Placement of Endovascular Stent for Reperfusion of Cerebral Infarct After Pediatric Traumatic Internal Carotid Artery Dissection.

Background: Traumatic intracranial ICA dissections are not commonly seen in children. Dissection resulting in perfusion deficit warrants intervention. Here we encountered a patient who experienced traumatic ICA dissection, treated by endovascular stenting. Methods: A 10-year-old female presented with aphasia and right sided weakness following trauma. Imaging showed deficit in the left MCA territory without core. Further imaging showed dissection of the left supraclinoid ICA, confirmed by digital subtraction angiography. Results: A Neuroform Atlas stent was placed without complication. All dysarthria and weakness had resolved on follow-up 5 months post-stenting. Conclusions: Acute stroke symptoms in children can result in lasting deficits if not treated quickly. Medical management is regarded to be first line, depending on presentation. Endovascular stenting may provide a promising means to treat pediatric ICA dissections involving perfusion deficits and mitigate permanent ischemic changes.

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.

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.

Assessment of association between the carotid web and dissection in spontaneous internal carotid artery dissection patients using vessel wall MRI.

BACKGROUND: Internal carotid artery dissection (ICAD) is the major cause of ischemic stroke in young to middle-aged people. Recognition of predisposing factors may facilitate in early individual risk prediction and expand treatment. PURPOSE: To evaluate the association between a carotid web and dissection in patients with ICAD using vessel wall magnetic resonance imaging (VW-MRI). MATERIAL AND METHODS: A retrospective study was conducted of 223 patients who underwent VW-MRI. Of these patients, 58 patients with craniocervical artery dissection (CCAD) (33 ICAD and 25 vertebrobasilar artery dissection [VBAD]) were included. The control group (n = 165) consisted of patients without arterial dissection who had undergone VW-MRI . The presence of a carotid web in the posterior aspect of carotid bulb was recorded. The distance between the carotid web and start of dissection in ICA was recorded. RESULTS: The presence of a carotid web showed a significant difference between the ICAD, VBAD, and control groups (19 [57.6%] vs. 5 [20%] vs. 36 [21.8%], respectively; P < 0.001). In multi-nominal analysis, the presence of a carotid web showed a significant difference between the ICAD and VBAD groups and the ICAD and control groups (P < 0.05), with odds ratios of 5.41 (95% confidence interval [CI]=1.634-17.973) and 4.81 (95% CI=2.176-10.651), respectively. Out of 19 ICAD patients with carotid web, 16 had occurrence of dissection in the C1 segment of the ICA with a mean distance of 1.91 ± 1.71 cm from the carotid web. CONCLUSION: Presence of a carotid web was more frequent in patients with ICAD. The carotid web may be one of the predisposing factors for development of dissection in patients with ICAD.

Vertebral Artery Tortuosity and Morphometric Characteristics of Patients with Recurrent Cervical Artery Dissection.

BACKGROUND: Cervical Artery Dissection is an important cause of stroke in the young. Data on incidence and associations of recurrence in patients with cervical artery dissection are lacking. Increased Vertebral Artery Tortuosity Index has been reported in patients with cervical artery dissection and associated with earlier age of arterial dissection in patients with connective tissue disease. OBJECTIVE: To test the hypothesis that increased vertebral artery tortuosity is associated with recurrent cervical artery dissection. METHODS: We reviewed data from a single-center registry of cervical artery dissection patients enrolled between 2011-2021. CT angiography was reviewed for neck length, vertebral artery dominance, and vertebral artery tortuosity index. Incidence rate of recurrent dissection was calculated using Poisson regression. Differences between groups were analyzed using the Kruskal-Wallis rank sum test and Fisher's exact test. RESULTS: The cohort included 155 patients: women (56%), mean (SD) age 42 (±10) years, and 116 single and 39 multiple artery dissections. Eleven (7.1%) had a recurrence with an incidence rate (95% CI) of 1.91 (1.06, 3.44) per 100 person-years. Vertebral artery tortuosity did not differ significantly between single and recurrent groups (median (IQR) 46.81 (40.85, 53.91) vs 44.97 (40.68, 50.62) p = 0.388). Morphometric characteristics of height, neck length, and BMI were not associated with recurrence. There was no difference in vertebral artery tortuosity by dissection location (carotid vs vertebral). CONCLUSION: In this single center cohort of patients with cervical artery dissection, there was no difference in VTI between single and recurrent groups.

