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A 62 year-old man, who was taking prednisolone for nephrotic syndrome, was diagnosed with herpes zoster of the trigeminal nerve and treated with oral valacyclovir. One month later, he reported pain from the right side of the head and vomiting. MRI revealed an acute infarction in the right frontal lobe and dissection of the internal carotid artery of the right cervix. Trauma or other potential triggers were not observed. In consideration of the preceding condition of varicella zoster virus infection, acyclovir was administered in addition to unfractionated heparin, but an intramural hematoma emerged in the left internal carotid artery. Furthermore, evidence showing progression of these lesions was found. On the fifth day, prednisolone was increased to 1 mg/kg/day, and progression of vascular lesions was not observed. This case may prove valuable because it suggests a relationship between cervical artery dissection and herpes zoster.

Objectives: To assess the delayed (15 days) histological and ultrastructural changes occurring following endovascular treatment with a direct aspiration first pass technique (ADAPT) or stent retrievers (SRs) and to compare the findings in order to determine which is the least harmful technique and what changes occur. Materials and Methods: Damage to the wall of swine extracranial arteries was evaluated after ADAPT with the Penumbra system or thrombectomy with various SRs. The procedures were performed using two pigs as animal models; extracranial cervical arteries were selected based on their diameters in order to reproduce the procedures as in human intracranial arteries, and endovascular thrombectomies were done after the injection of autologous thrombi. Two weeks later, the animals were euthanized, and 60 arterial samples were obtained for analysis by optical and electron microscopy. Results: Optical and electron microscopy revealed that both techniques cause, in different way, alterations to the structure of the vessel wall. Conclusions: Both techniques caused damage to the vessel wall. The main damages were localized at the level of the tunica media and adventitia, instead of the tunica intima as in the acute phase. Further investigation is required to better understand whether these alterations could have chronic consequences.

Cervical artery dissection (CeAD), a common cause of ischemic stroke in young and middle-aged adults, accounts for ∼15% of all stroke in patients

Cervical arterial dissection, can occur spontaneously and is a rare but catastrophic adverse event associated with neck manipulation. Pathophysiology involves altered integrity of the arterial wall increasing its vulnerability to minor trauma. Those at risk are difficult to detect. Previous screening investigated blood flow but altered mechanical properties as stiffness of cervical arterial wall could provide a more valid indication of arterial integrity or even early dissection.To investigate suitability and intra-rater reliability of shear wave ultrasound elastography to measure mechanical properties of the cervical arterial wall. Suitability was assessed by ability to track arteries along their length and measurement accuracy.Observational and intra-rater reliability study.Internal carotid (ICA) and vertebral arteries (VA) of healthy participants were examined with shear wave elastography. Shear wave velocity (m/s) indicative of wall stiffness was measured with the head in the neutral position: proximally (C3-4) and distally (C1-2) where injuries have been more commonly reported. Proximal measures were repeated to assess intra-rater reliability.Thirty healthy participants (13 female), mean age of 29 (±12.8) years were imaged. Mean VA wall stiffness (3.4 m/s) was greater than ICA (2.3 m/s) (p 0.000). Intra-rater reliability for ICA was ICC 0.81 (CI 0.52 to 0.92) and for VA ICC 0.76 (CI 0.38 to 0.9). Standard error of measurement was 0.16 for ICA and 0.34 for VA.Shear wave ultrasound elastography appears a suitable and reliable method to measure cervical arterial wall stiffness, justifying further research into its use for screening arterial integrity.

Lenvatinib is a tyrosine kinase inhibitor (TKI) approved by the FDA for the treatment of radioiodine-refractory (RAIR) thyroid cancers. Side effects can be severe, however, and include headaches, hypertension, arterial and venous thromboembolic events, and fatalities. Cervical artery dissections (CADs) are leading contributors of cerebral ischemia in young adults, yet the pathophysiology is poorly understood. Here, we describe a case of a 34-year-old female with recurrent, metastatic, RAIR papillary thyroid cancer who, following her second week of lenvatinib treatment, developed significant CAD which resolved following the termination of the TKI therapy. Given the lack of risk factors for the disorder in the patient’s history, the known cardiovascular events associated with the drug, previously described cases of arterial dissections linked to VEGF inhibitors, and the temporal relationship between the onset of symptoms and the treatment start date, a causal relationship between the CAD and lenvatinib is suggested.

Background Spontaneous cervical artery dissections more often manifest in young people and have been associated with catastrophic consequences. Some indeterminate risk factors have been identified, making the diagnosis of developing dissections quite difficult. Fluoroquinolone antibiotics have been recognized for their degradative effects on connective tissue. Recent studies have implicated fluoroquinolones in the genesis of aortic artery aneurysms. It is the purpose of this paper to provide reasoning for a testable hypothesis of whether fluoroquinolones constitute a risk factor associated with cervical artery dissections. Methods A PubMed search was conducted to investigate whether cervical artery dissection has been associated with fluoroquinolone use. An assessment of risk factors was made of hereditary connective tissue disorders, infection, and seasonal predisposition related to cervical artery dissection. These factors were considered in conjunction with reports of connective tissue toxicity associated with fluoroquinolone medications. Results It appears that no reported cases of cervical artery dissection have previously been correlated with fluoroquinolone use. Heritable connective tissue disorders, infection, seasonal predisposition and condition latencies are associated with fluoroquinolone medications. Several recent articles have implicated fluoroquinolones with aortic dissections and aneurysm. Conclusion A causal relationship of fluoroquinolone antibiotics to cervical artery dissection is plausible. The suppositions developed in this paper are insufficient to suggest that fluoroquinolones currently represent an established risk factor in the development of cervical artery dissections. Fluoroquinolones may indeed be a novel and previously unrecognized cause of cervical artery dissections.

In litigated cases, the suspected causes of cervical artery dissections (CADs) are a source of considerable debate among experts. In this study, we sought to examine the factors influencing court decisions and discover how Canadian tribunals analyzed and arbitrated conflicting expert opinions in CAD cases. Cases for this review were identified through searches of the Canadian CANLII database. First, the results of this study show that there is no standardized methodology to assist health care personnel in the processing and interpretation of data in individual cases of CAD. This leads to wide ranges of personal interpretations and opinions which may confuse tribunals. Of concern is the implication of treating physicians who may not have the objectivity to act as expert witnesses when one of their patients is engaged in a legal proceeding.

