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BackgroundThe Advanced Thrombectomy System (ANCD) provides a new funnel component designed to reduce clot fragmentation and facilitate retrieval in patients with stroke by locally restricting flow, allowing distal aspiration in combination with a stent retriever (SR).ObjectiveTo evaluate the preclinical efficacy and safety of the ANCD in a swine clot model.MethodsSoft and firm clots were implanted in the lingual and cervical arteries of 11 swine to obtain Thrombolysis in Cerebral Infarction (TICI) 0 blood flow. Mechanical thrombectomy was performed with either a balloon guide catheter+Solitaire 2 stent retriever (BGC+SR, n=13) or ANCD+SR (n=13). TICI flow was evaluated and successful revascularization was defined as TICI 3 (normal perfusion). To characterize safety, a total of 3 passes were performed in each vessel independent of recanalization. Tissues were explanted for histopathological analysis after 3 and 30 days, respectively.ResultsFirst pass reperfusion rates were ANCD+SR: 69% and BGC+SR: 46%. Reperfusion increased after the third pass in both groups (ANCD+SR: 100%, vs BGC+SR: 77%). Recanalization was achieved after an average of 1.4 and 1.9 passes in ANCD+SR and BGC+SR (p=0.095), respectively. Vessel injury was comparable in both groups; endothelial loss at 3 days was the most common injury seen (ANCD+SR: 1.78±1.22; BGC+SR: 2.03±1.20; p=0.73), while other histopathological markers were absent or minimal. Tissues downstream from targeted vessels also showed absence or minimal lesions across both groups.ConclusionsResults in a swine clot model support the high efficacy of the ANCD+SR without causing clinically significant vessel injury potentially related to the new funnel component.

A 16-year-old Korean boy presented with acute onset vertigo, dysphagia and gait ataxia of 16 hours duration. He had history of headache and neck pain along with transient vertigo during a water slide ride 12 days before presentation. CT brain showed left cerebellar and left lateral medullary infarcts. CT angiography showed left vertebral dissection with occlusion of left posterior inferior cerebellar artery. A 52-year-old Indian man, presented with acute onset global aphasia and right hemiparesis within 3 hours of onset of symptoms. He received intravenous tissue plasminogen activator (tPA) with partial improvement in his symptoms. He had headache and neck pain since 2 weeks, ever since he had a water slide ride. CT brain was normal, while the CT angiogram showed left carotid dissection. Cervical artery dissection has been reported with roller coaster rides and rarely with delayed presentations. Delayed presentation of cervical artery dissection after water rides have not been reported.

Background: Headache or neck pain is a frequent symptom of spontaneous cervical artery dissection (sCAD). Patients and methods: Patients were drawn from an ongoing hospital-based registry of consecutive cases diagnosed with sCAD. Only patients with isolated pain were included in this series. Pain topography, dynamics, severity and quality, imaging findings and outcome were analysed. Results: 20 of 245 (8%) patients with sCAD presented with pain as the only symptom (mean (SD) age 39 (8) years; 14 (70%) women). Of them, 12 had vertebral artery dissection, 3 had internal carotid dissection and 5 had multiple dissections. The median delay from symptom onset to diagnosis was 7 days (range 4 h to 29 days). 6 patients presented with headache, 2 with neck pain and 12 with both. Onset of headache was progressive in 6, acute in 8 and thunderclap-type in 4 patients; neck pain was progressive in 7 and acute in 7. Headache was throbbing in 13 and constrictive in 5 patients; neck pain was throbbing in 4 and constrictive in 10. Pain was unilateral in 11 and bilateral in 9. Pain was different from earlier episodes in all but one case. All patients were pain free at 3 months. Conclusion: Pain may be the only symptom in sCAD, even when multiple arteries are dissected. Pain topography, dynamics, quality and intensity were heterogeneous. Data from this study lend support to recommendations favouring imaging studies of the cervical arteries in patients with new-onset unexplained headache or neck pain.