An Unusual Cause of Internal Carotid Artery Dissection: Mobile Phone Misuse.

The use of mobile phones has become an indispensable part of our lives, especially due to widespread use of the internet. We report the case of a 38-year-old male patient who developed internal carotid artery dissection after talking on the phone between her left shoulder and ear by laterally flexing the neck for 20 minutes. In addition to many positive effects of technology that facilitate the daily life, the development of neurological deficits may be observed with widespread use of mobile phones. Misuse of mobile phone should be considered in patients with carotid artery dissection.

Traumatic Internal Carotid Artery Injuries: Do We Need a Screening Strategy? Literature Review, Case Report, and Forensic Evaluation.

Internal carotid artery dissection (ICAD) represents the cause of ictus cerebri in about 20% of all cases of cerebral infarction among the young adult population. ICAD could involve the extracranial and intracranial internal carotid artery (ICA). It could be spontaneous (SICAD) or traumatic (TICAD). It has been estimated that carotid injuries could complicate the 0,32% of cases of general blunt trauma and the percentage seems to be higher in cases of severe multiple traumas. TICAD is diagnosed when neurological symptoms have already occurred, and it could have devastating consequences, from permanent neurological impairment to death. Thus, even if it is a rare condition, a prompt diagnosis is essential. There are no specific guidelines regarding TICAD screening. Nevertheless, TICAD should be taken into consideration when a young adult or middle-aged patient presents after severe blunt trauma. Understanding which kind of traumatic event is most associated with TICAD could help clinicians to direct their diagnostic process. Herein, a review of the literature concerning TICAD has been carried out to highlight its correlation with specific traumatic events. TICAD is mostly correlated to motor vehicle accidents (94/227), specifically to car accidents (39/94), and to direct or indirect head and cervical trauma (76/227). As well, a case report is presented to discuss TICAD forensic implications.

Spinal manipulative therapy and cervical artery dissection: A retrospective comparison with spontaneous, traumatic, and iatrogenic etiologies at a single academic medical center.

OBJECTIVE: Cervical artery dissection (CAD) has been associated with spinal manipulative therapy (SMT). Although uncommonly reported, SMT-associated CADs hold devastating neurological consequences, warranting further exploration. We endeavored to investigate this association through the comparison of all CAD etiologies at a single academic medical center. METHODS: A retrospective chart review was conducted of patients diagnosed with CAD or transferred to our institution for primary management of CAD during the 10-year period from 2010 to 2020 (n = 578). Patients were divided into SMT-associated (within 1 month of presentation), spontaneous, traumatic, and iatrogenic cohorts. RESULTS: SMT-associated dissections represented 23/578 (4%) of all dissections and 5.9% of vertebral artery dissections specifically. These patients were generally younger than those in the spontaneous (p = .004) and iatrogenic groups (p < .001), and more often non-smokers or former smokers compared to the spontaneous (p = .009), traumatic (p = .001), and iatrogenic (p = .008) groups. Additionally, the SMT group had a higher mean low-density lipoprotein (LDL) than the spontaneous (p = .009) and traumatic (p = .003) types. SMT-associated CADs were more often vertebral and bilateral, compared to the spontaneous (p = .003; p < .001), traumatic (p = .047; p = .004), and iatrogenic (p = .002; p = .002) groups. Outcomes including infarct (p = .112), medical treatment (p = .523), intervention (p = .47), and length of stay (p = .512) were similar between the SMT and spontaneous groups. CONCLUSIONS: In this unique study comparing SMT-associated CADs with other dissection etiologies, SMT-associated CADs were uncommon and not associated with worse clinical outcomes. However, SMT-associated CADs were more likely to be bilateral and affected the vertebral arteries in young, non-smoking patients with high LDL.

Traumatic Dissection of Arterial Cervical Vessels: Report of Two Cases and Literature Review

Even though traumatic dissection of cervical arterial vessels is themajor cause of stroke among adults, it is still an underdiagnosed disease in neurosurgical emergencies, since most patients do not have or present subtle clinical signs in the acute phase. The authors report two interesting cases of cervical artery dissection with different traumatic mechanisms and present a broad literature review about this subject.

A near-fatal consequence of chiropractor massage: massive stroke from carotid arterial dissection and bilateral vertebral arterial oedema.

