Cervical Spine Manipulation and Causation of Cervical Artery Dissection: A Review of 10 Case Reports.

Recent media coverage of high-profile cases of cervical artery dissection (CAD) has ignited the discussion about the role of cervical spine manipulation (CSM) in causing cervical artery dissection. However, research does not support a causal association between cervical spine manipulation and cervical artery dissection in a healthy cervical spine. The objective of this study was to review the 10 most recent case reports of cervical spine manipulation and cervical artery dissection for convincing evidence of the causation of cervical artery dissection by cervical spine manipulation. Nine of 10 case reports showed no convincing evidence of a causal relationship between cervical spine manipulation and cervical artery dissection. The 10th case report was exceptional as the CSM was contraindicated by pre-existing cervical spine pathology. We conclude that these 10 case reports provide no convincing evidence of the causation of cervical artery dissection by cervical spine manipulation in a healthy cervical spine. One case report demonstrated that cervical spine manipulation can cause cervical artery dissection when performed in the presence of pre-existing cervical spine pathology. Therefore, we conclude that practitioners should exclude cervical spine pathology before performing cervical spine manipulation.

A narrative review on cervical artery dissection-related cranial nerve palsies.

Introduction: This study aimed to emphasize the importance of cranial nerve (CN) palsies in spontaneous cervical artery dissection (sCeAD). Methods: A search term-based literature review was conducted on "cervical artery dissection" and "cranial nerve palsy." English and German articles published until October 2023 were considered. Results: Cranial nerve (CN) palsy in sCeAD is evident in approximately 10% of cases. In the literature, isolated palsies of CN II, III, VII, IX, X, and XII have been reported, while CN XI palsy only occurs in combination with other lower cranial nerve palsies. Dissection type and mural hematoma localization are specific to affected CN as CN palsies of II or III are solely evident in those with steno-occlusive vessel pathologies located at more proximal segments of ICA, while those with CN palsies of IX, X, XI, and XII occur in expansive sCeAD at more distal segments. This dichotomization emphasizes the hypothesis of a different pathomechanism in CN palsy associated with sCeAD, one being hypoperfusion or microembolism (CN II, III, and VII) and the other being a local mass effect on surrounding tissue (CN IX, X, XI, and XII). Clinically, the distinction between peripheral palsies and those caused by brainstem infarction is difficult. This differentiation is key, as, according to the reviewed cases, peripheral cranial nerve palsies in sCeAD patients mostly resolve completely over time, while those due to brainstem stroke do not, making cerebrovascular imaging appraisal essential. Discussion: It is important to consider dissections as a potential cause of peripheral CN palsies and to be aware of the appropriate diagnostic pathways. This awareness can help clinicians make an early diagnosis, offering the opportunity for primary stroke prevention.

The Relationship between Ischemic Optic Neuropathy and Internal Carotid Artery Dissection: A Systematic Review.

Background: To evaluate and review the current evidence regarding the association between ischemic optic neuropathy (ION) and internal carotid artery dissection (ICAD). Methods: We systematically reviewed studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA), searching three databases (Scopus, Pubmed, and Embase) for relevant articles that clearly described the correlation between ION and ICAD. All studies that examined the association between ICAD and the development of ION were synthesized. Quality assessment using the Newcastle-Ottawa Scale (NOS) and Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports and Case Series were conducted. Results: Our search yielded 198 manuscripts published in the English language. Following study screening, fourteen studies were selected. The number of participants with ION following ICAD ranged from one to four, with sixteen patients experiencing either anterior ION, posterior ION, or a combination of both. The anterior or posterior ischemic optic neuropathy (AION and PION) patients' ages were 48.75 ± 11.75 and 49.62 ± 12.85, respectively. Fourteen out of sixteen patients experienced spontaneous ICAD, whereas the traumatic etiology was ascertained in two patients. Conclusions: Hence, albeit rare, ophthalmologists should consider ICAD a potential cause of ION, especially in young adults with concomitant cephalic pain and vision reduction.

Use of a new low-profile coronary stent graft for the treatment of intracranial carotid blow-out.

