Extracranial Carotid and Vertebral Artery Dissection: A Review

Dissection of the extracranial carotid and vertebral arteries is increasingly recognized as a cause of transient ischemic attacks and stroke. The annual incidence of spontaneous carotid artery dissection is 2.5 to 3 per 100,000, while the annual incidence of spontaneous vertebral artery dissection is 1 to 1.5 per 100,000. Traumatic dissection occurs in approximately 1% of all patients with blunt injury mechanisms, and is frequently initially unrecognized. Overall, dissections are estimated to account for only 2% of all ischemic strokes, but they are an important factor in the young, and account for approximately 20% of strokes in patients less than 45 years of age. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe stenosis or occlusion. Available evidence strongly favors embolism as the most common cause. Both anticoagulation and antiplatelet agents have been advocated as treatment methods, but there is limited evidence on which to base these recommendations. A Cochrane review on the topic of antithrombotic drugs for carotid dissection did not identify any randomized trials, and did not find that anticoagulants were superior to antiplatelet agents for the primary outcomes of death and disability. Healing of arterial dissections occurs within three to six months, with resolution of stenosis seen in 90%, and recanalization of occlusions in as many as 50%. Dissecting aneurysms resolve on follow-up imaging in 5- 40%, decrease in size in 15-30%, and remain unchanged in 50-65%. Resolution is more common in vertebral dissections than in carotid dissections. Aneurysm enlargement occurs rarely. The uncommon patient presenting with acute hemodynamic insufficiency should be managed with measures to increase cerebral blood flow, and in this setting emergency stent placement to restore cerebral perfusion may be considered, provided that irreversible infarction has not already occurred.

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Bilateral Vertebral Artery Dissection and Unilateral Carotid Artery Dissection in Case of Ehlers-Danlos Syndrome Type IV

World Neurosurgery ◽

10.1016/j.wneu.2018.09.236 ◽

2019 ◽

Vol 121 ◽

pp. 83-87 ◽

Cited By ~ 2

Author(s):

Tomotaka Ohshima ◽

Shigeru Miyachi ◽

Taiki Isaji ◽

Naoki Matsuo ◽

Reo Kawaguchi ◽

...

Keyword(s):

Carotid Artery ◽

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Carotid Artery Dissection ◽

Artery Dissection ◽

Syndrome Type ◽

Ehlers Danlos Syndrome ◽

Type Iv ◽

Danlos Syndrome

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Vertebral Artery Dissection Mimicking Migraine: A Case Report

Emergency Medicine - Open Journal ◽

10.17140/emoj-7-162 ◽

2021 ◽

Vol 7 (1) ◽

pp. 21-24

Author(s):

Rahalkar Kshitij ◽

◽

Hong K. Lau ◽

R Ponampalam ◽

◽

...

Keyword(s):

Magnetic Resonance ◽

Vertebral Artery ◽

Thrombus Formation ◽

Vertebral Artery Dissection ◽

Vascular Occlusion ◽

Antiplatelet Agents ◽

Vascular Wall ◽

Neurological Deficits ◽

Artery Dissection ◽

Common Symptom

Vertebral artery dissection (VAD) is caused by an intimal tear that leads to bleeding into the vascular wall, which may cause vascular occlusion by thrombus formation and subsequent distal emboli (leading to ischemic stroke), aneurysm formation and subarachnoid hemorrhage. Cervical artery dissections (either carotid or vertebral artery dissection) are an important cause of stroke in patients under 50-years of age. Headache with or without neck pain is a common symptom. Usually, it occurs with focal neurological signs but sometimes it may occur without any neurological deficits and may mimic migraine. Often it occurs spontaneously without trauma but sometimes there is history of minor traumas, sudden neck movements or chiropractic manipulation. Imaging modalities include magnetic resonance imaging (MRI) brain, magnetic resonance angiography (MRA), and computed tomography angiography (CTA). Treatment involves anticoagulation or antiplatelet agents.

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Anticoagulation vs Antiplatelet Treatment in Patients with Carotid and Vertebral Artery Dissection: A Study of 370 Patients and Literature Review

Neurosurgery ◽

10.1093/neuros/nyw086 ◽

2017 ◽

Vol 80 (3) ◽

pp. 368-379 ◽

Cited By ~ 26

Author(s):

Badih Daou ◽

Christine Hammer ◽

Nikolaos Mouchtouris ◽

Robert M. Starke ◽

Sravanthi Koduri ◽

...

