mean age: 41.8 ± 12.6; 40.4% female; 28 and 19 ICAD and VAD cases, respectively). The crude incidence rate of CAD-induced stroke was 1.20/100,000/year (0.66/100,000/year and 0.45/100,000/year for strokes due to ICAD and VAD, respectively). mRS ≤ 2 was present in 63.8% of the patients after 1 year of follow-up. History of exercise during the last days before stroke occurrence was associated with a better follow-up mRS (ß = -3.1, p-value: 0.037). Administration of anticoagulant or double-antiplatelets was related neither to mRS nor recanalization results. Trauma (27.7%), smoking (21.3%), and headache disorders/migraine (21.3%) were the most common reported factors. CONCLUSION: We found a crude incidence rate of 1.20/100,000/year for CAD-induced stroke. Trauma, smoking, and headache disorders were the most common reported factors among our patients. CAD-induced stroke had a favorable long-term prognosis regardless of the type of the involved vessel or the used medication.

Stroke Recurrence in Children with Vertebral Artery Dissecting Aneurysm.

BACKGROUND AND PURPOSE: Pediatric vertebral artery dissecting aneurysm is a subtype of vertebral artery dissection that can be challenging to diagnose and may be associated with stroke recurrence. This study examines the presenting features, clinical outcomes, and recurrence risk in a cohort of children with vertebral artery dissection, comparing those with aneurysms with those without. MATERIALS AND METHODS: The medical records of children evaluated for vertebral artery dissection were retrospectively reviewed for neurologic presentation, treatment, stroke recurrence, and angiographic appearance of dissection. Cohort patients were categorized into 2 groups based on the presence or absence of a vertebral artery dissecting aneurysm and compared via the Fisher exact test, Student t test, and log-rank analyses. P < .05 was deemed statistically significant. RESULTS: Thirty-two patients met the inclusion criteria, including 13 with vertebral artery dissecting aneurysms. Five cases of vertebral artery dissecting aneurysm were missed on the initial evaluation and diagnosed retrospectively. All patients received antiplatelet or anticoagulation therapy at the time of diagnosis. Children in the vertebral artery dissecting aneurysm group were more likely to present with stroke (P = .059), present at a younger age (P < .001), and have recurrent stroke (P < .001) compared with the group of children with vertebral artery dissection without an aneurysm. After surgery, no patients with vertebral artery dissecting aneurysm experienced recurrent stroke (P = .02). CONCLUSIONS: Vertebral artery dissecting aneurysm is often missed on the initial diagnostic evaluation of children presenting with stroke. In children with vertebral artery dissection, the presence of an aneurysm is associated with stroke presentation at a younger age and stroke recurrence.

A case of atlantoaxial dislocation associated with ipsilateral vertebral and carotid artery dissections: highlighting the injury biomechanics and management strategy.

INTRODUCTION: Traumatic cervical artery dissections carry significant morbidity and mortality among blunt trauma victims. The current paper illustrates a case with a young male who presented with atlantoaxial dislocation associated with ipsilateral carotid and vertebral artery dissections complicated by middle cerebral artery (MCA) infarction. CASE REPORT: We report a young male who presented to the emergency department with ipsilateral carotid and vertebral artery dissections complicated by middle cerebral artery (MCA) stroke associated with atlantoaxial dislocation after jumping into the water from a height. A young patient presented to us 1 year after sustaining an injury. We did posterior C1/2 fusion using the technique described by Harms and Goel to treat his atlantoaxial dislocation. The patient tolerated the surgery well and was discharged on postoperative day 4. CONCLUSIONS: We highlighted the complicated course of the simultaneously traumatic dissections of ipsilateral cervical arteries along with atlantoaxial dislocation, the biomechanics of this combination of injuries, and their management strategy.

Isolated ruptured dissecting aneurysm of PICA with extremely narrow neck managed by a novel endovascular technique-a case report and review of literature.