Cervical artery dissection is a frequent cause of stroke, more so in young patients. Innominate artery (IA) dissection is uncommon, and most often associated with dissection of other major arteries like the aorta. The leading cause of IA injury is high-energy thoracic trauma, as in motor vehicle crash. IA dissection after blunt trauma is rare. We described here the unusual case and iconography of an isolated IA dissection after rifle recoil initially presenting as a stroke.

Fibromuscular dysplasia (FMD), which usually affects the renal artery, also affects the carotid, vertebral, and intracranial arteries. Previous studies have shown a high prevalence of concomitant renal artery and cervicocranial lesions in FMD patients. However, the analyzed subjects were mostly Caucasians in Western countries. We performed a retrospective analysis to examine the prevalence of cervicocranial vascular lesions in Japanese FMD patients with renal artery involvement at a single institution. The presence of cervicocranial lesions was evaluated by Doppler echography and magnetic resonance angiography. We compared this prevalence with that reported in the literature. Thirty-one Japanese FMD patients with renal artery lesions were studied. The mean age was 30 ± 12 years, 71% were women, and 16% were smokers; all patients were Asians and had hypertension. Multifocal, tubular, and unifocal types of renal lesions were found in 52, 35, and 13% of patients, respectively. Bilateral renal lesions were found in 13% of patients. None of the patients had a cervical vascular lesion associated with FMD. Only two patients (8%) had a lesion in the intracranial artery, of which one was a known case of moyamoya disease. These findings suggest that cervical artery involvement and intracranial artery involvement are not common in renal FMD patients in Japan, which is in contrast to the data reported for Caucasian patients in Western countries. Ethnic differences could influence the occurrence of cervicocranial lesions. A study with a larger sample size should be performed to validate these findings.

Introduction: The pathogenesis of spontaneous cervical artery dissection (sCeAD), a common cause of stroke in young adults, is poorly understood. The majority of published data in sCeAD derive from populations of European ancestry, including a recent genome-wide study identifying an association with the rs9349379 polymorphism of the PHACTR1 gene. Little is known about sCeAD in individuals of African ancestry despite robust epidemiological data showing increased risk of stroke at younger ages, partially explained by higher prevalence of traditional vascular risk factors. We hypothesize that people of African ancestry with sCeAD have different epidemiology and clinical profiles compared to those of European ancestry, and a different genetic architecture related to rs9349379 of the PHACTR1 gene. Methods: We searched a single-center database of sCeAD (n=278) to identify individuals of African and European ancestry. We compared differential prevalence of sCeAD versus all young stroke (≤ 60) between patients of African and European ancestry at our center. We characterized clinical profiles, confirmed by electronic medical record review. Data include descriptive statistics reported as medians or percentages as appropriate. We also used the publicly available HapMap Project to obtain allele frequencies of rs9349379 in different ancestral populations. Results: Conclusion: Individuals of African Ancestry account for a relatively smaller proportion of sCeAD cases compared to the proportion of all young stroke cases. Despite similar ages at time of event, individuals of African ancestry suffering sCeAD have higher prevalence of vascular risk factors compared to individuals of European Ancestry. Reviewing HapMap data demonstrates striking differences in allele frequencies for rs9349379 in the PHACTR1 gene between ancestral populations. Further prospective research is needed to clarify these associations and disparities in the pathogenesis of sCeAD.

Introduction: Cervical artery dissection (CeAD) of the carotid and vertebral arteries is a prevalent cause of stroke in young adults. While the pathogenesis of incident CeAD remains poorly understood, clinical and genetic associations suggest a systemic arteriopathy at time of event. Hypothesis: Individuals suffering CeAD express a distinct gene expression profile at time of event compared to (1) age and sex-matched controls and (2) convalescent profiles within the same individual at a later time point. Methods: We enrolled 37 consecutive patients with carotid or vertebral artery dissection (with and without ischemic stroke) from 2013-2016, excluding concurrence of major trauma. Cases were age and sex matched to non-CeAD ischemic stroke controls (n=16) and healthy controls (n=11). Whole blood samples were collected within four weeks from time of event, and again at 3 and 6-month follow-up. We used IlluminaHT-12 microarrays to assess differential gene expression at time of CeAD relative to controls, and relative to gene expression at >3 month follow-up within CeAD cases. Mixed effects regression models included relevant covariates of age, sex, race/ethnicity, time of enrollment, and occurrence of stroke. We used a False Discovery Rate (FDR) cutoff of 5% to account for multiple testing as well as a 1.5 fold change cutoff to identify robust, differential gene expression. Results: We identified 538 differentially expressed genes between CeAD patients and healthy controls with 30 of these genes reaching our predetermined 1.5x fold change limit. Within CeAD cases, 1,238 genes showed differential expression at a 5% FDR compared to time points at 3-6 month follow-up, with 31 genes showing at least a 1.5 fold change. Compared to controls and convalescent profiles, 12 genes were significant using the 5% FDR and 1.5 fold change cutoffs. Preliminary gene-ontology analysis indicate the largest differential expression for genes associated with oxygen and gas transport. Conclusion: In this consecutive cohort of individuals with CeAD, we identified a distinct gene expression profile associated with incident dissection. These data are limited by small sample size and results are hypothesis generating. Replication in larger, independent cohorts is warranted.