A history of migraine, particularly without aura, should be considered as a marker for increased risk of ischaemic stroke caused by cervical artery dissection, researchers have said in JAMA Neurology . The multicentre Italian Project on Stroke in Young Adults study, one of the largest registries of patients with early onset ischaemic stroke, found that migraine was consistently associated with cervical artery dissection.1 …

Cervical artery dissection (CAD) is being increasingly diagnosed due to improved neuroimaging methods. The mean age of patients with CAD is about 40 years, with a peak between 40 and 45 years of age. Proven data on the incidence of CAD in older patients are missing. Therefore, whether CAD should also be considered as a probable cause of cerebral ischemic events in the elderly was investigated. All consecutive patients referred to our clinic with a diagnosis of cerebral ischemia from January 1999 until June 2000 were thoroughly assessed for the presence of CAD. In addition, the records of all stroke patients treated in our department from January 1995 to December 1998 were analysed retrospectively for a diagnosis of CAD. A total of 34 patients (11 women) had suffered from internal carotid (n = 29) or vertebral artery (n = 5) dissection. Their mean (SD) age was 50.3 (14.6) years, with 32.4% being older than 60 years. Clinical presentation of CAD did not differ depending on the patients' age. The results show that CAD is a possible cause of cerebral ischemia in the elderly and thus has also to be considered in the diagnostic investigation in this patient group.

OBJECTIVES--To study the prevalence of degenerative changes in the arteries supplying the cervicobrachial region, and their relation to cervical disc degeneration. METHODS--Fifty postmortem aortic arch angiographies were evaluated for occlusions and variations in the diameter of the vertebral arteries and thyro- and costocervical trunks, as well as for tortuosity, average diameter and the highest cervical level to which the ascending cervical artery, an upward continuation of the thyrocervical trunk, and the deep cervical artery, an upward continuation of the costocervical trunk, ascended. RESULTS--Localised segmental narrowings, usually situated close to the ostia of the arteries, were common, whereas total occlusions were rare. Thirty (60%) of the subjects showed a segmental narrowing at least in one of the six arteries analysed, while only two (4%) showed an occluded artery, which in both the cases was the thyrocervical trunk. Narrowings were most common in vertebral arteries, followed by costocervical and thyrocervical trunks. Segmental narrowings, as well as general tortuosity of the arteries, increased with age. It was also found that ascending and deep cervical arteries did not run as high up in the posterior neck muscles in older people as in younger ones. Twenty three subjects with marked cervical disc degeneration showed on average 2.3 arteries with segmental narrowings, while the corresponding figure for twenty seven subjects without disc degeneration was 0.6. Both the segmental narrowings and the disc degeneration, however, were strongly associated with age, and thus the causality between the former two remained unclear. CONCLUSION--The study showed that degenerative changes are common in the arteries supplying the cervicobrachial area, indicating that impaired blood flow might play a part in some cervicobrachial disorders.

Introduction Neurofibromatosis type-1(NF-1) is a rare autosomal dominant disease that affects one out of 3000 individuals. Patients of NF-1 are characterized by neuroectodermal tumors in the peripheral nervous system and cafe-au-lait spots. It can affect any organ system including vascular tissues. It was reported that 3.6% of patiens with NF-1 have associated vasculopathy which includes stenosis, aneurysms, and arteriovenous malformations. Spontaneous rupture of aneurysms is rare but when it happens, it can cause neurological deficit and life-threatening events such as neck hematoma compressing trachea and hemothorax. In general, patient’s tissue of neurofibromatosis-1 is very fragile and we have to consider this condition when we make treatment strategies for the patients. The pathogenesis and natural history of vascular lesions of NF-1 remains unknown. Materials and methods We reviewed literatures of NF-1 patients who presented cervical artery pseudoaneurysm, specifically carotid, vertebral, or subclavian artery pseudoaneurysm and investigated the initial symptom, rupture or not, treatment and clinical outcome. Results Total 52 cases, 59 pseudoaneurysms were reported in the English and Japanese literatures between 1967 and 2014. The mean age at the time of diagnosis was 43.84years old (range, 1–74 years). Twenty two cases were men and 30 cases were women. Seven cases had peudoaneurysms in multiple arteries. Fourteen lesions were at the extracranial internal carotid artery, one lesion of common carotid artery, 6 lesions of external carotid artery, 24 lesions of extracranial vertebral artery and 14 lesions of subclavian artery. Fifteen lesions were incidental and in the remaining 44 lesions, the symptom were ruptured psedoaneurysm (26 lesions), expanding mass (6 lesions), and neurological symptom (12 lesions). The treatments were surgery in 21 lesions, endovasclular treatment in 24 lesions, and the remaining 14 lesions received conservative treatment or were untreated. Most cases got recovery from the initial symptoms. Mortality was mostly associated with untreated cases and massive hemorrhage at the initial rupture of the aneurysm. Conclusion Surgical repair and vessel reconstruction are limited by fragile nature of the artery in patients with NF-1. An endovascular approach, such as stenting and coil embolization is preferable in NF-1 associated pseudoaneurysms. Disclosures M. Takano: None. O. Hamasaki: None. H. Chikuie: None.

