Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association.

Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.

Epidemiology of Spontaneous Cervical Artery Dissection: Population-Based Study.

BACKGROUND: Cervical artery dissection (CeAD) represents up to 15% to 25% of ischemic strokes in people under the age of 50 years. Noninvasive vessel imaging is increasingly used in clinical practice, but the impact on the frequency of detection of CeAD is unknown. In 2006, the yearly incidence rate of CeAD was estimated at 2.6 per 100 000 person-years, but the current incidence is unknown. METHODS: In this population-based retrospective observational cohort study, we utilized the resources of the Rochester Epidemiology Project to ascertain all adult residents of Olmsted County, MN, diagnosed with internal carotid artery dissection and common carotid artery dissection or vertebral artery dissection from 2002 to 2020. Patients with only intracranial involvement or CeAD following major trauma were excluded. Age-adjusted sex-specific and age- and sex-adjusted incidence rates were estimated using the US White 2010 decennial census, with rates expressed per 100 000 person-years. We assessed longitudinal trends by dividing the data into 5-year time intervals, with the last being a 4-year interval. RESULTS: We identified 123 patients with a diagnosis of CeAD. There were 63 patients with internal carotid artery dissection, 54 with vertebral artery dissection, 2 with concurrent internal carotid artery dissection and vertebral artery dissection, and 4 with common carotid artery dissection. There were 63 (51.2%) female patients and 60 (48.8%) male patients. The average age at diagnosis was 50.2 years (SD, 15.1 [95% CI, 20.1-90.5] years). The incidence rate of spontaneous CeAD encompassing all locations was 4.69 per 100 000 person-years (2.43 for internal carotid artery dissection and 2.01 for vertebral artery dissection). The incidence rate increased from 2.30 per 100 000 person-years from 2002 to 2006 to 8.93 per 100 000 person-years from 2017 to 2020 (P<0.0001). The incidence rate for female patients rose from 0.81 per 100 000 person-years from 2002 to 2006 to 10.17 per 100 000 person-years from 2017 to 2020. CONCLUSIONS: The incidence rate of spontaneous CeAD increased nearly 4-fold over a 19-year period from 2002 to 2020. The incidence rate in women rose over 12-fold. The increase in incidence rates likely reflects the increased use of noninvasive vascular imaging.

Endovascular reconstruction of high cervical and long-segment carotid artery dissections with Leo plus stent.

PURPOSE: Endovascular reconstruction has emerged as a viable alternative for carotid artery dissections (CADs) that are unresponsive to antithrombotic therapy. However, high cervical and long-segment CADs pose challenges during endovascular treatment due to their distal location and tortuous anatomy. We presented our experiences using endovascular reconstruction with the Leo plus stent for this type of CAD. METHODS: We conducted a retrospective review of patients with high cervical and long-segment CADs treated using the Leo plus stent. We analyzed patient demographics, clinical presentations, procedural features, complications, and follow-up outcomes. RESULTS: A total of 17 patients (mean age, 48.1 years) with 17 CADs were identified. Seven of these dissections were accompanied by pseudoaneurysm. The mean length of the dissection was 5.7 cm, and the mean degree of stenosis was 92.3%. A single Leo plus stent was deployed in 15 patients, while another Wallstent carotid stent was used in 2 cases. All stents were successfully positioned in their intended sites. The average degree of residual stenosis was 22.2%. There were no perioperative complications. With a median follow-up duration of 29 months, no ischemic stroke events occurred. All but one Leo plus stent remained patent during follow-up, and all 7 pseudoaneurysms had disappeared at the last radiological assessment. CONCLUSION: Our experience in treating high cervical and long-segment CADs with the Leo plus stent demonstrates that this approach is practical, safe, and effective, as evidenced by long-term observations. The Leo Plus stent appears to be a suitable option for managing this type of CAD.

High risk and low prevalence diseases: Spontaneous cervical artery dissection.