A 35-year-old Chinese man with no risk factors for stroke presented with a 2-day history of expressive dysphasia and a 1-day history of right-sided weakness. The presentation was preceded by multiple sessions of neck, shoulder girdle and upper back massage for pain relief in the prior 2 weeks. CT of the brain demonstrated an acute left middle cerebral artery infarct and left internal carotid artery dissection. MRI cerebral angiogram confirmed left carotid arterial dissection and intimal oedema of bilateral vertebral arteries. In the absence of other vascular comorbidities and risk factors, massage-induced internal carotid arterial dissection will most likely precipitate the near-fatal cerebrovascular event. The differential diagnosis of stroke in a younger population was consequently reviewed and discussed.

Spontaneous Cervical Artery Dissection in Vascular Ehlers-Danlos Syndrome: A Cohort Study.

BACKGROUND AND PURPOSE: Vascular Ehlers-Danlos syndrome is a rare inherited connective tissue disorder because of pathogenic variants in the COL3A1 gene. Arterial complications can affect all anatomic areas and about 25% involve supra-aortic trunks (SATs) but no systematic assessment of cervical artery lesions has been made. The primary objective was to determine an accurate prevalence of spontaneous SAT lesions in a large series of patients with vascular Ehlers-Danlos syndrome at diagnosis and during follow-up. Secondary objectives were to study their neurological consequences (transient ischemic attack or stroke) and the possible relationships with sex, genotype, ascertainment status. METHODS: A retrospective review of a monocentric cohort of patients with molecularly proven vascular Ehlers-Danlos syndrome followed in a tertiary referral center from 2000 to 2017. RESULTS: One hundred forty-four patients were analyzed, 56.9% (n=82) had SAT lesions: 64.6% females, 74.4% index-case patients. Most lesions were identified in early arterial assessment (48% at first work-up, mean age of 35.7±13.0 years). Cumulative incidence of a first identification of a SAT lesion was 41.7% at 40 years old. On the complete period of survey, 183 SAT lesions (with 132 dissections and 33 aneurysms) were identified, mainly in internal carotid arteries (56.3%) and vertebral arteries (28.9%), more rarely in patients with COL3A1 null mutations (P=0.008). Transient ischemic attack or stroke were reported in n=16 (19.5%) of the 82 patients with SAT lesions without relation with age, sex, treatment, or hypertension. CONCLUSIONS: Cervical artery lesions are frequent and mostly asymptomatic in patients with vascular Ehlers-Danlos syndrome. Local dissections and aneurysms are the most frequent type of lesions, but transient ischemic attack or stroke seem rare.

Unusual Presentation of Bilateral Carotid Artery Dissection: The Importance of Reasoning Outside the Box.

A bilateral internal carotid artery dissection presenting with atypical symptoms of cerebral hypoperfusion has been rarely reported, especially in the absence of obvious precipitating factors. A middle-aged woman presented to the emergency department with a 2-day-history of progressive left arm numbness and weakness, confusion, disorientation and clumsiness worsened by upright position. A cerebral hypoperfusion condition was hypothesized and confirmed by a CT angiography, which showed bilateral internal carotid dissection with uncertain etiology. Screening for predisposing conditions to spontaneous carotid arteries dissection was basically negative. Regarding potential precipitating factors, the patient had used an electric olive harvester days before symptoms onset, without any painful sensation or sudden sequelae. Portable harvesters in olive growing transmit vibrations to the hand-arm system but it remains to be elucidated if hand-arm vibrations can be implicated in vessels wall injury and dissection. Bilateral carotid artery dissection is an infrequent and life-threatening condition which can rarely present with non-specific symptoms of cerebral hypoperfusion. The absence of typical symptoms and known precipitating factors can made the diagnosis quite hard to achieve.

Can Styloid Process and Internal Carotid Artery Anatomy be Used to Predict Carotid Artery Dissection?

BACKGROUND: Carotid artery dissection is a common cause of stroke in the young. It has been related to the association of the carotid artery with fixed neighboring anatomical structures. This study assesses the association between styloid process length, internal carotid artery position and cervical carotid artery dissection (CCAD). This information would provide potential predicative radiological measurements, which could prevent delays in CCAD diagnosis. METHODS: Retrospective data was collected from 2 central London hospitals over 5 years. CCAD cases were identified from individuals who underwent computer topography angiography of the neck for suspected CCAD. The following data was collected: evidence of CCAD; bilateral styloid process length and presence of styloid-hyoid ligament calcification; bilateral styloid process-internal carotid distance; calcification of carotid arteries and whether their position was aberrant. Cases were dissection-side, age and gender matched with two non-dissection controls. RESULTS: Three hundred and fifty-five individuals were identified. Fifty individuals had CCAD, of which 4 had bilateral dissection. In individuals with CCAD, average styloid process length was 27.5 mm and styloid process-internal carotid distance was 5.14 mm. There was no significant association between styloid process length or styloid process-internal carotid distance, and CCAD when compared with matched controls. Internal carotid artery aberrancy was significant for nondissection. CONCLUSIONS: In this study, there was no association between styloid process length and styloid process-internal carotid distance with CCAD. These measurements can not be used to predict the possibility of a CCAD following trauma.

