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

Neurosurgery ◽  
2017 ◽  
Vol 80 (3) ◽  
pp. 368-379 ◽  
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.

D-Dimer As An Indicator of Vertebral Artery Dissection: A Case Control Study

2021 ◽  
Author(s):  
Atsuyuki Watanabe ◽  
Hiroshi Ito ◽  
Kazushi Maruo ◽  
Junzo Nakao ◽  
Takako Kaino ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Neck Pain ◽  
Vertebral Artery ◽  
Laboratory Data ◽  
Vertebral Artery Dissection ◽  
Young Patients ◽  
Artery Dissection ◽  
Diagnostic Model ◽  
Common Symptom ◽  
D Dimer

Abstract Background Vertebral artery dissection (VAD), which can possibly lead to stroke, presents various symptoms such as headache, neck pain, transient ischemic attacks, and vertigo. We evaluated the effect of D-dimer to distinguish VAD from benign diseases by retrospective single-center observational study. Methods All VAD cases received in the emergency department between January 2013 and June 2020 were reviewed. Comparing those cases to vertigo with benign etiologies, the correlation between VAD and D-dimer was analyzed. Using stepwise multivariate logistic regression, possible symptoms to suspect VAD were also determined from physical findings and some laboratory data, including D-dimer. Results Eleven patients were included in the VAD group, and 59 patients were enrolled in the control (benign vertigo [BV]) group. The most common symptom in VAD patients was hemiplegia (N = 7, 63.6%) and cranial neuropathy (N = 7, 63.6%), followed by classic occipital or posterior neck pain (N = 4, 36.4%), gait ataxia (N = 3, 27.3%), and confusion (N = 1, 9.1%). Two patients (18.2%) were free from any symptoms except vertigo. D-dimer was not significantly different between the two groups at the positive cutoff value of 500 ng/mL (p = 1). By stepwise selection, age (odds ratio (OR): 0.92, [0.87–0.98], p < 0.01) and systolic blood pressure (sBP; OR: 1.06 [1.02–1.10], p < 0.01) were selected in the diagnostic model. In combination, age under 60 and sBP over 160 mmHg yielded 63.6% sensitivity, 98.3% specificity, and 37.5 positive likelihood ratio. Conclusions In our study, D-dimer was not found to be an effective indicator of VAD. By contrast, disproportionate hypertension (high blood pressure in young patients) can be a key factor to suspect VAD. Future studies with larger sample sizes are warranted.

Carotid and Vertebral Artery Dissection Syndromes.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 4145-4145
Author(s):  
Beatriz Grand ◽  
Jorge Solimano ◽  
Adriana Ventura ◽  
Ernesto Quiroga Micheo ◽  
Dardo Riveros
Keyword(s):  
Vertebral Artery ◽  
Clinical Presentation ◽  
Oral Anticoagulants ◽  
Vertebral Artery Dissection ◽  
Clinical Signs ◽  
Young Patients ◽  
Complete Recovery ◽  
Artery Dissection ◽  
Hemorrhagic Complication ◽  
Progressing Stroke

Abstract Objetives: To describe the clinical presentation, diagnosis and treatment of patients with carotid and vertebral artery dissection (CAD, VAD). Design: Retrospective, observational Patients and methods: Clinical recording were evaluated from 1996 to 2005; 6 patients (3 women, 3 men, mean age 37 years) with CAD (3) and VAD (3) were referred to our hematology unit. Clinical presentation: progressing stroke 4/6 and transient ischemic attack (TIA) 2/6; warning sings and symptoms preceding the onset of stroke in 80%. Vascular risk factors included smoking and hypertension; associated features were headache, visual symptoms and Horner’s syndrome; Predisposing factors as physical exercise and trauma were found in 4/6. One patient was at 20 weeks of pregnancy. Diagnosis: Diagnostic tests included: Doppler ultrasound, magnetic resonance imaging (MRI) and angiography (MRA). On admission angiographic studies showed occlusion or stenoses of dissected arteries. Treatment: Anticoagulation with heparin or low molecular weight heparin followed by oral anticoagulants. Outcome: No hemorrhagic complication, no recurrence, complete recovery in 5 patients and mild dysarthria in one. Conclusion: TIA and progressing stroke in young patients are presenting features of CAD and VAD. The diagnosis is based on clinical signs and confirming angiographic investigation. Our experience shows that anticoagulation is the treatment of choice, although controlled studies to show their effectiveness are lacking.

scholarly journals Extracranial Carotid and Vertebral Artery Dissection: A Review

2008 ◽  
Vol 35 (2) ◽  
pp. 146-152 ◽  
Author(s):  
Gary John Redekop
Keyword(s):  
Vertebral Artery ◽  
Cochrane Review ◽  
Vertebral Artery Dissection ◽  
Antiplatelet Agents ◽  
Carotid Artery Dissection ◽  
Annual Incidence ◽  
Artery Dissection ◽  
Blunt Injury ◽  
Injury Mechanisms

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.

scholarly journals Spontaneous Vertebral Artery Dissection Presenting with Crescendo TIAs and Headache

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.