Periodontal infections might represent one of the causative factors for cervical artery dissection. We present a case of a 49-year-old woman admitted due to headache. The patient had been suffering from a right second inferior molar infection with a cervical phlegmon for 1 week prior to admission. On 2 October 2014, the patient went to the dentist and a molar extraction was performed in the morning. In the afternoon, the patient began to experience right hemifacial pain that progressed towards an intense and bilateral headache. Neurological status at the time of admission revealed right miosis, ptosis and conjuntival hyperaemia. A CT angiography showed a right internal carotid artery dissection provoking a high-degree stenosis. The relationship between periodontal infection and vascular disease has been previously presented. Microbial agents may directly, and inflammatory and immunological host response indirectly, influence inflammatory changes in cervical arteries favouring dissections with minor traumas.

Cervical artery dissection (CAD) is one of the most frequent causes (14.5%) of stroke in young adults. Cases with involvement of more than two arteries are rare. Arnold et al described 11 cases (1.5%) with triple CAD of a reported 740 patients and just a single (0.1%) quadruple case in the same population. Simultaneous dissection of the four principal vessels is extremely rare. According to Papagiannaki et al, the incidence of simultaneous three or four CADs is 1–3/million in the general population. To the best of our knowledge, there are only three published cases of spontaneous quadruple CAD.

Background and purpose Effectiveness of currently used mechanical thrombectomy devices has been evaluated using animal models mainly based upon the angiographical data analysis. However very little has been described about the histologic changes observed in the arteries treated with mechanical thrombectomy devices. The purpose of this study is to evaluate acute arterial histologic changes induced by mechanical thrombectomy using a dedicated swine stroke model. Materials and Methods A total of eight Superficial Cervical Arteries in four swine were occluded with experimental thrombus and treated using the Merci Clot Retrieval System®. Each treated artery was harvested immediately after the procedure and histologic analysis of each arterial sample was performed. Four untreated Superficial Cervical Arteries were used as controls. Results A total of 24 attempts at clot retrieval were made. The average number of retrieval attempts per artery was three. Circumferential intimal denudation and separation of smooth muscle layers in the tunica media were seen in all samples. The intimal denudation was seen regardless of the number of retrieval attempts. A minor sub-intimal dissection was seen in one artery. Arterial perforation with sub-adventitial hematoma was seen in two arteries and these findings were associated with microwire/microcatheter navigation rather than the use of the clot retrieval device. Conclusion Minor histologic changes including intimal denudation and separation of smooth muscle layers in tunica media were seen in every artery treated by mechanical thrombectomy. Two arteries that showed major histologic change (sub-adventitial hematoma) were both associated with microwire/catheter navigation rather than the use of the clot retrieval device. It is possible that major arterial injury (eg vessel perforation) during the mechanical thrombectomy is more likely to be associated with microcatheter/microwire navigation rather than clot retrieval itself. This animal model may be useful in the preclinical safety evaluation of the mechanical thrombectomy devices. Competing interests I Yuki: None. I Kan: None. A Golshan: None. H Vinters: None. R Kim: None. N Yin: None. G Duckwiler: Concentric Medical. F Vinuela: None. Y Murayama: None. F Vinuela: None.