INTRODUCTION: Spontaneous cervical artery dissection (sCAD) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of sCAD, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: sCAD is a condition affecting the carotid or vertebral arteries and occurs as a result of injury and compromise to the arterial wall layers. The dissection most commonly affects the extracranial vessels but may extend intracranially, resulting in subarachnoid hemorrhage. Patients typically present with symptoms due to compression of local structures, and the presentation depends on the vessel affected. The most common symptom is headache and/or neck pain. Signs and symptoms of ischemia may occur, including transient ischemic attack and stroke. There are a variety of risk factors for sCAD, including underlying connective tissue or vascular disorders, and there may be an inciting event involving minimal trauma to the head or neck. Diagnosis includes imaging, most commonly computed tomography angiography of the head and neck. Ultrasound can diagnose sCAD but should not be used to exclude the condition. Treatment includes specialist consultation (neurology and vascular specialist), consideration of thrombolysis in appropriate patients, symptomatic management, and administration of antithrombotic medications. CONCLUSIONS: An understanding of sCAD can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Ten-year follow up of incidental spontaneous extracranial internal carotid artery dissection in a Japanese asymptomatic older man: A case report.

This report presents a unique finding of an incidental right internal carotid artery dissection in an asymptomatic 69-year-old man. The report highlights the possible trigger and long-term outcomes of this condition. The patient had participated in Japanese archery competitions for many years. His medical history included hypertension and a prior ischemic stroke in the left lateral medulla, resulting in Wallenberg syndrome. During a routine visit, head magnetic resonance angiography revealed right internal carotid artery dissection. He was managed conservatively with antiplatelet therapy and close monitoring. Follow-up imaging after 10 years showed no changes, and the patient remained asymptomatic. Therefore, routine screening for incidental findings is important even in asymptomatic patients. Archery competitions may be a possible trigger for internal carotid artery dissection. The presence of re-entry in the lesion at the time of onset can be a predictor of a good long-term prognosis.

Endovascular Treatment for Spontaneous bilateral carotid artery dissection with acute ischemic stroke: A Case Report with automated postprocessing CT perfusion findings and Review of the Literature.

Carotid artery dissection (CAD) is a common cause of stroke, accounting for up to 25% of all ischemic strokes in young and middle-aged patients. CAD should be considered in young patients with unexplained head and neck pain, with or without focal neurological symptoms and signs. While the clinical features may raise suspicion for CAD, the diagnosis is confirmed by its typical neuroimaging findings. Meanwhile, simultaneous spontaneous dissection of the bilateral carotid artery has rarely been reported. We herein describe a clinically challenging case of a simultaneous bilateral CAD that was successfully treated with bilateral carotid artery stenting (CAS). The patient recovered satisfactorily after completing the whole course of treatment. Keywords: Acute stroke, Bilateral Spontaneous carotid artery dissection, Endovascular treatment.

Cerebral hyperperfusion syndrome after stenting for revascularization of intracranial internal carotid artery dissection.

Cerebral hyperperfusion syndrome (CHS) is one of the complications of cerebral revascularization. The main pathophysiology of CHS was considered to be cerebral autoregulation impairment due to long-standing cerebral hypoperfusion. Herein, we describe the case of a 40-year-old man with symptomatic intracranial arterial dissection (IAD) related to internal carotid artery stenosis. The patient underwent intracranial stenting 11 days after onset due to severe cerebral hypoperfusion presenting with neurological symptoms, and CHS presenting with intracerebral hemorrhage, post-operatively. The present case indicated not only the potential risk of CHS after intracranial stenting in IAD-related stenosis but also that cerebral hypoperfusion-even in a short period-might lead to CHS.

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.

The proximity between styloid process and internal carotid artery as a possible risk factor for dissection: a case-control study.