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

2015 ◽  
Vol 2015 ◽  
pp. 1-4 ◽  
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.

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

1994 ◽  
Vol 80 (4) ◽  
pp. 667-674 ◽  
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.

scholarly journals Dissecting spontaneous vertebral artery aneurysms (V4). Endovascular Reconstructive techniques with fd stents. Case series

2020 ◽  
Vol 31 (4) ◽  
pp. 305-313
Author(s):  
João Victor Amaro de Souza ◽  
Guilherme Cabral de Andrade ◽  
Alexandre Lescszysnki ◽  
Helvercio F P Alves
Keyword(s):  
Endovascular Treatment ◽  
Vertebral Artery ◽  
Vertebral Artery Dissection ◽  
Young Patients ◽  
Case Series ◽  
Arterial Occlusion ◽  
Artery Dissection ◽  
Surgical Morbidity ◽  
Reconstructive Technique

Background: Spontaneous vertebral artery dissection (SVAD) is rare and occurs in young patients with subarachnoid hemorrhage (HSA) or stroke (3 to 5%). Only 11% occur in the V4 segment of VA. Its treatment changed in parallel with the progress of endovascular technology. Material and Methods: Six consecutive cases of dissecting vertebral artery aneurysms V4 are reported. All males with mean age 35 years. Clinical presentation with headache and neckache in all cases, ischemic stroke and SAH one case each. All patients underwent reconstructive endovascular treatment with FD stent, with or without microcoils. Results: All patients were under dual antiplatelet therapy before EVT (Aspirin 200mg and clopidogrel 75mg or ticagrelor 180mg/day). Reconstructive technique was performed with FD stent in two cases, associated of microcoils and “jailing technique” in two cases or multiple telescoping stents in three cases. Occlusion of the aneurysm and arterial permeability were found in long term follow up in 5 cases. In a case of fusiform aneurysm, there was late thrombosis of the telescoped stents and arterial occlusion without clinical repercussion. Conclusion: Due to the high rate of surgical morbidity, endovascular treatment became the first line for this kind of aneurysm. The reconstruction using a flow bypass and device reconstructive technique is an attractive alternative, showing long-term favorable clinical and angiographic outcomes with the ability to maintain patency of the parental and lateral branch arteries.

scholarly journals Dissecting pseudoaneurysms: predictors of symptom occurrence, enlargement, clinical outcome, and treatment

2016 ◽  
Vol 125 (4) ◽  
pp. 936-942 ◽  
Author(s):  
Badih Daou ◽  
Christine Hammer ◽  
Nohra Chalouhi ◽  
Robert M. Starke ◽  
Pascal Jabbour ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Medical Treatment ◽  
Recurrent Stroke ◽  
Vertebral Artery Dissection ◽  
Smoking History ◽  
Artery Dissection ◽  
History Of ◽  
Ischemic Attack ◽  
Average Size

OBJECTIVE Dissection of the carotid and vertebral arteries can result in the development of aneurysmal dilations. These dissecting pseudoaneurysms can enlarge and cause symptoms. The objective of this study is to provide insight into the progression of dissecting pseudoaneurysms and the treatments required to manage them. METHODS A review of the electronic medical records was conducted to detect patients with carotid and vertebral artery dissection. An imaging review was conducted to identify patients with dissecting pseudoaneurysms. One hundred twelve patients with 120 dissecting pseudoaneurysms were identified. Univariate and multivariate analyses were conducted to assess the factors associated with undergoing further interventions other than medical treatment, pseudoaneurysm enlargement, pseudoaneurysms resulting in ischemic and nonischemic symptoms, and clinical outcome. RESULTS Overall, 18.3% of pseudoaneurysms were intracranial and 81.7% were extracranial, and the average size was 7.3 mm. The mean follow-up time was 29.3 months; 3.3% of patients had a recurrent transient ischemic attack, no patients had a recurrent stroke, and 14.2% of patients had recurrence of nonischemic symptoms (headache, neck pain, Horner syndrome, or cranial nerve palsy). Follow-up imaging demonstrated that 13.8% of pseudoaneurysms had enlarged, 30.2% had healed, and 56% had remained stable. In total, 20.8% of patients had an intervention other than medical treatment. Interventions included stenting, coiling, flow diversion, and clipping. Predictors of intervention included increasing size, size > 10 mm, location in the C2 (petrous) segment of the internal carotid artery (ICA), younger age, hyperlipidemia, pseudoaneurysm enlargement, and any symptom development. Significant predictors of enlargement included smoking, history of trauma, C2 location, hyperlipidemia, and larger initial pseudoaneurysm size. Predictors of pseudoaneurysm resulting in recurrent ischemic and nonischemic symptoms included increasing size and location in the petrous segment of the ICA. Smoking was a predictor of unfavorable outcome. CONCLUSIONS Dissecting pseudoaneurysms have a benign course and most will not cause symptoms or enlarge on follow-up. Medical treatment can be a sufficient, initial treatment for dissecting pseudoaneurysms.

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

2018 ◽  
Vol 24 (6) ◽  
pp. 639-642 ◽  
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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