Development of a diagnostic support tool for predicting cervical arterial dissection in primary care.

OBJECTIVES: Cervical arterial dissection (CAD) is an important cause of stroke in young people which may be missed because early features may mimic migraine or a musculoskeletal presentation. The study aimed to develop a diagnostic support tool for early identification of CAD. DESIGN: Retrospective observational study. SETTING: Tertiary hospital. PARTICIPANTS: Radiologically confirmed CAD cases (n = 37), non-CAD stroke cases (n = 20), and healthy controls (n = 100). MAIN OUTCOME MEASURES: The presence of CAD is confirmed with imaging. Predictive variables included risk factors and clinical characteristics of CAD. Variables with a p-value <0.2 included in a multivariable model. Predictive utility of the model is assessed by calculating area underthe ROC curve (AUC). RESULTS: The model including four variables: age 40-55 years (vs < 40), trauma, recent onset headache, and > 2 neurological features, demonstrated excellent discrimination: AUC of 0.953 (95% CI: 0.916, 0.987). A predictive scoring system (total score/7) identified an optimal threshold of ≥ 3 points, with a sensitivity of 87% and specificity of 79%. CONCLUSIONS: The study identified a diagnostic support tool with four variables to predict increased risk of CAD. Validation in a clinical sample is needed to confirm variables and refine descriptors to enable clinicians to efficiently apply the tool.Optimum cutoff scores of ≥ 3/7 points will help identify those in whom CAD should be considered and further investigation instigated. The potential impact of the tool is to improve early recognition of CAD in those with acute headache or neck pain, thereby facilitating more timely medical intervention, preventing inappropriate treatment, and improving patient outcomes.Wordcount: 3195.

Changes in internal carotid and vertebral arterial wall stiffness with head movement can be detected with shear wave elastography.

Background: Safe practice is important for patients with neck pain, with the potential for injury to cervical arteries. Cervical manipulation or end range techniques/positions may place considerable strain on the arteries. Altered integrity of the arterial wall may render them more susceptible to minor trauma, particularly in the upper cervical region. Screening of blood flow velocity is limited for predicting those at risk. Examining properties of the cervical arterial wall (stiffness characteristics) and their response to head movement may provide an alternate measure of arterial susceptibility.Objectives: To investigate whether shear wave ultrasound elastography can detect any changes in internal carotid (ICA) and vertebral (VA) arterial wall stiffness in neutral compared with contralateral head rotation.Design: Observational studyMethods: Shear wave ultrasound elastography was used to measure the stiffness of the ICA and VA. Shear wave velocity (m/s), indicative of arterial stiffness, was measured in both arteries proximally (C3-4) and distally (C1-2) in neutral and contralateral head rotation as were intimal thickness (mm) and flow velocity (cm/s).Results: Thirty participants (20-62 years) were successfully imaged. The VA was stiffer than ICA and it became significantly stiffer in contralateral rotation (p = 0.05). The ICA became significantly less stiff (p = 0.01). Effects were more apparent at C1-2 but significant in the ICA only (p = 0.03). Flow velocity and intimal thickness were unchanged in rotation.Conclusions: Changes in VA and ICA arterial wall stiffness can be measured with shear wave ultrasound elastography. This measure may ultimately help identify arteries with greater vulnerability to rotational stresses.

Risk factors, radiological features, and infarct topography of craniocervical arterial dissection.

BACKGROUND: Craniocervical arterial dissection is a common cause of ischemic stroke in the young to middle-aged population. There have been a number of previous studies where radiological features have been described but few with detailed mapping of infarct topography and none where these features have been related to the reported risk factors. AIMS: The aims of this study were to describe the radiological characteristics of dissection patients ≤55 years and relate these to reported risk factors. METHODS: Craniocervical arterial dissection cases ≤55 years, and age- and gender-matched controls were identified from a medical records database between 1998 and 2009. Control cases had stroke from another cause than dissection. Records and radiology were reviewed. RESULTS: Thirty-six radiologically confirmed dissection cases [20 (56%) vertebral artery, 16 (44%) internal carotid], and 43 controls were identified. Dissections were extracranial with intracranial extension in 10 (28%) cases. Infarction was demonstrated in 22 (61%) dissection cases. The most common wall deficit identified was an intimal flap. Twenty-three (64%) dissection cases had a recent history of neck trauma (P > 0·000) and 13 (36%) had vascular variants (P = 0·013). CONCLUSION: Craniocervical arterial dissection cases, particularly vertebral artery, were more likely to have a history of neck trauma. Dissections were most commonly extracranial, in the upper cervical region, with intracranial extension in 28%. Dissection cases with trauma more commonly had a dissection flap and evidence of infarction in the lateral medulla, anterior or posterior inferior cerebellar artery territory. Close inspection of the V3 segment of the vertebral or skull base for internal carotid artery may be warranted with a history of neck trauma.