Increased Internal Carotid Artery Tortuosity is a Risk Factor for Spontaneous Cervicocerebral Artery Dissection.

OBJECTIVE: Spontaneous cervicocerebral artery dissection (sCCD) is an important cause of ischaemic stroke that often occurs in young and middle aged patients. The purpose of this study was to investigate the correlation between tortuosity of the carotid artery and sCCD. METHODS: Patients with confirmed sCCD who underwent computed tomography angiography (CTA) were reviewed retrospectively. Age and sex matched patients having CTA were used as controls. The tortuosity indices of the cervical arteries were measured from the CTA images. The carotid siphon and the extracranial internal carotid artery (ICA) were evaluated according to morphological classification. The carotid siphons were classified into five types. The extracranial ICA was categorised as simple tortuosity, coiling or kinking. Independent risk factors for sCCD were investigated using multivariable analysis. RESULTS: The study included sixty-six patients with sCCD and 66 controls. There were no differences in vascular risk factors between the two groups. The internal carotid tortuosity index (ICTI) (25.24 ± 12.37 vs. 15.90 ± 8.55, respectively; p < .001) and vertebral tortuosity index (VTI) (median 11.28; interquartile range [IQR] 6.88, 18.80 vs. median 8.38; IQR 6.02, 12.20, respectively; p = .008) were higher in the patients with sCCD than in the controls. Type III and Type IV carotid siphons were more common in the patients with sCCD (p = .001 and p < .001, respectively). The prevalence of any vessel tortuosity, coiling and kinking of the extracranial ICA was higher in the patients with sCCD (p < .001, p = .018 and p = .006, respectively). ICTI (odds ratio [OR] 2.964; p = .026), VTI (OR 5.141; p = .009), and Type III carotid siphons (OR 4.654; p = .003) were independently associated with the risk of sCCD. CONCLUSION: Arterial tortuosity is associated with sCCD, and greater tortuosity of the cervical artery may indicate an increased risk of arterial dissection.

Spontaneous extracranial arterial dissections in a case of patient with osteogenesis imperfecta.

Background: Osteogenesis imperfecta (OI), also known as brittle bone disease, is an inherited disease characterized by increased bone brittleness and decreased bone mass. OI patients may also be associated with exoskeleton manifestations such as hearing loss, articular ligament laxity, and heart valve lesions. Reports of internal carotid and cerebral artery dissection related to OI patients are very rare. We present the first case of acute cerebral infarction caused by the progressive stripping of the carotid artery dissection Chinese patient with Osteogenesis imperfecta.Case: A 48-year-old Chinese male who had no prior medical history or bad habits was to admitted the hospital due to leftside temporal headache, paroxysmal right limb weakness, and prolonged blurred vision experienced for a week. After a series of tests were performed to exclude superficial temporal arteritis, the patient was diagnosed with transient ischemic attack and was given aspirin, clopidogrel and atorvastatin without further headache and blurred vision. However, he was again admitted to the emergency department the following day due to right limb weakness for 7 h that was considered acute cerebral infarction caused by left carotid artery dissection.Conclusion: The findings in this case support that internal carotid and cerebral artery dissection may be one of the complications of Osteogenesis imperfecta.

Thyrotoxicosis and bilateral internal carotid artery dissections.

Cervical artery dissection is a rare but important diagnosis to consider in young patients presenting with stroke. Multiple etiologies of cervical artery dissections have been previously reported, but the association with thyrotoxicosis is extremely rare. A previously healthy 43-year-old female presented to the emergency department with new symptoms related to thyrotoxicosis and bilateral internal carotid artery dissections. Her atrial fibrillation and hypertension resolved by treating the underlying hyperthyroidism with methimazole and propranolol. The bilateral internal carotid artery dissections were managed conservatively with acetylsalicylic acid. Despite an initially poor prognosis, the patient made a complete recovery with resolution of her neurological symptoms.