Stenting as a treatment for cranio-cervical artery dissection: Improved major adverse cardiovascular event-free survival.

INTRODUCTION: Cranio-cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement. METHODS: COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥ 18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1 year evaluating MACE as the primary endpoint. RESULTS: One-hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including sneezing, carrying heavy load, chiropractic manipulation. Stent was placed in 10 (10%) subjects (extracranial carotid n = 9; intracranial carotid n = 1; extracranial vertebral n = 1) at the physician's discretion along with medical management. Reasons for stent placement were early development of high-grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in-hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year. CONCLUSION: In this single high-volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high-grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

A near-fatal consequence of chiropractor massage: massive stroke from carotid arterial dissection and bilateral vertebral arterial oedema.

A 35-year-old Chinese man with no risk factors for stroke presented with a 2-day history of expressive dysphasia and a 1-day history of right-sided weakness. The presentation was preceded by multiple sessions of neck, shoulder girdle and upper back massage for pain relief in the prior 2 weeks. CT of the brain demonstrated an acute left middle cerebral artery infarct and left internal carotid artery dissection. MRI cerebral angiogram confirmed left carotid arterial dissection and intimal oedema of bilateral vertebral arteries. In the absence of other vascular comorbidities and risk factors, massage-induced internal carotid arterial dissection will most likely precipitate the near-fatal cerebrovascular event. The differential diagnosis of stroke in a younger population was consequently reviewed and discussed.

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.

Bilateral vertebral artery dissection and cerebellar stroke: a rare complication of massage.

Dissection of a cervical artery is a well-known cause of stroke, especially in younger patients. We describe the case of a 39-year-old male, who presented to our emergency department after a one-day history of headache and vomiting, with associated sudden onset posterior neck pain and cerebellar signs following a massage. Computed tomography angiogram and brain demonstrated bilateral vertebral artery dissection and cerebellar stroke. He was admitted to hospital for monitoring and conservative management with antiplatelet therapy, resulting in a good outcome. This is the first reported case of bilateral vertebral artery dissection and stroke to be associated with massage. This case also suggests, unlike many reports in the literature, that significant vascular pathology can result from massage even without cervical spine manipulation.

Stroke prevention by endovascular treatment of carotid and vertebral artery dissections.

INTRODUCTION: Endovascular intervention for cervical carotid artery dissection (CAD) and vertebral artery dissection (VAD) may be indicated in specific circumstances. OBJECTIVE: To review our institutional experience with endovascular treatment of cervical dissections over the past 20 years to examine indications for treatment, interventional methods, and outcomes. METHODS: Retrospective review of a prospectively maintained database to identify patients with extracranial dissection who underwent endovascular intervention between January 1996 and January 2016. Demographic data and details of procedures, outcomes, and complications were extracted. RESULTS: Of 116 patients [93 CAD, 23 VAD; mean age 44.9 years (range 5-76 years)], 104 underwent stent placement; 11, coil occlusion of the parent artery; and 1, stenting with contralateral vessel occlusion. The cohorts were well matched for age, sex, dissection etiology, and admission and follow-up modified Rankin Scale (mRS) scores. Patients with CAD had significantly more stent placements (p<0.001), failure of medical therapy (p=0.004), and interventions for enlarging pseudoaneurysms (p=0.01) or thromboembolic events (p=0.004). Patients with VAD had significantly more interventions for traumatic occlusion with recanalization (p<0.001). Dissections were spontaneous (n=67), traumatic (n=36), or iatrogenic (n=13). Traumatic dissections in patients with CAD were associated with poor admission mRS scores (p=0.01). Six of 67 (9.0%) patients with spontaneous dissection reported recent chiropractic manipulation. Mean follow-up was 3.5 years (range 1-146 months). Permanent morbidity/mortality was 3.4%, including two deaths. Over a follow-up period of 364 patient-years, 1 stroke occurred (0.27% per year). At last follow-up, 41 previously disabled patients [CAD, 31/93 (33.3%); VAD, 10/23 (43.5%)] were no longer disabled; no patient reported worsened disability. CONCLUSIONS: Patients with CAD and VAD differ significantly in presentation, indications for treatment, and treatment methods. Endovascular treatment of CAD and VAD has low procedural morbidity and is associated with a low incidence of future stroke.

Extracranial vertebral artery rupture likely secondary to "cupping therapy" superimposed on spontaneous dissection.

The extracranial vertebral artery (VA) is vulnerable to dissection and the V3 segment is the most common location for dissection. Dissection accounts for about 2% of all ischemic strokes and can occur after trauma or chiropractic neck maneuvers. We report an extremely rare case of spontaneous extracranial VA dissection presenting with posterior neck hematoma aggravated after cupping therapy, a treatment in traditional Oriental medicine. We treated the patient successfully by endovascular treatment without any complication.

Vertebrobasilar ischemia after cervical spine manipulation: a case report.