PURPOSE: The anatomical proximity of the styloid process (SP) to the ipsilateral internal carotid artery (ICA) has been recently recognized as a possible risk factor for carotid artery dissection (CAD). We aimed to verify this hypothesis by comparing the minimum distance between SP and ICA in young adult patients (< 55 years) with and without CAD. METHODS: Thirty-one CAD patients (cases) were compared with 41 sex-matched patients without dissection, group one of control (G1), and with 16 sex-matched patients with vertebral artery dissection (VAD), group two of control (G2). Two independent observers measured, on CT angiography images, the minimum distance on the axial plane between the SP and ICA in cases and controls. They evaluated both the intercentric and the marginal distance. Differences between groups were estimated by Student t-test. RESULTS: SP-ICA intercentric distance ipsilateral to dissection was significantly shorter compared to that of the contralateral side of cases (p < 0.001), to those of left and right side of G1 patients (p < 0.001 for both), and to those of left and right side of G2 patients (p < 0.001 for both). SP-ICA marginal distance of cases was significantly shorter compared to those of left and right side of G1 patients (p < 0.001 for both) and to those of left and right side of G2 patients (p < 0.001 for both). CONCLUSION: A short SP-ICA distance appears to be a risk factor for CAD as it likely induces a continuous microtraumatism of the vessel wall during normal head and neck movements.

Ultrasound Criteria for Diagnosing Spontaneous Cervical Artery Dissections. / Ultraschallkriterien zur Diagnose spontaner Halsarterien-Dissektionen.

Spontaneous dissection of brain-supplying cervical arteries, which also includes findings after minor injuries, is one of the main causes of ischaemic strokes in young adults. Strokes due to dissection are usually due to arterio-arterial embolism. They are rarely the first symptom of dissection because an intraluminal thrombus must first develop. Therefore, early diagnosis of dissection can contribute to stroke prevention - through immediate therapy with anticoagulants or antiplatelet drugs. This article describes the diagnostic criteria and typical findings of spontaneous dissection, in which no dissecting membrane is to be expected as in aortic dissection. Traumatic dissections following blunt or penetrating injuries also present with different findings. Examiners should be aware of possible differential diagnoses whose ultrasound image may mimic a dissection. A frequently occurring but avoidable cause of misdiagnosis is idiopathic carotidynia. Ultrasound also enables differentiation between dissection and vasculitis or carotid web and detection of normal variants such as fenestration of the vertebral artery. Further possibilities for misdiagnosis may arise in the presence of a variant of the ascending pharyngeal artery or in extracranial vasospasm. The different imaging techniques for the detection of a dissection are complementary, as false-negative findings occur with all techniques; no method serves as the gold standard. In any case, ultrasound can make an important contribution to the detection of a dissection, and it is worth knowing the diagnostic criteria.

Internal carotid artery dissection in a patient with hemophilia A: a case report and literature review.

Spontaneous cervical artery dissection (sCeAD) is the most common cause of ischemic stroke at a young age, but its pathogenetic mechanism and risk factors are not fully elucidated. It is reasonable to think that bleeding propensity, vascular risk factors such as hypertension and head or neck trauma, and constitutional weakness of the arterial wall together play a role in the pathogenesis of sCeAD. Hemophilia A is known to be an X-linked condition that leads to spontaneous bleeding in various tissues and organs. To date, a few cases of acute arterial dissection in patients with hemophilia have been reported, but the relationship between these two diseases has not been studied so far. In addition, there are no guidelines indicating the best antithrombotic treatment option in these patients. We report the case of a man with hemophilia A who developed sCeAD and transient oculo-pyramidal syndrome and was treated with acetylsalicylic acid. We also review previous published cases of arterial dissection in patients with hemophilia, discussing the potential pathogenetic mechanism underlying this rare association and potential antithrombotic therapeutic options.

Internal carotid artery dissection with different interventions and outcomes: two case reports.