Introduction: Cervical artery dissection (CeAD) is the most frequent cause of ischemic stroke in young adults. It is suggested that connective tissue dysplasia (CTD) underlies in the arterial wall weakness predisposing to dissection. The aim : to elucidate CTD signs that have prognostic and diagnostic significance for CeAD. Methods: We examined 80 patients (mean age 38,5±13,5; 49 females, 61,2%) with CeAD, verified by MRI/MRA and 20 healthy volunteers (mean age 30,3±6,7; 12 females 60%). We assessed 48 signs selected from criteria of the vascular type of Ehlers-Danlos syndrome, Marfan syndrome, Beighton criteria of joint hypermobility and other. In addition we estimated arterial hypotension (≤100/70 mm Hg), and headache in the past history. Each sign was counted as present or absent, resulting in an individual CTD score. On the basis of linear regression analysis these signs were divided into major and minor signs. Results: CTD signs were found more frequently in CeAD patients than in the control (mean score 7,9 ± 3,6 vs 4,6 ± 2,5; p Conclusion: CTD signs are highly prevalent in patients with CeAD that is in accordance with our morphological data that arterial wall dysplasia is a main cause of spontaneous dissection. The presence of 4 major and 2 minor signs may be used to estimate the predisposition to CeAD and in some cases as additional argument at clinical diagnosis.

Background: Data on endovascular therapy (EVT) in patients with stroke attributable to CeAD is scarce. We performed a systematic review and meta-analysis of all studies comparing EVT to intravenous thrombolysis (IVT) in CeAD-patients and compared EVT to IVT with regard to 3-month outcome and complications. Additionally, we included data of IVT-/EVT-treated CeAD-patients from a Swiss multicenter IVT-/EVT registry based cohort study. Methods: We systematically searched the pubmed® database to identify all existing studies comparing IVT to EVT in CeAD-patients. Studies were eligible if IVT-treated CeAD- patients were compared to EVT-treated patients, and 3-month outcomes were reported as modified Rankin Scale (mRS) score. Outcome measures in this study were favorable 3-month outcome (i.e. mRS 0-2), excellent 3-month outcome (i.e. mRS 0-1), symptomatic intracranial hemorrhage (sICH) and death. Additionally, in a Swiss multicenter IVT-/EVT registry based cohort-study (SWISS) we identified all consecutive patients with ischemic stroke attributable to CeAD and included outcome data of these patients in our analyses. In a meta-analysis across all studies, we compared EVT to IVT with regard to primary and secondary outcome measures using a fixed-effect Mantel-Haenszel model. Results: The literature search yielded 388 results. We identified 7 eligible studies for a systematic comparison of EVT versus IVT. Data on 62 patients from the SWISS cohort were included as an additional study. In total, we compared EVT (n=102) versus IVT (n=110) in 212 CeAD-patients. With regard to the occurrence of mRS 0-2, there was no significant difference between both treatment groups (OR 1.04 (95% CI 0.57-1.88)). Separate Data on mRS 0-1 was available in 5 studies (OR 0.88 (95% CI 0.39-2.00)). There was no difference between groups with regard to death at 3 months (OR 0.66 (0.22-1.94)) which was separately reported in 6 studies. For sICH there were too few data (n=5 patients) available for meta-analysis. Conclusion: In this systematic review and meta-analysis of all existing studies comparing EVT to IVT in CeAD patients there was no clear signal of superiority of EVT. Further investigation of EVT with up-to-date devices is warranted.

The cervical spinal nerve occupies the lower part of the foramen with the periradicular veins in the upper part. The radicular arteries arising from the vertebral, ascending cervical, and deep cervical arteries lie in close approximation to the spinal nerve.

An 82-year-old woman with a history of hypertension presented to the emergency department with a 1-week history of 3 episodes of word-finding difficulty and right arm weakness lasting for a few minutes each without any known triggers or associated neurological symptoms. On arrival, her blood pressure was 174/84 mm Hg. Her general and neurological examination showed mild expressive aphasia. Neuroimaging was immediately undertaken with computerized tomographic angiogram of the brain and neck, demonstrating high-grade proximal left M1 stenosis without cervical artery stenosis (Figure 1). She then underwent magnetic resonance imaging (MRI) of the brain with perfusion imaging with rapid processing of perfusion and diffusion (RAPID), which demonstrated delayed perfusion in the left middle cerebral artery territory and small left hemispheric infarcts (Figure 2, top). She was started on aspirin, clopidogrel, and high-intensity statin therapy and admitted to the stroke unit. A transthoracic echocardiogram was unremarkable, her glycosylated hemoglobin was 5.7%, and low-density lipoprotein was 131 mg/dL. Her stroke was attributed to intracranial atherosclerosis. She was discharged on dual antiplatelet therapy and high-intensity statin therapy with persistent mild expressive aphasia. Figure 1. Computed tomographic angiogram demonstrates critical left proximal middle cerebral artery (M1) stenosis. Figure 2. The patient’s sequential rapid processing of perfusion and diffusion (RAPID) magnetic resonance imaging (MRI) demonstrates the evolution of the perfusion deficit. The top of the figure shows the initial RAPID MRI with punctate left hemispheric infarcts and delayed perfusion in the left middle cerebral artery territory with 61-mL volume of brain tissue with T max >6-s delay. Middle of figure shows second RAPID MRI with infarct expansion and 61-mL volume of brain tissue with T max >6-s delay. The bottom of the figure shows the last RAPID MRI after blood pressure augmentation showing stable left hemispheric infarcts without areas of brain tissue with T max >6-s delay. ADC indicates …

Introduction Pathophysiology of cervical artery dissection is complex and poorly understood. In addition to well-known causative and predisposing factors, including major trauma and monogenic connective tissue disorders, morphological characteristics of the styloid process have been recently recognized as a possible risk factor for cervical internal carotid artery dissection. Aims To study the association of the anatomical characteristics of styloid process with internal carotid artery dissection. Methods Retrospective, multicenter, case–control study of patients with internal carotid artery dissection and age- and sex-matched controls. Consecutive patients with internal carotid artery dissection and controls with ischemic stroke or transient ischemic attack of any etiology excluding internal carotid artery dissection, who had performed computed tomography angiography, diagnosed between January 2010 and September 2016. Two independent observers measured styloid process length and styloid process distance to internal carotid artery. Results Sixty-two patients with internal carotid artery dissection and 70 controls were included. Interobserver agreement was good for styloid process length and styloid process–internal carotid artery distance (interclass correlation coefficient = 0.89 and 0.76, respectively). Styloid process ipsilateral to dissection was longer than left and right styloid process in controls (35.8 ± 14.4 mm versus 30.4 ± 8.9 mm and 30.3 ± 8.2 mm, p = 0.011 and p = 0.008, respectively). Styloid process–internal carotid artery distance ipsilateral to dissection was shorter than left and right distance in controls (6.3 ± 1.9 mm versus 7.2 ± 2.1 mm and 7.0 ± 2.3 mm, p = 0.003 and p = 0.026, respectively). Internal carotid artery dissection was associated with styloid process length (odds ratio = 1.04 mm−1, 95% confidence interval = 1.01–1.08, p = 0.015) and styloid process–internal carotid artery distance (OR = 0.77 mm−1, 95% confidence interval = 0.64–0.92, p = 0.004). Conclusion Longer styloid process and shorter distance between styloid process and cervical internal carotid artery are associated with cervical internal carotid artery dissection.