Dissecting aneurysms of posterior inferior cerebellar artery (PICA) are usually extensions of vertebral artery dissection. Isolated dissecting aneurysms of PICA are extremely rare. A 5-month-old female child presented with history of fall from a height of around 2 ft., followed by incessant crying and multiple episodes of vomiting. The anterior fontanelle was lax. Plain CT scan brain showed IVH in the fourth ventricle with no hydrocephalus. Twenty-four hours after admission, the child had one episode of vomiting and became unresponsive. The child was intubated, and a repeat CT scan brain showed thick acute SDH in the posterior fossa with hydrocephalus. Emergency suboccipital craniectomy and evacuation of thick acute subdural hematoma were done. Organized clot noted in the midline between the tonsils was not removed. Digital subtraction angiography (DSA) done 48 h after surgery showed ruptured dissecting aneurysm of left PICA. Endovascular temporary parent artery occlusion by coil deployment was performed, after which a check angiogram revealed complete exclusion of aneurysm from circulation. Endovascular proximal parent artery occlusion is the preferred treatment modality for dissecting aneurysms of PICA. Selective coil or Onyx embolization of the aneurysm with parent vessel preservation technique is a valid and increasingly used alternative. In this case, a novel technique of endovascular temporary parent artery occlusion by coil deployment was performed successfully. This technique may be recommended in select cases.

Dynamic compression in vertebral artery dissection in children: apropos of a new protocol.

PURPOSE: Our goals are (1) to report a consecutive prospective series of children who had posterior circulation stroke caused by vertebral artery dissection at the V3 segment; (2) to describe a configuration of the vertebral artery that may predispose to rotational compression; and (3) to recommend a new protocol for evaluation and treatment of vertebral artery dissection at V3. METHODS: All children diagnosed with vertebral artery dissection at the V3 segment from September 2014 to July 2020 at our institution were included in the study. Demographic, clinical, surgical, and radiological data were collected. RESULTS: Sixteen children were found to have dissection at a specific segment of the vertebral artery. Fourteen patients were male. Eleven were found to have compression on rotation during a provocative angiogram. All eleven underwent C1C2 posterior fusion as part of their treatment. Their mean age was 6.44 years (range 18 months-15 years). Mean blood loss was 57.7 mL. One minor complication occurred: a superficial wound infection treated with oral antibiotics only. There were no vascular or neurologic injuries. There have been no recurrent ischemic events after diagnosis and/or treatment. Mean follow-up was 33.3 months (range 2-59 months). We designed a new protocol to manage V3 dissections in children. CONCLUSION: Posterior C1C2 fusion is a safe and effective option for treatment of dynamic compression in vertebral artery dissection in children. Institution of and compliance with a strict diagnostic and treatment protocol for V3 segment dissections seem to prevent recurrent stroke.

Headache in cerebrovascular diseases.

Headache is a common accompanying symptom of cerebrovascular diseases. The most common patterns of headache for different cerebrovascular disorders, aetiology and pathogenesis and diagnostic workup are reviewed with emphasis on distinguishing characteristics. It will be a clinical guide for physicians who treat patients with headache or cerebral vascular disease.

Successful endovascular coil embolisation of a ruptured V1-segment vertebral artery dissecting aneurysm making a fistula with the adjacent vein.

Sudden supraclavicular pain is often associated with myocardial infarction but seldom due to a rupture of V1-segment vertebral artery aneurysm. A ruptured V1 segment of vertebral artery dissecting aneurysm making a fistula with the adjacent vein has rarely been described in literature. Here we present a case of a 29-year-old healthy woman with sudden supraclavicular pain and palpable mass that developed after pain. Initial ultrasound showed suspicion of large haematoma. CT angiogram showed a left-sided dissecting V1-segment vertebral artery ruptured aneurysm. Angiography showed an additional fistula between the aneurysm and the adjacent vein. The patient was treated successfully with coil embolisation. The vertebral artery occlusion was well tolerated without any complications. Endovascular coiling is a fast and effective treatment modality. However, a parent vessel occlusion can be sometimes dangerous if the contralateral vertebral artery supply is not sufficient. Surgical possibilities to reconstruct the parent vessel should also be considered in complex cases.