Spontaneous internal carotid artery dissection (ICAD) is a rare disease and an important cause of stroke in young patients. The presentation of ICAD is variable and atypical. We have used three-dimensional T1-weighted volume isotropic turbo spin-echo acquisition to help diagnose ICAD. ICAD should be considered in young patients presenting with relevant symptoms in an emergency setting. We herein report ICAD with an unexplained onset in two patients. Neither had a history of large or small cervical trauma, but both had a history of hypertension. The first patient was a 33-year-old man who presented with upper extremity numbness and mobility impairment, and the second patient was a 40-year-old man with onset of visual impairment. There were no obvious triggers in either case. Both patients were diagnosed with ICAD by blood vessel examination. However, their prognoses differed. The first patient recovered after endovascular therapy, whereas the second patient was successfully managed with medical treatment. ICAD can cause different symptoms depending on where the dissection occurs. Clinicians must be aware of the different clinical manifestations of ICAD, make the correct diagnosis in a timely manner, make appropriate treatment plans according to the patient's condition, and strive for timely recanalization of the blood vessels.

Association between spontaneous internal carotid artery dissection and perivascular adipose tissue attenuation on computed tomography angiography.

BACKGROUND: Spontaneous cervical artery dissection (sCAD) is a leading cause of ischemic stroke in young patients. Studies using high-resolution magnetic resonance imaging and positron emission tomography have suggested vessel wall inflammation to be a pathogenic factor in sCAD. Computed tomography (CT) attenuation of perivascular adipose tissue (PVAT) is an established non-invasive imaging biomarker of inflammation in coronary arteries, with higher attenuation values reflecting a greater degree of vascular inflammation. OBJECTIVES: We evaluate the CT attenuation of PVAT surrounding the internal carotid artery (PVATcarotid) with and without spontaneous dissection. METHODS: Single-center prospective observational study of 56 consecutive patients with CT-verified spontaneous dissection of the internal carotid artery (ICA). Of these patients, six underwent follow-up computed tomography angiography (CTA). Twenty-two patients who underwent CTA for acute neurological symptoms but did not have dissection formed the control group. Using semi-automated research software, PVATcarotid was measured as the mean Hounsfield unit (HU) attenuation of adipose tissue within a defined volume of interest surrounding the ICA. RESULTS: PVATcarotid was significantly higher around dissected ICA compared with non-dissected contralateral ICA in the same patients (-58.7 ± 10.2 vs -68.9 ± 8.1 HU, p < 0.0001) and ICA of patients without dissection (-58.7 ± 10.2 vs -69.3 ± 9.3 HU, p < 0.0001). After a median follow-up of 89 days, there was a significant reduction in PVATcarotid around dissected ICA (-57.5 ± 13.4 to -74.3 ± 10.5 HU, p < 0.05), while no change was observed around non-dissected contralateral ICA (-71.0 ± 4.4 to -74.1 ± 4.1 HU, p = 0.19). ICA dissection was an independent predictor of PVATcarotid following multivariable adjustment for age and the presence of ICA occlusion. CONCLUSION: PVATcarotid is elevated in the presence of sCAD and may decrease following the acute event.

Internal carotid artery dissection caused by elongated styloid process.

A 69-year-old man with impaired consciousness, right hemiplegia, and aphasia was admitted to our emergency room for thorough examination. Magnetic resonance imaging (MRI) and 3-dimensional computed tomography (3D CT) scan of the head revealed a cerebral infarction due to dissection of the left internal carotid artery. Contrast-enhanced CT prior to internal carotid artery stenting showed that the left elongated styloid process ran in close proximity to the left internal carotid artery, with a minimum distance of 2 mm. The patient underwent stenting at the internal carotid artery 16 days after disease onset. The patient was referred to our department for left elongated styloid process resection to reduce the risk of further internal carotid artery injury. Resection of the left styloid process through a cervical incision was performed. Six months after surgery, there was no recurrence of the internal carotid artery dissection.

Current Treatment Results of Intracranial Carotid Artery Dissection Causing Cerebral Ischemia: A Japanese Nationwide Survey.