Cervical artery dissection was first reported in an autopsy report by Fred Thomas in 1947 (Schievink, New Engl J Med 344:898–906, 2001). Cervical artery dissection (CAD) is a general term including both carotid and vertebral artery dissections. A CAD occurs when there is a tear in the intimal layer of a carotid or vertebral artery that leads to the development of an intramural hematoma. The hematoma can cause stenosis, occlusion, or aneurysmal dilation. Early detection is of paramount importance as the risk of recurrent stroke is highest during the first month following a CAD. CAD is now recognized as one of the most common causes of stroke in the young, accounting for up to 30% of stroke cases (Ducrocq et al., Revue Neurol 155(8): 575–82, 1999). The present chapter will focus on the clinical features, diagnosis, and available treatment options for spontaneous (non-traumatic) CAD.

BACKGROUND AND PURPOSE: We investigated whether university education is more likely in cervical artery dissection (CeAD)-patients than in age- and sex-matched patients with ischemic stroke (IS) due to other causes (non-CeAD-IS-patients). METHODS: Patients from the Cervical Artery Dissection and Ischemic Stroke Patients study with documented self-reported profession before onset of IS due to CeAD (n = 715) or non-CeAD causes (n = 631) were analyzed. In the reported profession, the absence or presence of university education was assessed. Professions could be rated as academic or non-academic in 518 CeAD and 456 non-CeAD patients. Clinical outcome at 3 months was defined as excellent if modified Rankin Scale was 0-1. RESULTS: University education was more frequent in CeAD-patients (100 of 518, 19.3%) than in non-CeAD-IS-patients (61 of 456, 13.4%, p = 0.008). CeAD-patients with and without university education differed significantly with regard to smoking (39 vs. 57%, p = 0.001) and excellent outcome (80 vs. 66%, p = 0.004). In logistic regression analysis, university education was associated with excellent outcome in CeAD-patients (OR 2.44, 95% CI 1.37-5.38) independent of other outcome predictors such as age (OR 0.97, 95% CI 0.84-0.99), NIHSS (OR 0.80, 95% CI 0.76-0.84) and local signs (OR 2.77, 95% CI 1.37-5.57). CONCLUSION: We observed a higher rate of university education in patients with CeAD compared with non-CeAD patients in our study population. University education was associated with favorable outcome in CeAD-patients. The mechanism behind this association remains unclear.

Introduction In patients with stroke attributable to cervical artery dissection, we compared endovascular therapy to intravenous thrombolysis regarding three-month outcome, recanalisation and complications. Materials and methods In a multicentre intravenous thrombolysis/endovascular therapy-register-based cohort study, all consecutive cervical artery dissection patients with intracranial artery occlusion treated within 6 h were eligible for analysis. Endovascular therapy patients (with or without prior intravenous thrombolysis) were compared to intravenous thrombolysis patients regarding (i) excellent three-month outcome (modified Rankin Scale score 0–1), (ii) symptomatic intracranial haemorrhage, (iii) recanalisation of the occluded intracranial artery and (iv) death. Upon a systematic literature review, we performed a meta-analysis comparing endovascular therapy to intravenous thrombolysis in cervical artery dissection patients regarding three-month outcome using a random-effects Mantel–Haenszel model. Results Among 62 cervical artery dissection patients (median age 48.8 years), 24 received intravenous thrombolysis and 38 received endovascular therapy. Excellent three-month outcome occurred in 23.7% endovascular therapy and 20.8% with intravenous thrombolysis patients. Symptomatic intracranial haemorrhage occurred solely among endovascular therapy patients (5/38 patients, 13.2%) while four (80%) of these patients had bridging therapy; 6/38 endovascular therapy and 0/24 intravenous thrombolysis patients died. Four of these 6 endovascular therapy patients had bridging therapy. Recanalisation was achieved in 84.2% endovascular therapy patients and 66.7% intravenous thrombolysis patients (odds ratio 3.2, 95% confidence interval [0.9–11.38]). Sensitivity analyses in a subgroup treated within 4.5 h revealed a higher recanalisation rate among endovascular therapy patients (odds ratio 3.87, 95% confidence interval [1.00–14.95]), but no change in the key clinical findings. In a meta-analysis across eight studies (n = 212 patients), cervical artery dissection patients (110 intravenous thrombolysis and 102 endovascular therapy) showed identical odds for favourable outcome (odds ratio 0.97, 95% confidence interval [0.38–2.44]) among endovascular therapy patients and intravenous thrombolysis patients. Discussion and Conclusion In this cohort study, there was no clear signal of superiority of endovascular therapy over intravenous thrombolysis in cervical artery dissection patients, which – given the limitation of our sample size – does not prove that endovascular therapy in these patients cannot be superior in future studies. The observation that symptomatic intracranial haemorrhage and deaths in the endovascular therapy group occurred predominantly in bridging patients requires further investigation.

