Predisposing factors and radiological features in patients with internal carotid artery dissection or vertebral artery dissection.

BACKGROUND: Cervicocerebral artery dissection is an important cause of ischemic stroke in young and middle-aged individuals. However, very few studies have compared the differential features between internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD), including both cervical and intracranial artery dissections. We conducted a study to investigate the predisposing factors and radiological features in patients with ICAD or VAD. METHODS: All cases diagnosed with cervicocerebral artery dissection, ICAD, or VAD were identified through a medical records database, between January 2010 and January 2020. Baseline characteristics, predisposing factors, and radiological features of ICAD versus VAD were compared. RESULTS: A total of 140 patients with cervicocerebral artery dissection were included in the study, including 84 patients in the ICAD group and 56 in the VAD group. The mean age of patients in the ICAD and VAD groups was 43.37 ± 14.01 and 41.00 ± 12.98 years old, respectively. Patients with ICAD were more likely to be men compared with VAD (85.71% vs. 67.86%, p = 0.012). The frequency of hypertension, diabetes, smoking, drinking, and cervical trauma did not differ between ICAD and VAD. Dissections of ICAD were more frequently at the extracranial portions of the artery compared with those of VAD (70.24% vs. 44.64%, p = 0.003). In contrast, dissections of VAD were more common in the intracranial artery (55.36% vs. 29.76%, p = 0.003). Radiologically, double lumen (36.90% vs. 19.64%, p = 0.029) and intimal flap (11.90% vs. 1.79%, p = 0.029) were more frequently observed in ICAD than in VAD, and dissecting aneurysms were less frequent (13.10% vs. 26.79%, p = 0.041). CONCLUSIONS: The distributions of cervical and intracranial artery dissections were different between ICAD and VAD. The frequencies of radiological features detected in patients with ICAD and VAD also differed.

Cervical artery dissection-an easily neglected cause of stroke: a case report.

BACKGROUND: In recent years, the incidence of stroke has gradually increased in young people. There are many reasons causing stroke, including atherosclerosis, artery embolization, and cervical artery dissection and so on. However, cervical artery dissection is a major cause of stroke in young people. We present a case of ischemic stroke caused by dissection, whose distal vascular occlusion due to detachment of the thrombosis in the right internal carotid artery. CASE PRESENTATION: A 33-year-old male patient was admitted to the hospital because of stroke. Imaging examination showed that there was no visualization of the right middle cerebral artery and there were a large number of mural thrombus in the C1 segment of the right internal carotid artery. After emergency surgery, the patient had vascular recanalization and the symptoms were significantly improved. Magnetic resonance imaging showed a high signal in the C1 segment of the right internal carotid artery, the abnormal signal disappeared after antiplatelet therapy. CONCLUSIONS: When a patient has symptoms of stroke, we need to explore the root cause of stroke. Especially in young people, cervical artery dissection is an important reason that can't be ignored. Through review and analysis of this case, we hope to improve the understanding of radiologists and clinicians about the cervical artery dissection, reduce the rate of misdiagnosis, and improve patients' prognosis.

Persistent isolated mydriasis as an early sign of internal carotid artery dissection: Pourfour du petit syndrome.

BACKGROUND: The dissection of the internal carotid artery (ICA) is commonly associated with miosis in Bernard-Horner syndrome (BHS). The presence of mydriasis is exceptional but can occur in the context of Pourfour du Petit syndrome (PDPS), a rare entity opposite of BHS accompanied by eyelid retraction and hyperhidrosis and caused by hyperactivity of the sympathetic cervical chain. AIM: To report on a case of PDPS as the first manifestation of an ICA dissection. METHOD: A 54-year-old man presented with isolated left mydriasis with no other abnormalities in the examination. Six months later, he suffered an ischemic stroke in the left middle cerebral artery territory secondary to a left ICA dissection. RESULTS: The initial study with Intracranial computed tomographic angiography and brain magnetic resonance imaging ruled out compressive cause of the third cranial nerve or structural lesion in the midbrain. The absence of hypersensitivity to Pilocarpine discarded postganglionic parasympathetic involvement. CONCLUSIONS: In the presence of unilateral mydriasis and once common causes are ruled out an imaging examination of the supra-aortic trunks should be completed, since it could represent the first sign of carotid pathology in the context of PDPS.