Keyword(s):

Clinical Outcome ◽

Vertebral Artery ◽

Recurrent Events ◽

Combined Treatment ◽

Vertebral Artery Dissection ◽

Young Patients ◽

Artery Dissection ◽

Antiplatelet Treatment ◽

Hemorrhagic Events

Abstract BACKGROUND: Dissection of the carotid and vertebral arteries is an important cause of stroke in young patients. OBJECTIVE: The objective of this study is to compare antithrombotic treatments in patients with carotid and vertebral dissections. METHODS: Three hundred seventy patients with carotid and vertebral artery dissections were included. Univariate and multivariate analyses were conducted to analyze the association between treatment and new or recurrent events and clinical outcome. RESULTS: Mean follow-up was 24.3 months. In patients with spontaneous dissection, 55% received antiplatelets, 29.4% anticoagulation, and 12.6% combined treatment. New or recurrent ischemic and hemorrhagic events occurred in 9.6% of patients on antiplatelets, 10.4% on anticoagulation, and 13.3% on combined treatment. For traumatic dissection, 58.3% received antiplatelets, 26.9% anticoagulation, and 10.2% combined treatment. New or recurrent ischemic and hemorrhagic events occurred in 6.9% on antiplatelets, 11.1% on anticoagulation, and 20% on combined treatment. In patients with intracranial dissection, 63.1% were started on antiplatelets, 19.7% on anticoagulation, and 14.5% on combined treatment. Ischemic and hemorrhagic events occurred in 8.5% on antiplatelet treatment, 15.4% on anticoagulation, and 18.2% on combined treatment. In patients with extracranial dissection, 54.4% were on antiplatelets, 28.9% on anticoagulation, and 11.2% on combined treatment. Ischemic and hemorrhagic events occurred in 10.1% on antiplatelet treatment, 9.3% on anticoagulation, and 13.8% on combined treatment. The association between antithrombotic treatment and ischemic/hemorrhagic events and clinical outcome was not significant for all subtypes of dissection. CONCLUSION: The rate of new or recurrent events is similar with antiplatelet and anticoagulation treatment in treating intracranial and extracranial carotid and vertebral artery dissection.

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Spontaneous Vertebral Artery Dissection Presenting with Crescendo TIAs and Headache

Global Journal of Medical Research ◽

10.34257/gjmrkvol19is1pg1 ◽

2019 ◽

pp. 1-6

Author(s):

Dr. Nosakhare I Idehen ◽

Dr. Mohammed Awad

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Vertebral Artery Dissection ◽

Symptomatic Improvement ◽

Neurological Deficits ◽

Artery Dissection ◽

Neurological Sequelae ◽

Cerebellar Artery ◽

Ct Brain

We present the case of a man in his thirties who had attended the emergency department with complaint of a distressing headache and associated intermittent facial droop with occasional slurred speech. The patient’s symptoms were bizarre in their nature as they were random, not sustained and he had long intervals when he was asymptomatic and was his normal self. During the course of admission his symptoms evolved resulting in neurological deficits which were more sustained, prompting the need for further imaging beyond the initial plain CT brain which showed no abnormality. This led to the diagnosis of vertebral artery dissection (VAD) complicated with an ischaemic stroke in the posterior inferior cerebellar artery distribution (PICA) on MRI/MRA. Dual anti-platelet treatment was commenced with the patient attaining gradual symptomatic improvement prior to discharge. He has reported some degree of neurological sequelae which he described as intermittent poor coordination on follow up visit in clinic after discharge.