Stroke is defined as the acute onset of focal neurological disturbance arising due to a cerebrovascular cause, confirmed histopathologically or on imaging, where other causes have been excluded. Strokes may either be ischaemic (approximately 80% of cases) or haemorrhagic (20%). Although often thought of as a single disease, stroke represents the end stage of many different pathologies, each of which can result in cerebral ischaemia and/or haemorrhage. Therefore when investigating a stroke patient, investigations are performed to identify the underlying cause. Most cases of ischaemic stroke are caused by one of three pathologies: large vessel atherosclerotic disease (LVD), cerebral small vessel disease (SVD) or cardioembolism, although there are multiple rarer causes including cervical artery dissection. However, even with detailed investigation an underlying cause cannot be found in approximately a quarter of all ischaemic strokes. Haemorrhagic strokes are categorized according to the brain region they arise from; lobar or cortical haemorrhages are commonly caused by cerebral amyloid angiopathy, or an underlying structural lesion for example an arteriovenous malformation. Subcortical haemorrhages are usually associated with hypertension and believed to be often a manifestation of SVD.

Fibromuscular dysplasia (FMD) is an idiopathic, segmental, non-atherosclerotic and non-inflammatory disease of the musculature of arterial walls, leading to stenosis of small and medium-sized arteries, mostly involving renal and cervical arteries. As a result of better and more systematic screening, it appears that involvement of the splanchnic vascular bed is more frequent than originally assumed. We review epidemiology, pathogenesis, clinical picture as well as diagnosis and treatment of visceral artery (VA) FMD. The clinical picture is very diverse and diagnosis is based on CT-, MR- or conventional catheter-based angiography. Involvement of VAs generally occurs among patients with multi-vessel FMD. Therefore, screening for VA FMD is advised especially in renal artery (RA) FMD and in case of aneurysms and/or dissections. Treatment depends on the clinical picture. However, the level of evidence is low and much of the common practice is extrapolated from visceral atherosclerotic disease. This article is protected by copyright. All rights reserved.

yassa, murat/0000-0001-8661-1192; dogan, ozan/0000-0002-0016-8749 WOS: 000454997800010 Objectives: The aim of the present study was to investigate the diagnostic effectiveness of uterine and cervical vascularity alone or in combination with human papillomavirus (HPV) DNA testing and with cytology. Methods: Data were prospectively collected from 129 patients in an outpatient clinic of a secondary setting. Routine liquid-based cervical cytology and HPV-DNA testing were obtained. An abnormal result of any of these high-risk types was viewed as positive. Pulsatility (PI) and resistance (RI) indices of uterine (UA) and cervical (CA) arteries were assessed by Doppler sonography. Pathological diagnosis was considered as the gold standard for assessment. Diagnostic efficiency of alone and joint screening of the three indices for discriminating cervical intraepithelial neoplasia (CIN-I) or above from below was assessed. Results: UA-RI and CA-RI were significantly lower in the HPV (+) group than in the controls (p=0.02 and p=0.03, respectively). In subsequent sub-analysis among patients with positive HPV-DNA, UA-PI was significantly higher in the HPV-16 (+) group than in the HPV-18 (+) group (p=0.04). High-risk HPV (Hr-HPV) testing had the highest sensitivity compared with Doppler and cytology (76.5%, 64.7%, and 58.5%, respectively). Combining CA-RI with cytology or Hr-HPV significantly reduced the sensitivity (23.5% and 29.4, respectively) but improved the specificity from 54.4% to 69.8% and 40.9% to 70.7%, respectively. Combining UA-PI with Hr-HPV slightly increased the positive predictivity when compared with testing Hr-HPV alone (36.1% vs. 33.3%). Conclusion: The potential of the Doppler indices of UA and CA was doubtful in discriminating CIN-I or above lesions in the early period. In addition, RI of UA and CA differed with regard to the presence of HPV infection, whereas CA-RI differed in high-risk HPV cases.

Background Cerebral blood flow volume (BFV) is important factor for accurate diagnosis of neurovascular diseases and treatment indication. Study aims to assess correlations of BFV measurements in cervical and intracranial arteries between quantitative magnetic resonance angiography (qMRA) and duplex sonography. Methods Consecutive patients with suspicion of cerebral vascular pathology were included in prospective study. All patients underwent qMRA and duplex sonography of the cervical and intracranial arteries with measurement of BFV in bilateral common (CCA), internal (ICA) and externa carotid arteries, vertebral arteries (VAs), middle, anterior and posterior cerebral arteries, posterior communicanting arteries and basilar artery (BA). DS was performed using two ultrasound machines by experienced sonographers. Two patients were examined twice. Correlations between BFV measurements were evaluated using Spearman's correlation coefficient and inter-class correlation coefficient (ICC). Results Totally 21 subjects (15 males, mean age 56.3±6.2 years) were included to the study. Duplex sonography inter-investigator correlation was excellent (ICC=0.972) as well as intra-investigator correlations of both qMRA and duplex sonography (ICC˃0.990). Mostly high correlations were recorded between qMRA and duplex sonography BFV measurements in particular cervical arteries but only low to moderate correlations were obtained for intracranial arteries. Mean differences between BFV measurements in CCA and its branches were 10.9±8.1%/15.0±11.9% when using qMRA/duplex sonography, in ICA siphon and its branches 13.5±11.8%/35.4±34.2% when using qMRA/duplex sonography, and in both VAs and BA 24.1±19.7%/44.9±44.0% when using qMRA/duplex sonography, resp. Conclusion Duplex sonography and qMRA are highly reproducible methods for blood flow volume measurement in cervical and intracranial arteries in routine clinical practice. The study was registered at ClinicalTrials.gov. NCT03591523 and supported by the Ministry of Health of the Czech Republic grants No. 16-29148A, 16-30965A, 17-31016A.