Combined reconstructive and deconstructive endovascular approach for bilateral vertebral artery dissection with subarachnoid hemorrhage.

The video highlights a challenging case of bilateral vertebral artery dissection presenting with subarachnoid hemorrhage. The patient was found to have a critical flow-limiting stenosis in his dominant right vertebral artery and a ruptured pseudoaneurysm in his left vertebral artery. A single-stage endovascular treatment with stent reconstruction of the right vertebral artery and coil embolization sacrifice of the left side was performed. The case highlights the rationale for treatment and potential alternative strategies.The video can be found here: https://youtu.be/e0U_JE2jISw.

Bilateral Vertebral Artery Dissection and Unilateral Carotid Artery Dissection in Case of Ehlers-Danlos Syndrome Type IV.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a rare genetic connective tissue disorders, but the vascular type (type IV) typically poses the greatest risk to patients. We report a case of multiple cranial artery dissection, which was successfully treated with carotid artery stenting. CASE DESCRIPTION: A 50-year-old woman presented with recurrent severe headaches caused by bilateral vertebral artery dissections that were treated conservatively at our hospital. However, she developed right cervical pain and dizziness at 3 days after admission, and a magnetic resonance angiogram revealed dissection of the right internal carotid artery. Because the dissected portion of the artery had narrowed, a stent was placed. The pearl and string formations in the bilateral vertebral arteries then improved spontaneously. Subsequently, the patient was diagnosed with EDS type IV via a skin biopsy, and review of her family history revealed that multiple family members had suffered from subarachnoid hemorrhages. No neurologic deficits were observed, and the patient was discharged without further events at 30 days after admission. CONCLUSIONS: It is extremely rare for multiple artery dissections to occur at the same time. EDS type IV should be considered as an important differential diagnosis in similar cases, even in adult patients without a known history of connective tissue disease or vascular complications.

Occipital Artery-to-Vertebral Artery Bypass to Stop Transient Ischemic Attacks Caused by Traumatic Vertebral Artery Dissection.

BACKGROUND: Ischemic symptoms caused by traumatic vertebral artery dissection after cervical maneuvers are treated medically and surgically. This is a report of the infrequently documented occipital to vertebral artery bypass to stop the transient ischemic attacks following traumatic vertebral artery dissection. CASE DESCRIPTION: A 33-year-old man presented with a sudden right posterior neck pain following a sudden neck movement, accompanied by left lower quadrant anopsia and rotational vertigo. The neurologic symptoms had already been resolved on arrival. Magnetic resonance imaging and digital subtraction angiography revealed an extracranial vertebral artery dissection with no evidence of cerebral infarction. Although medical therapy was initiated, he repeatedly complained of ischemic symptoms. A bypass was performed from the occipital artery to the atlas loop of the vertebral artery with distal occlusion of the lesion. The patient was neurologically intact after the surgery, and magnetic resonance imaging showed no cerebral infarction. CONCLUSION: A bypass from the occipital artery to the atlas loop of the vertebral artery is an effective procedure for traumatic extracranial vertebral artery dissection with ischemic symptoms.

Approach to cervicogenic dizziness: a comprehensive review of its aetiopathology and management.

PURPOSE: Though there is abundant literature on cervicogenic dizziness with at least half a dozen of review articles, the condition remains to be enigmatic for clinicians dealing with the dizzy patients. However, most of these studies have studied the cervicogenic dizziness in general without separating the constitute conditions. Since the aetiopathological mechanism of dizziness varies between these cervicogenic causes, one cannot rely on the universal conclusions of these studies unless the constitute conditions of cervicogenic dizziness are separated and contrasted against each other. METHODS: This narrative review of recent literature revisits the pathophysiology and the management guidelines of various conditions causing the cervicogenic dizziness, with an objective to formulate a practical algorithm that could be of clinical utility. The structured discussion on each of the causes of the cervicogenic dizziness not only enhances the readers' understanding of the topic in depth but also enables further research by identifying the potential areas of interest and the missing links. RESULTS: Certain peculiar features of each condition have been discussed with an emphasis on the recent experimental and clinical studies. A simple aetiopathological classification and a sensible management algorithm have been proposed by the author, to enable the identification of the most appropriate underlying cause for the cervicogenic dizziness in any given case. However, further clinical studies are required to validate this algorithm. CONCLUSIONS: So far, no single clinical study, either epidemiological or interventional, has incorporated and isolated all the constitute conditions of cervicogenic dizziness. There is a need for such studies in the future to validate either the reliability of a clinical test or the efficacy of an intervention in cervicogenic dizziness.