Imaging of Carotid Dissection.

PURPOSE OF REVIEW: Here, we describe the four primary imaging modalities for identification of carotid artery dissection, advantages, limitations, and clinical considerations. In addition, imaging characteristics of carotid dissection associated with each modality will be described. RECENT FINDINGS: Recent advances in etiopathogenesis describe the genetic factors implicated in cervical artery dissection. MRI/MRA (magnetic resonance angiography) with fat suppression is regarded as the best initial screening test to detect dissection. Advances in magnetic resonance imaging for the diagnosis of dissection include the use of susceptibility-weighted imaging (SWI) for the detection of intramural hematoma and multisection motion-sensitized driven equilibrium (MSDE), which causes phase dispersion of blood spin using a magnetic field to suppress blood flow signal and obtain 3D T1- or T2*-weighted images. Digital subtraction angiography (DSA) remains the gold standard for identifying and characterizing carotid artery dissections. Carotid artery dissection is the result of a tear in the intimal layer of the carotid artery. This leads to a "double lumen" sign comprised of the true vessel lumen and the false lumen created by the tear. The most common presentation of carotid artery dissection is cranial and/or cervical pain ipsilateral to the dissection. However, severe neurological sequelae such as embolic ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage can also result from carotid artery dissection. Carotid artery dissection can be identified by a variety of different imaging modalities including computed tomographic angiography (CTA), MRI, carotid duplex imaging (CDI), and digital subtraction angiography (DSA).

Eagle's syndrome: a piercing matter.

We present an unusual case of Eagle's syndrome with bilateral internal carotid artery dissection in a 45-year-old man. Initial symptomatology included ipsilateral headaches and facial sensory symptoms. A right horner's syndrome was present on clinical examination. Radiological imaging revealed an old infarct, with bilateral carotid dissections and bilateral elongated styloid processes consistent with Eagle's syndrome. Despite initiation of secondary prevention with antiplatelet therapy, he had two further ischaemic events. The case highlights the symptomatology and complications of Eagle's syndrome, with its management discussed through a review of similar case reports.

Successful carotid artery stenting of a dissected, highly tortuous internal carotid artery after straightening with a peripheral microguidewire.

Endovascular reconstruction for carotid artery dissection (CAD) involving a highly tortuous segment of the cervical internal carotid artery (ICA) is challenging because the tortuous ICA may preclude navigation of large-profile carotid stents. Successful recanalization using low-profile neurostents has been reported in small case series only. We herein describe two patients with CAD of a tortuous segment who were successfully treated with large-profile carotid stents after straightening the ICA with a stiff peripheral microguidewire. In Case 1, a 33-year-old man presented with steno-occlusive left CAD involving coiling of the cervical ICA and left M2 occlusion. We could not navigate a carotid stent through the tortuous segment of the ICA using a standard neuro-guidewire. A carotid stent was successfully deployed after straightening the tortuous ICA with a peripheral guidewire, and subsequent thrombectomy using a large-bore aspiration catheter for the occluded M2 branch resulted in recanalization. In Case 2, a 64-year-old man presented with right steno-occlusive CAD involving kinking of the cervical ICA. We successfully deployed two carotid stents after straightening the tortuous ICA with a peripheral guidewire. Stenting after straightening with a peripheral microguidewire is feasible and may provide a therapeutic option for CAD in patients with a highly tortuous ICA.

Anatomical characteristics of the styloid process in internal carotid artery dissection: Case-control study.