Intracranial carotid artery dissection causing cerebral ischemia is a rare but important cause of cerebral infarction in children and adolescents. Although endovascular therapy has been reported to be effective, questions regarding the indications for intervention are yet to be addressed. Therefore, this study aimed to evaluate factors related to clinical outcomes through a nationwide survey. Overall, 35 neurosurgical centers reported patients within 2 weeks after ischemic onset due to intracranial carotid artery dissection causing cerebral ischemia treated between January 2015 and December 2020. Data on clinical and radiological findings were statistically analyzed. Twenty-eight patients met the inclusion criteria. The median age was 36 years (range, 7-59 years), without sex differences. Headache at onset was documented in 60.7% of the patients. Dissection findings were categorized into stenosis (71.4%) or occlusion (28.6%). Initial treatments, including various antithrombotic agent combinations in 23 (82.1%) patients, effectively improved or prevented aggravation in half of the patients. The patients with stenotic dissection were significantly more likely to experience aggravation during the initial treatment than did those with occlusive dissection (P = 0.03). In addition, the patients with moderate to severe neurological deficits on admission had poorer outcomes at discharge more frequently than did those with mild neurological deficits on admission. Eight patients undergoing endovascular therapy had no procedural complications or further aggravation after intervention. In conclusion, patients with intracranial carotid dissection causing cerebral ischemia who had a stenotic dissection were at risk of further aggravation, and endovascular therapy effectively improved or prevented aggravation.

Concurrent subarachnoid haemorrhage and internal carotid artery dissection: a transcranial colour-coded sonography diagnosis.

We report the case of a young woman affected by an aneurysmal subarachnoid haemorrhage (SAH) and numerous anatomic abnormalities. A Transcranial Colour-Coded Duplex Sonography, performed with the aim of monitoring the vasospasm, showed a non-pulsatile flow with loss of sharp systolic peak and lowering of mean flow velocities in the right extracranial Internal Carotid Artery (ICA) and all its intra-cranial branches. This event suggested a possible concomitant acute right ICA sub-occlusion with a lack of collateral circulation. This type of flow is typically found in systemic and brain arteries of patients undergoing to venous-arterial extracorporeal membrane oxygenation or to left ventricular assist devices. The absence of an adequate cerebral collateral circulation might be the explanation for this type of atypical flow. Aneurysms and arterial dissections contribute to SAH and ischemic stroke events, leading to long-term physical and cognitive disability. In our case, the prompt neurosonological diagnosis leaded to patient's good outcome.

Isolated traumatic supraclinoid internal carotid artery dissection diagnosed by high-resolution vessel wall MRI.

BACKGROUND: Isolated traumatic supraclinoid internal carotid artery (ICA) dissection is a rare complication of blunt craniomaxillofacial trauma, and differentiation from atherosclerosis is the key factor for confirming the diagnosis. CASE DESCRIPTION: A 53-year-old man was admitted because of blunt trauma to his head and face. His primary manifestations were disability of abduction of the left eye on day 2, recurrent epistaxis and a blowing murmur in the left ear on day 4. Neurological physical examination showed bilateral normal pupil diameter, a corrected visual acuity of 0.6 in the right eye and 0.3 in the left eye, and loss of abduction of the left eye. Craniofacial computed tomography scans revealed multiple craniomaxillofacial fractures mainly including a LeFort III injury of the left maxilla, fractures of the left ramus of the mandible, fractures of the left orbital apex, fractures of the sellar turcica, etc. Brain magnetic resonance (MR) findings showed multifocal lacunar infarcts in the left hemisphere. Cerebral angiography demonstrated severe intraluminal stenosis of the left supraclinoid ICA, which was highly suspicious of arterial dissection. A high-resolution vessel wall MR imaging performed on day 7 showed proximal intramural subacute haemorrhage and two distal intimal flaps at the injured region, both of which facilitated the exclusion of atherosclerosis and thus, confirmation of isolated arterial dissection. The patient underwent treatment with endovascular stent placement and antiplatelet agents two weeks later and had no ictus of symptomatic stroke during the next half-year duration. CONCLUSIONS: HR vw-MRI is able to assist in the diagnosis of isolated traumatic supraclinoid dissection complicated with underlying atherosclerosis.