[Bilateral Wallerian degeneration of pontocerebellar fibres secondary to pontine infarction]. / Degeneracion walleriana bilateral de haces pontocerebelosos secundaria a infarto protuberancial.

TITLE: Degeneracion walleriana bilateral de haces pontocerebelosos secundaria a infarto protuberancial.

[Characteristics of Headache and Neck Pain in Spontaneous Vertebral Artery Dissections].

PURPOSE: Sudden onset severe occipital/nuchal pain is believed to be a typical symptom of vertebral artery dissection(VAD). However, recent developments in diagnostic imaging have suggested that VAD is not always associated with such pain. This study aimed to analyze the clinical features of initial symptoms in patients with VAD. METHODS: In total, this study included 29 consecutive patients who were referred to our hospital because of only headache and/or nuchal pain due to VAD between 2011 and 2016. In this study, their clinical features were precisely assessed, including the pain location, onset pattern, duration, intensity, disease period, diagnosis modality, and prognosis. Both MRI and MRA were performed for all subjects. Cerebral angiography and thin-slice T1-weighted MRI were additionally performed in selected cases. RESULTS: Of the 29 patients, 23 presented with occipital headache and/or nuchal pain. The pain was persistent in 26/29 and ipsilateral in 29/29. However, only 16/29 reported a typical sudden onset. Only 12/29 complained of severe pain, while the other 17/29 presented with dull pain. The mean interval between onset and hospitalization was 7.4 days(0 to 30 days)and the mean interval between hospitalization and diagnosis was 3.9 days(0 to 21 days). Intramural hematoma was identified in 21/29 patients using thin-slice T1-weighted MRI. CONCLUSION: Only 55% of patients with VAD demonstrate typical occipital/nuchal pain with sudden onset. Both MRI and MRA should be indicated for patients who complain of persistent, unilateral pain in the occipital/nuchal regions to prevent VAD being missed during diagnosis.

Rare case of diffuse spinal arachnoiditis following a complicated vertebral artery dissection.

Spinal arachnoiditis (SA) is an extremely rare and delayed complication of subarachnoid hemorrhage (SAH). Little is known about its underlying pathogenesis and subsequent clinical course. A middle-aged patient presented with the worst headache of her life and a grade 3 SAH of the basal-cisterns and posterior fossa was identified on Computed Tomography scans (CT). Angiography revealed a ruptured dissecting aneurysm of the left vertebral artery (VA-V4), as well as an unruptured left Anterior Cerebral Artery (ACA-A1) aneurysm. The VA aneurysm was treated with flow diversion. The patient re-ruptured the stented aneurysm, another telescoping pipeline was placed. The patient developed polymicrobial ventriculitis, and returned several months later complaining of paraparesis and left sided weakness. Magnetic Resonance Imaging (MRI) revealed diffuse thecal dural thickening from the cervicomedullary junction to the sacrum. Loculations, diffuse edema and cord compression were noticed along the inferior surface of the cerebellum, and the cervico-thoracic spine with a T4-T6 syrinx. The patient underwent a posterior (T4-T8) spinal fusion and (T5-T7) decompression with arachnoid-cyst fenestration and placement of a subarachnoid-pleural shunt. On latest follow-up, the patient is weaning off the thoraco-lumbosacral orthosis and ambulating with a cane. SA is often a complicated two-staged disease in which a "free interval phase" separates the initial inflammatory reaction (IIR) from the late adhesive phase. Posterior fossa bleeding, warranting prolonged surveillance, additional bleeding and ventriculitis might augment the risk and the severity of arachnoiditis.