Introduction Pathophysiology of cervical artery dissection is complex and poorly understood. In addition to well-known causative and predisposing factors, including major trauma and monogenic connective tissue disorders, morphological characteristics of the styloid process have been recently recognized as a possible risk factor for cervical internal carotid artery dissection. Aims To study the association of the anatomical characteristics of styloid process with internal carotid artery dissection. Methods Retrospective, multicenter, case-control study of patients with internal carotid artery dissection and age- and sex-matched controls. Consecutive patients with internal carotid artery dissection and controls with ischemic stroke or transient ischemic attack of any etiology excluding internal carotid artery dissection, who had performed computed tomography angiography, diagnosed between January 2010 and September 2016. Two independent observers measured styloid process length and styloid process distance to internal carotid artery. Results Sixty-two patients with internal carotid artery dissection and 70 controls were included. Interobserver agreement was good for styloid process length and styloid process-internal carotid artery distance (interclass correlation coefficient = 0.89 and 0.76, respectively). Styloid process ipsilateral to dissection was longer than left and right styloid process in controls (35.8 ± 14.4 mm versus 30.4 ± 8.9 mm and 30.3 ± 8.2 mm, p = 0.011 and p = 0.008, respectively). Styloid process-internal carotid artery distance ipsilateral to dissection was shorter than left and right distance in controls (6.3 ± 1.9 mm versus 7.2 ± 2.1 mm and 7.0 ± 2.3 mm, p = 0.003 and p = 0.026, respectively). Internal carotid artery dissection was associated with styloid process length (odds ratio = 1.04 mm-1, 95% confidence interval = 1.01-1.08, p = 0.015) and styloid process-internal carotid artery distance (OR = 0.77 mm-1, 95% confidence interval = 0.64-0.92, p = 0.004). Conclusion Longer styloid process and shorter distance between styloid process and cervical internal carotid artery are associated with cervical internal carotid artery dissection.

Cerebrum-cervical arterial dissection in adults during sports and recreation / Dissecção arterial cérebro-cervical em adultos durante prática de esportes e recreação

Dissection of cervical arteries constitutes a medical emergency. Although relatively rarely, activities classified as sports and recreation may be a cause of arterial dissection independently of neck or head trauma. The purpose of the present paper was to present a series of cases of cerebrum-cervical arterial dissection in individuals during or soon after the practice of these sports activities. Methods Retrospective data on patients with arterial dissection related to sports and recreation. Results Forty-one cases were identified. The most frequently affected vessel was the vertebral artery. A large variety of activities had a temporal relationship to arterial dissection, and jogging was the most frequent of these. This is the largest case series in the literature. Conclusion Arterial dissection may be a complication from practicing sports.

A dissecção das artérias cervicais é uma emergência médica. Embora de forma relativamente rara, certas atividades descritas como esportes e recreação podem ser a causa de dissecção arterial independentemente de trauma de crânio ou cervical. O propósito do presente estudo é apresentar uma série de casos de dissecção de artérias cérebro-cervicais em indivíduos durante ou logo após a prática destas atividades desportivas. Métodos Dados retrospectivos de pacientes com dissecção arterial relacionada à prática de esportes e recreação. Resultados Quarenta e um casos foram identificados. A artéria mais frequentemente afetada foi a vertebral. Uma grande variedade de atividades teve relação temporal com a dissecção arterial, sendo a corrida a mais frequente delas. Esta é a maior série de casos da literatura. Conclusão Dissecção arterial pode ser uma complicação da prática de esportes.

Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study.

BACKGROUND AND PURPOSE: Internal carotid artery dissection is a common cause of stroke in young adults. It may be responsible for tandem occlusion defined by a cervical steno-occlusive carotid wall hematoma associated with an intracranial large-vessel stroke. Intravenous thrombolysis is associated with a poor clinical outcome in these cases, and endovascular treatment has not been specifically evaluated to date. Our aim was to evaluate endovascular treatment technical and clinical efficiency in this specific occlusion topography, in comparison with treatment of isolated anterior circulation stroke. MATERIALS AND METHODS: As part of our ongoing prospective stroke data base started in August 2009 (Prognostic Factors Related to Clinical Outcome Following Thrombectomy in Ischemic Stroke [RECOST] Study), we analyzed all carotid artery dissection tandem occlusion strokes and isolated anterior circulation occlusions. All patients were selected for endovascular treatment according to clinical-radiologic mismatch, NIHSS ≥ 7 and DWI-ASPECTS ≥5, within 6 hours after onset. For carotid artery dissection, the revascularization procedure consisted first of distal recanalization by a stent retriever in the intracranial vessel. Following assessment of the circle of Willis, internal carotid artery stent placement was only performed in case of insufficiency. Carotid artery dissection treatment efficacy, safety, and clinical outcome were compared with the results of the isolated anterior circulation occlusion cohort. RESULTS: Two hundred fifty-eight patients with an anterior circulation stroke were analyzed, including 57 with tandem occlusions (22%); among them, 20 were carotid artery dissection-related occlusions (7.6%). The median age of patients with tandem occlusions with internal carotid dissection was 52.45 versus 66.85 years for isolated anterior circulation occlusion (P < .05); the mean initial NIHSS score was 17.53 ± 4.11 versus 17.55 ± 4.8 (P = .983). The median DWI-ASPECTS was 6.05 versus 6.64 (P = .098), and the average time from onset to puncture was 4.38 for tandem occlusions versus 4.53 hours in isolated anterior circulation occlusion (P = .704). Complication rates and symptomatic intracranial hemorrhage were comparable in both groups (5% versus 3%, P = .49). The duration of the procedure was significantly prolonged in case of tandem occlusion (80.69 versus 65.45 minutes, P = .030). Fourteen patients with carotid artery dissection (70%) had a 3-month mRS of ≤ 2, without a significant difference from patients with an isolated anterior circulation occlusion (44%, P = .2). Only 5 carotid artery dissections (25%) necessitated cervical stent placement. No early ipsilateral stroke recurrence was recorded, despite the absence of stent placement in 15 patients (75%) with carotid artery dissection. CONCLUSIONS: Mechanical endovascular treatment of carotid artery dissection tandem occlusions is safe and effective compared with isolated anterior circulation occlusion stroke therapy. Hence, a more conservative approach with stent placement only in cases of circle of Willis insufficiency may be a reliable and safe strategy.