A 50-year-old male patient with a history of transcranial surgery and subsequent radiotherapy for a pituitary adenoma presented with repetitive pulsatile nasal bleeding. A right cavernous segment pseudoaneurysm was discovered on the angiogram, and the patient failed the balloon occlusion test. A Papyrus (Biotronik, Berlin, Germany) stent graft, which is approved for coronary interventions, was successfully deployed over a coaxial guiding system during the emergent treatment of the false aneurysm. The patient tolerated the procedure well and nasal bleeding did not recur after the procedure. At one-year angiographic follow-up, the stent graft was patent and there was no evidence of recanalization of the false aneurysm.

A Sudden Unilateral Visual Field Loss in a Recreational Tennis Player: Cervical Internal Carotid Artery Dissection Associated With Low-Impact Sports.

Traumatic cervical internal carotid artery dissection (CICAD) is a rare condition caused by blunt trauma to the neck, often through automobile- or sports-related collisions, assaults, or falls. Herein, we report an unusual case in which engaging in a low-impact sport (tennis) caused CICAD, without a direct injury. A 56-year-old man with hypertension suddenly experienced a visual field loss in his right eye while playing tennis. Carotid echocardiography revealed severe stenosis of the right internal carotid artery (ICA). Angiography revealed severe and irregular stenosis of the right ICA from the bifurcation to the petrous portion, suggesting CICAD. Upon admission, the patient had left upper visual field defects in his right eye and neck pain. Antiplatelet therapy was initiated with prasugrel (3.75 mg/day), with the intent to treat surgically if the stenosis or symptoms progressed. Follow-up angiography and magnetic resonance imaging showed gradual resolution of the stenosis, and the patient was discharged on day 28 with a modified Rankin Scale score of 1. The CICAD should be considered as a diagnosis for neurological symptoms, even in the context of low-impact sports such as tennis. Antithrombotic therapy is a reasonable first-line treatment for stable CICAD.

Plausible Mechanisms of Causation of Immediate Stroke by Cervical Spine Manipulation: A Narrative Review.

It has been proposed that cervical spine manipulation (CSM) can cause dissection in healthy cervical arteries, with resultant immediate stroke. However, research does not support a causal association between CSM and cervical artery dissection (CAD) in healthy cervical arteries. The objective of this study was to review the literature to identify plausible mechanisms of causation of immediate stroke by CSM. Immediate stroke is defined as a stroke occurring within seconds or minutes of CSM. Our review found plausible thromboembolic and thrombotic mechanisms of causation of immediate stroke by CSM in the literature. The common premise of these mechanisms is CAD being present before CSM, not occurring as a result of CSM. These mechanisms of causation have clinical and medicolegal implications for physicians performing CSM.

Transcarotid Artery Revascularization (TCAR): The Best Surgical Intervention Option in an Unusual Presentation of Carotid Dissection in a 37-Year-Old Pregnant Female.

Carotid artery dissection (CAD) is a condition that compromises blood flow and leads to serious complications such as a stroke or cerebrovascular accident (CVA). This case report demonstrates an unusual case of right internal carotid artery dissection, stenosis of >70%, and an intraluminal thrombus. The patient presented to the emergency department with complaints of right-sided neck pain and severe headache status-post a complicated pregnancy. A computed tomography (CT) angiogram of the right carotid was conducted and showed a right internal carotid artery dissection with 70% luminal stenosis and thrombosis. Carotid endarterectomy (CEA), transfemoral carotid angioplasty with stenting (CAS), or transcarotid artery revascularization (TCAR) were all surgical intervention options that were explored. Risks and benefits were compared between the three surgical intervention options, and transcarotid artery revascularization was deemed the best surgical option in this patient's case.

Multiple spontaneous isolated arterial dissections: a rare case report.

