Craniocervical Artery Dissections: A Concise Review for Clinicians.

Craniocervical artery dissection (CAD), although uncommon, can affect the young and lead to devastating complications, including stroke and subarachnoid hemorrhage. It starts with a tear in the intima of a vessel with subsequent formation of an intramural hematoma. Most CAD occurs spontaneously or after minor trauma. Patients with CAD may exhibit isolated symptoms of an underlying subclinical connective tissue disorder or have a clinically diagnosed connective tissue disorder. Emergent evaluation and computed tomography angiography or magnetic resonance imaging/angiography of the head and neck are required to screen for and to diagnose CAD. Carotid ultrasound is not recommended as an initial test because of limited anatomic windows; diagnostic catheter-based angiography is reserved for atypical cases or acutely if severe neurologic deficits are present. Patients with CAD can present with focal neurologic deficits due to ischemia (thromboembolism or arterial occlusion) or subarachnoid hemorrhage (pseudoaneurysm formation and rupture). Also common are local symptoms, such as head and neck pain, pulsatile tinnitus, Horner syndrome, and cranial neuropathy, or cervical radiculopathy from mass effect. Acute management of transient ischemic attack/stroke in CAD is not different from the management of ischemic stroke of other causes. Patients with CAD need long-term antithrombotic therapy for secondary stroke prevention. Anticoagulation or dual antiplatelet therapy followed by single antiplatelet therapy is recommended for extracranial CAD and antiplatelet therapy for intracranial CAD. Recurrent ischemic events and dissections are rare and typically occur early. Patients with CAD should avoid deep neck massage or chiropractic neck manipulation involving sudden excessive, forced neck movements.

Early Anticoagulation or Antiplatelet Therapy Is Critical in Craniocervical Artery Dissection: Results from the COMPASS Registry.

INTRODUCTION: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young patient population. Recent studies reported a low rate of major adverse cardiac events (MACEs) in patients with CeAD, with no significant difference between patients randomized to anticoagulation or antiplatelet therapy. OBJECTIVE: To compare the effectiveness of anticoagulation and antiplatelet therapy in patients with CeAD. METHODS: All CeAD patients from 2015 to 2017 were consecutively identified by an electronic medical record-based application and enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE defined as stroke, transient ischemic attack (TIA), or death. RESULTS: The cohort included 111 CeAD patients (age 53 ± 15.9 years, 56% Caucasian, 50% female). CeAD was detected by magnetic resonance (5%), computed tomography (88%), or catheter angiography (7%). CeAD was noted in the carotid (59%), vertebral (39%), and basilar (2%) arteries, 82% of which were extracranial dissections. CeAD was classified as grade I, II, III, and IV in 16, 33, 19, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%) of patients, including violent sneezing (21%), carrying a heavy load (19%), sports/recreational activity (11%), chiropractic manipulation (9%), abrupt/prolonged rotation of head (9%), and prolonged phone use (9%). At presentation, 41% had a stroke, 5% had TIA, 39% had headache, and 36% were asymptomatic. Favorable outcome defined as a modified Rankin Scale score of 0-2 was noted in 68% at 3 months and 71% at 12 months. The rate of MACEs at 3 and 12 months was 11 and 14%, respectively, with more events observed in patients who were not receiving anticoagulation/antiplatelet therapy due to contraindications (p = 0.008). CONCLUSIONS: We report diagnostic characteristics, as well as short- and long-term outcomes of CeAD. A high MACE rate was observed within the first 2 weeks of CeAD diagnosis, notably in patients not initiated on anticoagulation or antiplatelet therapy.

Rivaroxaban in cervical and "cervico-cerebral" artery dissections: a new therapeutic option?

Antiplatelet agents and vitamin K antagonists (VKA) are usually used in the treatment of cervical (carotid or vertebral) artery dissections (CADs); however, data about the use of direct oral anticoagulants (DOACs) in these conditions are very limited. DOACs have proven to be effective in stroke reduction in non-valvular atrial fibrillation and, when possible, they are preferred to warfarin because of their better safety profile. We describe four cases of CADs and, firstly in literature, cervico-cerebral (CCADs) in young patients (average age of 42 years) treated with rivaroxaban 20 mg daily. Three of these four dissections had affected the vertebral artery (condition with an unfavorable prognosis and more often complicated by subarachnoid hemorrhages), and the other one was a carotid dissection at the extra-intracranial passage. All patients were followed clinically and with serial neurosonological examinations at 1, 3, and 6 months and with magnetic resonance angiography (MRA) at 6 months. All patients presented a good outcome with vascular recanalization without stroke recurrence or bleedings, even in patients with intracranial vertebral artery involvement. DOACs could be an alternative in young patients with CADs and their use could be considered in intracranial artery dissections too.

Carotid dissection causing stroke in a 13-year-old boy with mild hyperhomocysteinemia: case report.

The author describes a 13-year-old Thai boy who developed stroke caused by carotid dissection and found mild elevation of plasma homocysteine (tHcy). The patient improved after anticoagulation therapy and his plasma tHcy decreased after vitamin supplement. With long-term follow-up, he is having normal neurological condition. This case proposes that the pathogenesis of carotid dissection may associate with mild hyperhomocysteinemia.

Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists.

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.

Early asymptomatic recurrence of cervical artery dissection: three cases.

Cervical artery dissection (CAD) recurrences are rare but the risk could be higher during the first month. Twenty-seven consecutive patients admitted for an acute CAD were investigated using a standardized imaging protocol. An early asymptomatic recurrence was observed in three patients 49 to 53 days after the initial diagnosis. Anticoagulation was maintained and the prognosis remained good. Early CAD recurrences may have been underestimated previously, because asymptomatic recurrences seem to be more frequent than symptomatic ones.