Optical coherence tomography of traumatic aneurysms of the internal carotid artery: report of 2 cases.

The pathophysiology of extracranial traumatic aneurysm formation has not been fully elucidated. Intraarterial optical coherence tomography (OCT), an imaging modality capable of micrometer cross-sectional resolution, was used to evaluate patients presenting with saccular traumatic aneurysms of the internal carotid artery (ICA). Two consecutive trauma patients diagnosed with saccular traumatic aneurysms of the cervical ICA, per the institutional screening protocol for traumatic cerebrovascular injury, underwent digital subtraction angiography (DSA) with OCT. Optical coherence tomography demonstrated disruption of the intima with preservation and stretching of the more peripheral layers. In 1 patient the traumatic aneurysm was associated with thrombus formation and a separate, more proximal dissection not visible on CT angiography (CTA) or DSA. Imaging with OCT indicates that saccular traumatic aneurysms may develop from disruption of the intima with at least partial preservation of the media and adventitia. This provides in vivo evidence that saccular traumatic aneurysms result from a partial arterial wall tear rather than complete disruption. Interestingly, OCT was also able to detect arterial injury and thrombi not visible on CTA or DSA.

Cerebrum-cervical arterial dissection in adults during sports and recreation.

UNLABELLED: Dissection of cervical arteries constitutes a medical emergency. Although relatively rarely, activities classified as sports and recreation may be a cause of arterial dissection independently of neck or head trauma. The purpose of the present paper was to present a series of cases of cerebrum-cervical arterial dissection in individuals during or soon after the practice of these sports activities. METHODS: Retrospective data on patients with arterial dissection related to sports and recreation. RESULTS: Forty-one cases were identified. The most frequently affected vessel was the vertebral artery. A large variety of activities had a temporal relationship to arterial dissection, and jogging was the most frequent of these. This is the largest case series in the literature. CONCLUSION: Arterial dissection may be a complication from practicing sports.

Gradual Growth of Spontaneous Dissecting Aneurysm of the Extracranial Internal Carotid Artery After Aneurysmal Subarachnoid Hemorrhage.

Spontaneous dissecting aneurysm of the extracranial internal carotid artery is uncommon, and simultaneous onset of multiple dissecting aneurysms is rare in patients without congenital or traumatic risk factors. A few reports suggest that extracranial internal carotid artery dissecting aneurysms can grow after SAH due to another intracranial dissecting aneurysm. The present report describes two cases in which gradual growth of unruptured dissecting aneurysm of extracranial internal carotid artery occurred after SAH due to ruptured dissecting aneurysm of the vertebral artery and in which carotid artery stenting was subsequently performed. A 42-year-old man was admitted to our hospital with SAH due to ruptured left vertebral artery dissecting aneurysm and was managed surgically. Dissecting aneurysm of the right extracranial internal carotid artery was found and showed gradual growth. The aneurysm was treated with a stent at 7 weeks after onset. In another case, a 47-year-old woman presented with SAH due to ruptured right vertebral artery dissecting aneurysm and was managed surgically. Concomitant left extracranial internal carotid artery dissecting aneurysm was found and showed gradual growth. The aneurysm was treated with stent and coils. These are rare cases of multiple dissecting aneurysms that originated from different arteries simultaneously and that showed growth after SAH.