Introduction. Cervical artery dissection (CeAD) is the most frequent cause of ischemic stroke in young adults. Arterial wall dysplasia underlies its weakness and predisposes to dissection. Objective. To assess clinical signs of connective tissue dysplasia (CTD) in patients with CeAD using special criteria of CTD, and to evaluate predisposing factors for the CeAD development. Materials and methods. We examined 80 patients (mean age 38,5±13,5; 49 females) with CeAD, verified by MRI/MRA and20 healthy volunteers. We estimated 48 signs of CTD included in the Villefranche diagnostic criteria for the vascular type of Ehlers–Danlos syndrome, the Ghent criteria for Marfan syndrome, the Beighton criteria of joint hypermobility and some others, as well as history of headache. Each sign was counted as present or absent, yielding the individual and mean CTD group scores. Results. Clinical CTD signs were more frequently detected in patients with CeAD than in controls (mean score 7.9 ± 3.6 vs. 4.6 ± 2.5; p < 0.0039). Significant signs (more than 8 points) were present in 53% of patients. Regression analysis was performed to determine diagnostic-prognostic value of CTD signs. The main diagnostic criteria included history of headache (p=0.022), arterial hypotension (р=0.012), extensive bruising (р=0.011), and widened atrophic scars (р=0.019). The additional diagnostic criteria included translucent skin (р=0.034), high palate (р=0.034), predisposition to constipation (р=0.050), nasal bleeding (р=0.043), and blue sclera (р=0.050). In the presence of the 4 main and 2 additional criteria, the predictive value of dissection according to regression model is 75–77% (ROC analysis: AUC 0.90, 95% CI, 0.84–0.96). Most patients 97% had various predisposing factors of CeAD development, either isolated 47% or combined 50%. Conclusions. The presence of the 4 main and 2 additional diagnostic criteria of CTD has a high predictive value of CeAD and can be used as its diagnostic-prognostic criteria. Dissection of the arterial wall with signs of dysplasia is provoked by various additional factors., №11 (2018)

International audience; Recently, time-of-flight (TOF) and gadolinium-enhanced MR angiography (MRA) imaging have been used to demonstrate subacute intramural hematoma in cervical artery dissection and to detect intraplaque haemorrhage. Our aim was to perform an exploratory study to analyse if venous thrombus-related signal changes (potentially showing iso- or hyperintensity) in cerebral venous sinus thrombosis (CVST) could be observed on 3D-TOF MRA imaging. We analysed retrospectively MRIs of CVST patients in whom both contrast-enhanced MR venography (CEMRV) and 3D-TOF sequences were performed in the acute/subacute phase (i.e.

Le diaphragme des arteres cervicales est une lesion de la paroi arterielle le plus souvent situee a la face posterieure du bulbe carotidien. C’est une cause rare d’infarctus cerebral du sujet jeune par embolie d’artere a artere. Son diagnostic est essentiel car il expose a un risque eleve de recidive dans le meme territoire vasculaire. Sa mise en evidence repose sur un angioscanner des troncs supra-aortiques de bonne qualite avec reconstruction en coupe sagittale. En cas d’infarctus cerebral recidivant avec imagerie non invasive normale, une arteriographie conventionnelle permet d’obtenir une meilleure resolution et de mettre en evidence une stagnation du produit de contraste caracteristique. La simple anti-agregation plaquettaire semble insuffisante pour prevenir la recidive. Ses alternatives sont l’anticoagulation curative, le stenting endovasculaire et l’endarteriectomie.

Paradoxical thrombotic embolism via right-to-left cardiac shunt (RLS) is a risk factor of cryptogenic ischemic stroke. Transtemporal Doppler (TTD) is a valid method used in the detection of patent foramen ovale (PFO). Temporal acoustic bone windows are missing with increasing age and in some younger subjects. We studied prospectively whether Doppler ultrasound of the cervical arteries (submandibular internal carotid artery [ICA] and vertebral artery [VA]) is an alternative, when compared to TTD, in the detection and quantification of PFO.

Arterial dissection of the wall of the carotid artery is a recognized and significant cause of stroke. We described a 22-year-old man presented to the emergency department after a motorcycle accident. He had a right acetabular fracture and had not complained of other symptoms. A few minutes after being admitted, the patient developed left side hemiparesis. Emergency brain magnetic resonance imaging (MRI) revealed an acute ischemia in the left basal ganglia. Conventional angiography confirmed almost complete occlusion of carotid artery lumen. We treated the patient with antiplatelet therapy and he is currently followed at the outpatient clinic with good recovery of motor symptoms. Early identification and management of cervical artery dissection is important, as it is one of the major causes of ischemic stroke in young adults. Despite previous published articles, the best treatment of carotid artery dissection, especially after trauma, remains controversial.

Background Fibromuscular dysplasia (FMD) is a noninflammatory nonatherosclerotic disease of small- to medium-sized arteries. The frequency of multisite involvement and its influence on prognosis has not been systematically assessed in patients with cervicocephalic FMD, and little is known about their mid-term clinical and arterial prognosis. The aim of our study was to assess the prevalence of renal involvement and clinical and arterial prognosis in patients with cervicocephalic FMD. Methods We reviewed clinical and radiological data of consecutive patients with a diagnosis of cervicocephalic FMD, admitted to our hospital between January 2000 and March 2010. Patients were identified retrospectively until December 2008, and prospectively from January 2009. For each cervical and intracranial artery, we recorded the presence and type (unifocal or multifocal) of FMD. We classified each FMD-related stenosis into four categories: 80% and occlusion. During the first six months of 2012, patients were scheduled for follow-up visit, including cervicocephalic follow-up imaging, and renal artery imaging, if not already available. On follow-up imaging, FMD-related stenosis was classified according to the same method used at baseline. Renal artery FMD was defined as the presence of the typical string of beads appearance, or as the presence of a unique stenosis of renal artery. Primary endpoints were stroke (ischemic or hemorrhagic), death, and progression of FMD lesions, defined by any increase in category of stenosis on follow-up imaging. Results Out of the 36 patients included (32 women), all with carotid artery involvement and 17 with associated vertebral artery involvement, 28 (78%) had ischemic symptoms and/or cervical artery dissection at the time of the diagnosis of FMD. Among the 30 patients who had renal artery imaging, 13 (43%) had renal FMD. Patients with renal artery disease did not differ from those without renal artery disease. After a median follow-up of 3.5 years, three patients had four strokes, one recurrent cervical dissection, one brain hemorrhage, and one fatal cardiac arrhythmia. Among the 31 patients who had follow-up imaging, two showed progression of cervicocephalic FMD (occlusion of carotid artery). Patients with renal involvement showed a non-significant trend toward a higher rate of stroke (P = 0.17). Conclusions In patients with cervicocephalic FMD, renal involvement is common. The risk of stroke, death or FMD progression was high in our cohort, suggesting that prognosis may not be as good as expected. This underlines the need for larger prospective studies to define the best treatment options.