INTRODUCTION: The most serious accidents after cervical spine manipulation are vertebrobasilar ischemia. Their incidence is underestimated. Their risk of apparition is lower if the contraindications are respected and if they are realised according to suitable practice. CASE REPORT: Mrs B, 39 years old, was an active smoker and had migraine for 10 years ago. One day, she presented an unusual headache associated with neck pain that was treated by a cervical spine manipulation. Seven hours after, she developed an alternate syndrome with a right sensory motor defect, a cerebellar syndrome, a pyramidal syndrome and a left defect of cranial nerves. The arteriography showed a thrombosis of the basilar trunk and a dissection of the left vertebral artery. A thrombolysis "in situ" was realized six hours and a half after the onset of the neurological defects. After eight months of rehabilitation, there were still a paralysis of the right upper limb, of the cranial nerves and a cerebellar syndrome but the patient was able to walk with two crutches and can eat by herself. DISCUSSION: Several risk factors were present in this case and there was also a major contraindication to manipulations: unusual acute occipital headache. Given the long period between the onset of neurological symptoms and the confirmation of the diagnosis, intravenous thrombolysis could not be done. Unfortunately, after eight months, important neurological sequels persisted. In order to avoid this type of accident after cervical manipulations, it is necessary to realize a strict medical examination and to implement the recommendations from the French society of manual and orthopaedic osteopathic medicine (Société française de médecine manuelle orthopédique et ostéopathique [SOFMMOO]).

Confirmation of blood flow in perforating arteries using fluorescein cerebral angiography during aneurysm surgery.

OBJECT: The authors performed fluorescein cerebral angiography in patients after aneurysm clip placement to confirm the patency of the parent artery, perforating artery, and other arteries around the aneurysm. METHODS: Twenty-three patients who underwent aneurysm surgery were studied. Aneurysms were located in the internal carotid artery in 12 patients, middle cerebral artery in six, anterior cerebral artery in three, basilar artery bifurcation in one, and junction of the vertebral artery (VA) and posterior inferior cerebellar artery in one. After aneurysm clip placement, the target arteries were illuminated using a beam from a blue light-emitting diode atop a 7-mm diameter pencil-type probe. In all patients, after intravenous administration of 5 ml of 10% fluorescein sodium, fluorescence in the vessels was clearly observed through a microscope and recorded on videotape. RESULTS: The excellent image quality and spatial resolution of the fluorescein angiography procedure facilitated intraoperative real-time assessment of the patency of the perforating arteries and branches near the aneurysm, including: 12 posterior communicating arteries; 12 anterior choroidal arteries; four lenticulostriate arteries; three recurrent arteries of Heubner; three hypothalamic arteries; one ophthalmic artery; one perforating artery arising from the VA; and one posterior thalamoperforating artery. All 23 patients experienced an uneventful postoperative course without clinical symptoms of perforating artery occlusion. CONCLUSIONS: Because the fluorescein angiography procedure described here allows intraoperative confirmation of the patency of perforating arteries located deep inside the surgical field, it can be practically used for preventing unexpected cerebral infarction during aneurysm surgery.

Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients.

BACKGROUND AND OBJECTIVES: Internal carotid artery dissection has been extensively studied and well-described. Although there has been a recent increase in the number of reported cases of vertebral artery (VA) dissection, the clinical variety of presentation and the early warning symptoms have not been well-described before. Our objectives in this study include: (1) To determine the early symptoms and warning signs which may help the clinician in the early identification and treatment of patients with VA dissection. (2) To explore the variety of clinical presentation of VA dissection and its relation to prognosis. DESIGN AND SETTING: Retrospective analysis of hospital records in a tertiary academic centre for the period 1989-1999. RESULTS: Twenty-six patients were identified (13 men and 13 women). The mean age was 48. Possible precipitating factors were identified in 14 patients (53%). Sporting activity and chiropractic manipulations were the most common (15% and 11% respectively). Headache and/or neck pain was the prominent feature in 88% of patients and was a warning sign in 53%, preceding onset of stroke by up to 14 days. The most common clinical features included vertigo (57%), unilateral facial paresthesia (46%), cerebellar signs (33%), lateral medullary signs (26%) and visual field defects (15%). Bilateral VA dissection presented in six patients (24%). The most common region of dissection was the C1-C2 level (16 arteries, 51%). Intracranial VA dissection was found in eight arteries (25%). The majority of patients (83%) had favorable outcome. Poor prognosis was associated with (1) bilateral dissection; (2) intracranial VA dissection accompanied by subarachnoid hemorrhage. Only two patients reported stroke recurrence. CONCLUSIONS: Our findings show that VA dissection affects mainly middle age persons and involves both sexes equally. Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Although the majority of patients will have excellent prognosis, this was less likely in patients presenting with subarachnoid hemorrhage or bilateral VA dissection. Recurrence rate was low.