Dynamic changes of intramural hematoma in patients with acute spontaneous internal carotid artery dissection.

BACKGROUND: We prospectively investigated temporal and spatial evolution of intramural hematomas in patients with acute spontaneous internal carotid artery dissection using repeated magnetic resonance imaging over six-months. AIM: The aim of the present study was to assess dynamic changes of intramural hematoma in patients with acute spontaneous internal carotid artery dissection at multiple follow-up time-points with T1w, PD/T2w, and magnetic resonance angiography. METHODS: We performed serial multiparametric magnetic resonance imaging in 10 patients with spontaneous internal carotid artery dissection on admission, at days 1, 3, 7-14 and at months 1·5, 3, and 6. We calculated the volume and extension of the hyperintense intramural hematoma using T1w and PD/T2w fat suppressed sequences and assessed the degree of stenosis due to the hematoma using magnetic resonance angiography. RESULTS: Mean interval from symptom onset to first magnetic resonance imaging was two-days (SD 2·7). Two patients presented with ischemic stroke, three with transient ischemic attacks, and five with pain and local symptoms only. Nine patients had a transient increase of the intramural hematoma volume, mainly up to day 10 after symptom onset. Fifty percent had a transient increase in the degree of the internal carotid artery stenosis on MRA, one resulting in a temporary occlusion. Lesions older than one-week were predominantly characterized by a shift from iso- to hyperintese signal on T2w images. At three-month follow-up, intramural hematoma was no longer detectable in 80% of patients and had completely resolved in all patients after six-months. CONCLUSIONS: Spatial and temporal dynamics of intramural hematomas after spontaneous internal carotid artery dissection showed an early volume increase with concomitant progression of the internal carotid artery stenosis in 5 of 10 patients. Although spontaneous internal carotid artery dissection overall carries a good prognosis with spontaneous hematoma resorption in all our patients, early follow-up imaging may be considered, especially in case of new clinical symptoms.

Distal internal carotid artery dissection due to the carotid shunt during carotid endarterectomy.

We described two cases of shunt-related distal internal carotid artery (ICA) dissection from high cervical ICA stenosis. These cases suggest that for high cervical internal carotid endarterectomy, surgeons should reconsider using a carotid shunt to reduce the risk of ICA dissection.

Congenital contractural arachnodactyly complicated with aortic dilatation and dissection: Case report and review of literature.

Congenital contractural arachnodactyly (CCA) is a connective tissue disease caused by mutations of the FBN2, which encodes fibrillin-2. CCA patients have a marfanoid habitus; however, aortic dilatation and/or dissection as observed in Marfan syndrome have been rarely documented. Here, we report on a Japanese familial case of CCA resulting from a FBN2 splicing mutation (IVS32+5g→a), which leads to exon 32 being skipped, and the patients developed aortic dilatation and type A dissection. Although CCA patients have been believed to have favorable prognoses, repetitive aortic imaging studies must be performed in some patients to detect possible aortic disease early, and genetic testing of FBN2 might be useful to identify such high-risk patients.

[Case of spontaneous cervical internal carotid artery dissection with embolic stroke after a job-change].

A 51 year old male was admitted to our hospital with sudden consciousness disturbance, global aphagia and right hemiparesis. Magnetic resonance imaging (MRI) revealed fresh infarctions in the territory of the left middle cerebral artery, and MR angiography (MRA) showed occlusion of the left carotid artery and the left middle cerebral artery. We started conservative therapy, including antiplatelet drug and blood pressure control. Three days later, cervical MRA revealed hematoma in the intracranial carotid wall of the petrous portion, leading to a diagnosis of spontaneous intracranial carotid artery dissection of the petrous portion. Two weeks after admission, MRA and angiography showed recanalization and pearl and string sign in the left petrous internal carotid artery. After that, the patient's neurological deficit improved, and the dissection also improved. Four months later, MR-angiography revealed an almost normalized condition.