Spontaneous dissections in multiple arteries are a rare condition with clinical presentation varying from asymptomatic conditions to sudden death. We present a rare case where a routine thoracic computed tomography (CT) scan showed a type B aortic dissection. Medical records showed that the patient previously had been diagnosed with bilateral spontaneous isolated internal carotid artery dissections, which caused an attack of amaurosis fugax a few months earlier. The patient was asymptomatic during the admission with type B aortic dissection. However, the patient had a high blood pressure which was medically treated. A new CT scan confirmed earlier findings and revealed a spontaneous isolated dissection in the superior mesenteric artery. No progression was seen when the scan was compared to a new CT scan performed 10 days later. The type B aortic dissection was considered to be chronic and stable with no need for vascular intervention. This case report illustrates a rare condition of four isolated arterial dissections. The present case demonstrates the necessity of further examinations, which should be considered carefully when a patient presents with several independent arterial dissections.

Internal Carotid Artery Dissection Presenting with Transient or Subclinical Horner Syndrome.

Introduction: The most frequently encountered symptoms in internal carotid artery dissection (ICAD) are head or neck pain and cerebral ischemia. Ocular symptoms or signs have been reported as the presenting feature in up to 50% of patients, with (painful) Horner syndrome being the most frequently associated. Horner syndrome is part of the classic triad that depicts the characteristic presentation of ICAD and that consists of pain in the ipsilateral neck, head and orbital regions, (partial) Horner syndrome, and cerebral or retinal ischemia. All patients presenting with painful Horner syndrome should therefore require prompt investigations to rule out carotid artery dissection. In patients with confirmed diagnosis, treatment should be started early to prevent permanent ocular or cerebral complications. Case Presentation: Case 1: A 61-year-old woman presented with right temporal headache, an episode of transient visual loss and drooping of the right upper eyelid. Examination revealed anisocoria, which was more important in darkness. Reversal of anisocoria was observed after instilling drops of apraclonidine 0.5%. Neuroimaging demonstrated intrapetrous ICAD. Headaches, eyelid ptosis, and anisocoria all had resolved the next day. Apraclonidine pharmacologic testing a few weeks later was no longer dilating the previously smaller pupil. Case 2: A 48-year-old man presented with drooping of the right upper eyelid and right occipital headache and facial pain that all started one day after an intense yoga workout. Anisocoria was noticed upon examination, with topical cocaine 10% pharmacologic testing confirming a right Horner syndrome. Neuroimaging revealed ICAD. The patient reported resolution of his eyelid ptosis a few days later. Eyelid ptosis and anisocoria had indeed resolved at a follow-up examination a few weeks later. However, cocaine drop testing still produced anisocoria, compatible with subclinical Horner syndrome. Conclusion: Transient or subclinical Horner syndrome can be the presenting feature in ICAD; in such cases, the characteristic eyelid ptosis and anisocoria may be short-lived and resolve in only a few days. If suspected by clinical history, pharmacologic testing may be helpful in identifying subclinical cases.

Surgical management of stylocarotid Eagle syndrome in a patient with bilateral internal carotid artery dissection: illustrative case.

BACKGROUND: Eagle syndrome is characterized by an elongated styloid process, which can cause acute neurological symptoms when the projection impinges on local structures. One method by which Eagle syndrome can cause acute stroke is via internal carotid artery dissection. OBSERVATIONS: A patient presented with acute aphasia and right-arm weakness. Imaging revealed a left internal carotid artery dissection, which was treated with stenting. Three years later, the patient presented with left-sided weakness, and imaging revealed a new right internal carotid artery dissection. Closer review of the patient's imaging revealed bilateral elongated styloid processes. The patient subsequently underwent staged bilateral styloidectomy and returned to his prior baseline postoperatively. LESSONS: This case report describes a patient with Eagle syndrome who had two internal carotid artery dissections separated by several years. A literature review revealed that styloidectomy is well tolerated in patients with carotid dissection due to Eagle syndrome. Patients with carotid dissection due to Eagle syndrome remain at risk for contralateral dissection, and prophylactic contralateral styloidectomy should be considered.

Internal carotid artery dissection associated with acute dengue virus infection: a case report / Dissecção da artéria carótida interna associada à infecção aguda pelo vírus da dengue: relato de caso

Cervical artery dissections (CAD) can occur spontaneously or as a direct result of significant trauma. Viral infections, such as SARS-CoV2, influenza, and Epstein Barr, are risk factors for spontaneous CAD. Dengue virus infections have dramatically increased in recent decades, and Brazil is one of the endemic areas. The dengue virus can cause headache and neurological complications such as encephalitis, myelitis, Guillain-Barré syndrome, and myositis. No report has yet been found in the literature of dissection of the internal carotid artery secondary to dengue infection. Our objective is to report the case of a patient with dissection of the internal carotid artery associated with acute dengue virus infection.