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Progressive Intracranial Vertebral Artery Dissection Presenting with Isolated Trigeminal Neuralgia-Like Facial Pain

Case Reports in Neurological Medicine ◽

10.1155/2015/387139 ◽

2015 ◽

Vol 2015 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Tomoki Nakamizo ◽

Takashi Koide ◽

Hiromichi Miyazaki

Keyword(s):

Trigeminal Neuralgia ◽

Vertebral Artery ◽

Facial Pain ◽

Brain Infarction ◽

Vertebral Artery Dissection ◽

Artery Dissection ◽

Life Threatening ◽

Magnetic Resonance Imaging Mri ◽

The Brain

Intracranial vertebral artery dissection (IVAD) is a potentially life-threatening disease, which usually presents with ischemic stroke or subarachnoid hemorrhage. IVAD presenting with isolated facial pain is rare, and no case with isolated trigeminal neuralgia- (TN-) like facial pain has been reported. Here, we report the case of a 57-year-old male with IVAD who presented with acute isolated TN-like facial pain that extended from his left cheek to his left forehead and auricle. He felt a brief stabbing pain when his face was touched in the territory of the first and second divisions of the left trigeminal nerve. There were no other neurological signs. Magnetic resonance imaging (MRI) of the brain 7 days after onset revealed dissection of the left intracranial vertebral artery without brain infarction. The pain gradually disappeared in approximately 6 weeks, and the patient remained asymptomatic thereafter, except for a brief episode of vertigo. Follow-up MRI revealed progressive narrowing of the artery without brain infarction. This case indicates that IVAD can present with isolated facial pain that mimics TN. IVAD should be considered in the differential diagnosis of acute facial pain or TN.

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Nonsurgical treatment of unruptured intracranial vertebral artery dissection with serial follow-up angiography

Journal of Neurosurgery ◽

10.3171/jns.1994.80.4.0667 ◽

1994 ◽

Vol 80 (4) ◽

pp. 667-674 ◽

Cited By ~ 102

Author(s):

Chifumi Kitanaka ◽

Jun-Ichi Tanaki ◽

Masanori Kuwahara ◽

Akira Teraoka ◽

Tomio Sasaki ◽

...

Keyword(s):

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Bed Rest ◽

Arterial Dissection ◽

Artery Dissection ◽

Aneurysmal Dilatation ◽

Content Type ◽

Brain Stem Ischemia ◽

Fine Print

✓ The question of whether unruptured intracranial vertebral artery dissections should be treated surgically or nonsurgically still remains unresolved. In this study, six consecutive patients with intracranial vertebral artery dissection presenting with brain-stem ischemia without subarachnoid hemorrhage (SAH) were treated nonsurgically with control of blood pressure and bed rest, and five received follow-up review with serial angiography. No further progression of dissection or associated SAH occurred in any of the cases, and all patients returned to their previous lifestyles. In the serial angiograms in five patients, the findings continued to change during the first few months after onset. Four cases ultimately showed “angiographic cure,” while fusiform aneurysmal dilatation of the affected vessel persisted in one case. In one patient, arterial dissection was visualized on the second angiogram despite negative initial angiographic findings. These results indicate that intracranial vertebral artery dissection presenting without SAH can be treated nonsurgically, with careful angiographic follow-up monitoring. Persistent aneurysmal dilatation as a sequela of arterial dissection seemed to form a subgroup of fusiform aneurysms of the posterior circulation. These aneurysms may be prone to late bleeding and may require surgical treatment.

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Early reappearance of disappeared ruptured small aneurysm with concomitant vertebral artery dissection

Interventional Neuroradiology ◽

10.1177/1591019918782964 ◽

2018 ◽

Vol 24 (6) ◽

pp. 639-642 ◽

Cited By ~ 1

Author(s):

Eugen Enesi ◽

Arben Rroji ◽

Fatmir Bilaj ◽

Eni Reka ◽

Adrian Ndroqi ◽

...

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Vertebral Artery Dissection ◽

Artery Aneurysm ◽

Artery Dissection ◽

Vitro Fertilization ◽

Ruptured Intracranial Aneurysm ◽

Frequent Event

Thrombosis of a previously ruptured intracranial aneurysm is a frequent event and it most commonly occurs in large or giant aneurysms. We present a dynamic short-term follow-up and management of thrombosis in a ruptured small posterior inferior cerebellar artery aneurysm with concomitant vertebral artery dissection (VAD). Clinical and radiological follow-up findings and reviewed literature on thrombosis of small ruptured aneurysms are the focus of this presentation. Early reappearance of a disappeared ruptured small cerebral aneurysm with a concomitant VAD may be attributed to the controlled ovarian hyperstimulation phase of in vitro fertilization and prolonged use of oral contraceptive pills.

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