We report an unusual case of homicidal stab wound of the cervical spinal cord, which illustrates the value of post-mortem computed tomography angiography (PMCTA) in cases of vascular injury. First, we noted a posterior and horizontal trajectory to the neck with complete section of the cervical spinal cord between the first and second cervical vertebrae. This lesion was accompanied by section of the right vertebral and right deep cervical arteries. We also noted an anterior cervical trajectory with an injury to the right internal jugular vein and an anterior right chest wound with a lung trajectory and section of the internal mammary vessels. Cases of spinal cord injuries secondary to stab wounds are rare in the literature. Only one large series has been published from Cape Town. Complete section of the cervical spinal cord accounts for only 4.5% of all cases. Furthermore, lethal cases are rare and classically victims survive and present neurological sequelae. We found only one similar case but despite the transection of the cervical spinal cord the patient survived. Some studies suggest that PMCTA may be very helpful in visualizing vascular system injuries. Our observations are consistent with this proposal. The use of different-time acquisitions was essential for detection of the injured vessels.

We categorised spontaneous cervical artery dissection (sCAD) by radiological features and investigated factors associated with favourable outcomes. We retrospectively analysed 128 patients with sCAD with a median follow-up duration of 25 months. Twenty-nine constituted the aneurysm group, 52 the stenotic group, and 47 the occlusive group. Various relevant factors, including National Institute of Health Stroke Scale (NIHSS) scores, type of antithrombotic therapy, stroke progression in the first week, and transcranial Doppler (TCD) flow-waveforms (in the occlusive subgroup) were analysed. Favourable outcomes were defined as a 1-year modified Rankin-Scale score of 0–1. Favourable anatomical outcomes were defined as a reversal of dissection-associated stenosis during follow-up. The aneurysm and stenotic groups showed favourable outcomes, while the occlusive group outcomes were less favourable. In the stenotic group, anticoagulation, an NIHSS score ≥4, and stroke progression were inversely associated with favourable long-term outcomes. Remarkably, in the occlusive group, flow abnormality more severe than minimal flow was associated with stroke progression, unfavourable long-term outcome, and arterial irreversibility. The outcome of sCAD depends on its radiological subtype. In the occlusive subtype, which is associated with the worst outcome, TCD flow analysis may predict acute stroke progression and long-term outcome. • Outcomes in cervical artery dissection may be determined by radiological subtypes. • The aneurysm and stenotic groups had favourable outcomes. • The occlusive group had less favourable functional outcomes. • Flow-waveform analysis by TCD could predict functional and anatomical outcomes.

Introduction: Cervical artery dissection (CAD) is the cause of 2% to 3% of ischaemic strokes and 10% to 25% of the ischaemic strokes in young people. Our objective is to evaluate whether the implementation of a comprehensive stroke centre (CSC) improves the diagnosis and modifies the prognosis of patients with acute stroke due to CAD. Patients and methods: Retrospective study of a registry of consecutive patients with acute stroke due to CAD. They were classified according to the period of care at our centre: pre-CSC (October 2004 to March 2008, 42 months) or post-CSC (April 2008 to June 2012, 51 months). We compared baseline characteristics, methods of diagnosis, treatment and outcome of these patients in both periods. Results: Nine patients were diagnosed with CAD in the pre-CSC and 26 in the post-CSC, representing 0.8% and 2.1% of all ischaemic strokes treated in each period, respectively. The diagnosis of CAD was made within the first 24 hours in 42.3% of the patients in the post-CSC versus 0% in the pre-CSC, through the use of urgent cerebral angiography as a diagnostic test in 46.2% of cases in the second period compared to 0% in the first. The severity of stroke (median NIHSS score 11 vs. 3, P = .014) and time to neurological care (265 min vs. 148, P = .056) were higher in the post-CSC period. Endovascular treatment was performed in 34.3%, all in the post-CSC. The functional outcome was comparable in both periods. Conclusions: The implementation of a CSC increases the frequency of the diagnosis of CAD, as well as the treatment options for these patients in the acute phase of stroke. Resumen: Introducción: La disección de arterias cervicales (DAC) es la causa del 2-3% de ictus isquémicos y del 10-25% en pacientes jóvenes. Nuestro objetivo es evaluar si la implementación de un centro terciario de ictus (CTI) facilita el diagnóstico y modifica el pronóstico de los pacientes con ictus agudo por DAC. Pacientes y métodos: Estudio retrospectivo de un registro de pacientes consecutivos con ictus agudo por DAC. Se clasificaron según el periodo de atención: pre-CTI (octubre 2004-marzo 2008, 42 meses) o post-CTI (abril 2008-junio 2012, 51 meses). Se compararon las características basales, el método diagnóstico, el tratamiento y la evolución de estos pacientes entre ambos periodos. Resultados: Se diagnosticó a 9 pacientes con DAC en el periodo pre-CTI y 26 en el post-CTI, representando el 0,8 y el 2,1% de los ictus isquémicos atendidos en cada periodo. El diagnóstico de DAC se realizó en las primeras 24 h en el 42,3% de pacientes en el periodo post-CTI frente al 0% en el pre-CTI, gracias al uso de la arteriografía cerebral urgente como prueba diagnóstica en el 46,2% de los casos en el segundo periodo frente al 0% en el primero. La gravedad del ictus (mediana puntuación escala NIHSS 11 vs. 3, p = 0,014) y el tiempo hasta la atención neurológica (265 minutos vs. 148, p = 0,056) fueron mayores en la fase post-CTI. Se realizó tratamiento endovascular en el 34,3%, todos en el periodo post-CTI. El pronóstico funcional fue comparable en ambos periodos. Conclusiones: La implementación de un CTI incrementa la frecuencia en el diagnóstico de DAC y aumenta las opciones terapéuticas en la fase aguda del ictus en estos pacientes. Keywords: Cervical artery dissection, Stroke, Comprehensive stroke centre, Angiography, Systemic thrombolysis, Endovascular treatment, Palabras clave: Disección de arterias cervicales, Ictus, Centro terciario de ictus, Arteriografía, Trombólisis sistémica, Tratamiento endovascular