As dissecções da artéria cervical (DAC) podem ocorrer espontaneamente ou como resultado direto de trauma significativo. Infecções virais, como SARS-CoV2, influenza e Epstein Barr, são fatores de risco para DAC espontânea. As infecções pelo vírus da dengue aumentaram dramaticamente nas últimas décadas, e o Brasil é uma das áreas endêmicas. O vírus da dengue pode causar dor de cabeça e complicações neurológicas como encefalite, mielite, síndrome de Guillain-Barré e miosite. Ainda não foi encontrado na literatura nenhum relato de dissecção da artéria carótida interna secundária à infecção por dengue. Nosso objetivo é relatar o caso de um paciente com dissecção da artéria carótida interna associada à infecção aguda pelo vírus da dengue.

Eagle syndrome: An updated review.

Background: This work aims to review the current literature and our experience on vascular Eagle syndrome (ES) that can present misleading clinical presentations and better understand the possible therapeutic strategies. Methods: We reviewed the existing literature on PubMed from January 1, 2017, to December 31, 2022, including the sequential keywords "vascular AND Eagle syndrome," "vascular AND styloid syndrome," "vascular AND elongated styloid process," "vascular AND stylocarotid syndrome," and "Eagle syndrome AND carotid artery dissection." Results: 38 vascular ES cases, including our experience, were analyzed. The most frequent clinical onset was hemiparesis (n 21, 57%), but other regular clinical presentations were aphasia, loss of consciousness, amaurosis, headache, or a combination of the latter. Massive oral bleeding was reported only once in the literature before our case. Twelve patients were treated with only antiplatelet therapy, either single or double. Nine patients were treated with anticoagulation therapy only. In 14 patients, a carotid artery stent was used, associated with anticoagulation or antiplatelet therapy. In 17 cases, a styloid process (SP) resection was performed. Conclusion: ES has many clinical presentations, and carotid artery dissection resulting in oral bleeding seems rare. Literature results and our experience make us believe that when dealing with vascular ES, the best treatment strategy is endovascular internal carotid artery stenting with antiplatelet therapy, followed by surgical removal of the elongated SP to prevent stent fracture.

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.

COVID-19 Does Not Increase the Risk of Spontaneous Cervical Artery Dissection.

Background Case reports have raised the possibility of an association between coronavirus disease 2019 (COVID-19) and spontaneous cervical artery dissection (sCeAD), yet no large studies have examined this association. We hypothesized that adults with confirmed COVID-19 would have an increased risk of sCeAD over the subsequent six months compared to test-negative controls after adjusting for confounding variables. Methods We obtained data from a United States medical records network (TriNetX, Inc., Cambridge, MA) of >106 million patients, providing adequate power needed for this rare outcome. We identified two cohorts of adults meeting the criteria of (1) test-confirmed COVID-19 or (2) non-COVID-19 test-negative controls, from April 1, 2020, to December 31, 2022. Patients with previous COVID-19 or conditions predisposing to sCeAD were excluded. Propensity matching was used to control for variables associated with sCeAD and markers of healthcare utilization. Results The number of patients reduced from before matching (COVID-19: 491,592; non-COVID-19: 1,472,895) to after matching, resulting in 491,115 patients per cohort. After matching, there were 22 cases of sCeAD in the COVID-19 cohort (0.0045%) and 20 cases in the non-COVID-19 cohort (0.0041%), yielding a risk ratio of 1.10 (95% CI: 0.60-2.02; P = 0.7576). Both cohorts had a median of five healthcare visits during follow-up. Conclusions Our results suggest that COVID-19 is not a risk factor for sCeAD. This null finding alleviates the concern raised by initial case reports and may better direct future research efforts on this topic.

A typically progressive dissection of the internal carotid artery with recurrent hiccups: A case report with continuous 2-year data recording.