Background C-arm cone beam CT (CBCT) with selective intra-arterial contrast injection combined with digital subtraction angiography (DSA) is currently used for the evaluation and treatment planning of cerebral arteriovenous malformations (AVMs). In some instances an AVM will derive its blood supply from more than one main cervical artery (carotid and/or vertebral artery) and a single-vessel injection will not adequately demonstrate the entire AVM nidus. Methods Three patients with cerebral AVM in whom the entire nidus could not be visualized by injection of a single cervical artery are reported. CBCT dataset acquisition was performed by intra-arterial contrast injection in the ascending thoracic aorta through a 5 F pigtail catheter. The injection of diluted iodinated contrast agent (35%) lasted 22 s at a rate of 8 ml/s for a total volume of 176 ml (61.6 ml of contrast agent). The dataset was then processed using standard reconstruction methods. Results Contrast injection in the ascending aorta during a single CBCT acquisition provided a volumetric dataset adequate for subsequent radiosurgical treatment planning. Conclusion This is a safe and effective angiographic technique for the acquisition of volumetric datasets using CBCT that are suitable for treatment planning of intracranial AVMs deriving their blood supply from more than one major cervical artery. This technique allows imaging of the entire AVM nidus during a single CBCT acquisition.

Cervicocerebral artery dissection (CAD) is “a common rare disease,” with an annual incidence of 2.6 to 2.9 patients per 100 000 people. In adults younger than 50 years of age, ∼15% of all ischaemic strokes are caused by CAD, while cardioembolism, representing a wider spectrum of pathological conditions, explain ∼20% of cases. Arnold et al 1 report the results of two studies, contributing to our understanding of the characteristics of CAD (see page 171) . They …

Since the advent of advanced radiological modalities such as MRI and magnetic resonance angiography (MRA), dissections of cervical arteries are increasingly recognised as a common cause of stroke in young adults. Auer et al 1recently advocated MRA as the initial diagnostic tool for vertebral artery dissection. Conventional angiography might be avoided altogether in subjects with a suspicious history and MRA images suggestive of a dissection (double lumen or mural haematoma).1 The sensitivity of MRA for the diagnosis of vertebral artery dissection was only 20% in one study, but the specificity was excellent (100%).2 The sensitivity was considerably better in the hands of Auer et al ,1 but in this study the specificity (true negative rate in subjects free of disease) was not considered because all patients had vertebral artery dissection. The following case report illustrates that care must be taken to avoid false positive results when using MRA for the diagnosis of vertebral artery dissection. A 47 year old male pilot suddenly experienced clumsiness and slight loss of strength in the right arm and leg during a long distance flight, while he stooped forward. During the following hours, he developed a global headache without irradiation to the neck, but the other symptoms gradually diminished. Prior history was unremarkable, except for a 3 hour period of horizontal diplopia which suddenly developed 3 months earlier. He had never smoked. Family history was negative for cardiovascular disorders. The patient later confessed that he had recently picked up the habit of gargling his throat with toothpaste twice a day, always with his …

Regional cerebral blood flow (CBF) was measured by an autoradiographic method in nine adult cats, using antipyrine-14C as a diffusible indicator. In seven of the cats, CBF measurements were made during stimulation of a cervical sympathetic trunk. Stimulation caused minor regional decreases of CBF in at least five of these seven cats. The decreases were non-uniform and occurred almost exclusively in cortical structures. Although constriction of cervical arteries probably accounts for some of the effects of sympathetic stimulation, the present study indicates that there is also an effect on cerebral regulatory arterioles. However, there is no convincing evidence that function of the autonomic nervous system is necessary for the normal regulation of the cerebral circulation.

Objective: To determine whether spinal manipulative therapy (SMT) is an independent risk factor for cervical artery dissection. Methods: Using a nested case-control design, the authors reviewed all patients under age 60 with cervical arterial dissection (n = 151) and ischemic stroke or TIA from between 1995 and 2000 at two academic stroke centers. Controls (n = 306) were selected to match cases by sex and within age strata. Cases and controls were solicited by mail, and respondents were interviewed using a structured questionnaire. The medical records of interviewed patients were reviewed by two blinded neurologists to confirm that the patient had stroke or TIA and to determine whether there was evidence of arterial dissection. Results: After interview and blinded chart review, 51 patients with dissection (mean age 41 ± 10 years; 59% female) and 100 control patients (44 ± 9 years; 58% female) were studied. In univariate analysis, patients with dissection were more likely to have had SMT within 30 days (14% vs 3%, p = 0.032), to have had neck or head pain preceding stroke or TIA (76% vs 40%, p Conclusions: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.