Patients with internal carotid artery dissection (ICAD) usually report headache, neck pain, Horner's syndrome, and ischemic stroke. Because the posterior cranial nerve is involved, some patients may show different forms of posterior cranial nerve paralysis. There have been no reports of patients with ICAD showing repeated hiccups. Here, to help clinicians identify ICAD early and gain a better understanding of the atypical manifestations of the disease, we report an atypical case of recurrent hiccup symptoms caused by ICAD.

Pregnancy and spontaneous cervical artery dissection: A propensity-matched retrospective cohort study.

OBJECTIVES: We hypothesized that pregnant women would have an increased risk of spontaneous cervical artery dissection (sCeAD) affecting the carotid or vertebral arteries over one-year follow-up after the first trimester ultrasound compared to matched non-pregnant controls. MATERIALS AND METHODS: We queried a United States research network (TriNetX, Inc.) of de-identified medical records of >111 million patients, with data spanning 2008-2023. We included women aged ≥18 and excluded those with trauma and conditions potentially causative of sCeAD. Women were divided into cohorts based on a1 first trimester ultrasound and subsequent labor, delivery, or full-term pregnancy, or2 gynecological examination and no pregnancy. We used propensity matching to control for variables associated with sCeAD and calculated the risk ratio (RR) of sCeAD occurring over one-year follow-up from the index date of ultrasound or gynecological exam. RESULTS: After matching, the incidence rate of sCeAD in the pregnancy cohort was 8.0 (95% CI: 8.0-8.1) per 100,000 person-years, compared to 3.9 (95% CI: 3.9-3.9) per 100,000 person-years in the non-pregnancy cohort, yielding an RR (95% CI) of 2.06 (1.17-3.61; P= .0104). A cumulative incidence graph suggested that most cases of sCeAD in the pregnancy cohort occurred during pregnancy rather than the postpartum period. CONCLUSIONS: Our findings demonstrate that women have a twofold increased risk of sCeAD during pregnancy and the postpartum period compared to non-pregnant women. Further research is needed to determine whether maternal comorbidities such as preeclampsia account for these findings, and clarify when sCeAD occurs in relation to pregnancy or the postpartum period.

Initial clinical experience with Xpert-Pro peripheral self-expanding stent system for internal carotid artery dissection: Two case reports.

Background: The standard treatment for internal carotid artery (ICA) dissection is obscure. Current therapeutic strategies include the use of antiplatelet drugs, anticoagulant drugs, intravenous thrombolysis, and endovascular treatment. Endovascular treatment is important in acute internal carotid artery dissection. This study reports two acute internal carotid artery dissection cases that were treated successfully using the Xpert-Pro peripheral self-expanding stent system. Case summary: The first case was of a 38-year-old male patient with transient speechlessness and paralysis of the right limb in July 2021. Cervical computed tomographic angiography (CTA) showed ICA occlusion on the left side. Digital subtraction angiography (DSA) showed severe stenosis of the C1 segment of the left internal carotid artery with intermural hematoma. The patient subsequently underwent Xpert-Pro peripheral self-expanding stent implantation, and his condition stabilized. The second case was of a 56-year-old male patient with speechlessness and paralysis of the right limb. Cervical CTA showed a dissected left ICA, and DSA showed an occluded left ICA and middle cerebral artery. The patient subsequently underwent stent implantation, and his condition stabilized.

Review article: Non-penetrating neck artery dissection in young adults: Not to be missed!

Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front-line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi-disciplinary team management of this condition. In general, guideline-based recommendation for the management of neck artery dissection involving an intimal flap is by anti-platelet therapy while treatment of neck artery dissection that results in a pseudo-aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.

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.

Electric scooter-related triple cervical artery dissection.

A 34-year-old female presented to the emergency department with neck pain, dysphonia and dysphagia ten days after a fall from an electric scooter. Subsequent computed tomography of the neck revealed bilateral vertebral artery and unilateral internal carotid artery non-occlusive dissections, which were managed with antiplatelet therapy. This case describes mechanisms of injury, clinical presentation, imaging appearances, and subsequent management of cervical artery dissection.