Objective The potential of computed tomography angiography (CTA) was assessed for early determination of stroke subtypes in a Brazilian cohort of patients with stroke. Method From July 2011 to July 2013, we selected patients with suspected hyperacute stroke (< 6 hours). Intracranial and cervical arteries were scrutinized on CTA and their imaging features were correlated with concurrent subtype of stroke. Results Stroke was documented in 50/106 selected patients (47.2%) based on both clinical grounds and imaging follow-up (stroke group), with statistically significant arterial stenosis and vulnerable plaques on CTA. Intracranial large artery disease was demonstrated in 34% of patients in the stroke group. Partial territorial infarct prevailed (86%) while artery-to-artery embolization was the most common stroke mechanism (52%). Conclusion Multidetector CTA was useful for the etiologic work-up of hyperacute ischemic stroke and facilitated the knowledge about the topographic pattern of brain infarct in accordance with its causative mechanism.

Cervical artery dissection (CAD) is a major cause of stroke in the young. A mural hematoma is detected in most CAD patients. The intramural blood accumulation should not be considered a reason to withhold intravenous thrombolysis in patients with CAD-related stroke. Because intravenous-thrombolyzed CAD patients might not recover as well as other stroke patients, acute endovascular treatment is an alternative. Regarding the choice of antithrombotic agents, this article discusses the findings of 4 meta-analyses across observational data, the current status of 3 randomized controlled trials, and arguments and counterarguments favoring anticoagulants over antiplatelets. Furthermore, the role of stenting and surgery is addressed.

BACKGROUND Magnetic resonance angiography (MRA) and diffusion-weighted imaging (DWI) have been widely used in the prediction of ischemic stroke; however, the differences of the 2 methods in detection the artery lesion differences between transient ischemic attack (TIA) and infarction patients have been long neglected. We performed the present study to investigate the differences between vessel characteristics detected by MRA and DWI in acute stroke and TIA patients. MATERIAL AND METHODS We classified 110 subjects into 2 groups and all the patients underwent both MRA and DWI. The degree of stenosis of cranial and cervical arteries, the distribution of the stenosis, the development and changes of the vessels, and the DWI scanning results of the brain tissue were all analyzed. RESULTS We detected a significant difference in the number and the degree of stenosis of cranial and cervical arteries among the 3 groups (P=0.006). Compared with health controls, patients with TIA and cerebral infraction had much more severe stenosis and occlusive arteries (P

Objective: To evaluate the incidence of cervical angiopathy caused by radiation therapy for head and neck cancer. Methods: Segments of 57 cervical arteries were obtained during surgery for head and neck malignant tumors and divided into two groups (irradiated group and non-irradiated group) based on the treatment prior to vascular resection. In order to evaluate vascular injury after radiation therapy, we examined the degree of medial atrophy, medial fibrosis, smooth muscle cell (SMC) differentiation in the media and intima, intimal hyperplasia and endothelial cell (EC) injury. Sections of arterial segments were stained with hematoxylin-eosin, Elastica van Gieson and Masson’s trichrome, and immunohistochemistry for α-smooth muscle actin (α-SMA), smoothelin, S100A4 and CD31 in the resected vessels was conducted. Results: The median interval between the completion of radiation therapy and vascular resection was nine months. No significant differences were observed between the two groups in terms of medial atrophy, medial fibrosis and intimal hyperplasia. The ratio of the smoothelin-positive area per α-SMA-positive area in the media and the S100A4-positive proportion in the intima, indicating the degree of differentiation of the medial SMC and dedifferentiation of the intimal SMC, respectively, showed no significant differences, despite the tendency toward a lower smoothelin-positive area per α-SMA-positive area in the media of the irradiated arteries. The EC coverage revealed on CD31 immunohistochemistry was significantly decreased, with mural thrombus adhesion, in the irradiated group. Conclusions: The ECs of small arteries are damaged by irradiation. Although we did not confirm the statistical significance of medial SMC dedifferentiation, a decreased expression of smoothelin tended to be observed in the media of the irradiated arteries. Our findings provide histopathological evidence of irradiation angiopathy in head and neck cancer and may help to improve the surgical safety of microvascular anastomosis and determine the treatment strategy for head and neck tumors.

Background: Patients with carotid artery dissection (CAD) have been reported to have different vascular risk factor profiles and clinical outcomes to those with vertebral artery dissection (VAD). However, there are limited data from recent, large international studies comparing risk factors and clinical features in patients with cervical artery dissection (CeAD) with other TIA or ischemic stroke (IS) patients of similar age and sex. Methods: We analysed demographic, clinical and risk factor profiles in TIA and IS patients ≤55 years of age with and without CeAD in the large European, multi-centre, Stroke In young FAbry Patients 1 (sifap1) study. Patients were further categorised according to age (younger: 18-44 years; middle-aged: 45-55 years), sex, and site of dissection. Results: Data on the presence of dissection were available in 4,208 TIA and IS patients of whom 439 (10.4%) had CeAD: 196 (50.1%) had CAD, 195 (49.9%) had VAD, and 48 had multiple artery dissections or no information regarding the dissected artery. The prevalence of CAD was higher in women than in men (5.9 vs. 3.8%, p < 0.01), whereas the prevalence of VAD was similar in women and men (4.6 vs. 4.7%, n.s.). Patients with VAD were younger than patients with CAD (median = 41 years (IQR = 35-47 years) versus median = 45 years (IQR = 39-49 years); p < 0.01). At stroke onset, about twice as many patients with either CAD (54.0 vs. 23.1%, p < 0.001) or VAD (63.4 vs. 36.6%, p < 0.001) had headache than patients without CeAD and stroke in the anterior or posterior circulation, respectively. Compared to patients without CeAD, hypertension, concomitant cardiovascular diseases and a patent foramen ovale were significantly less prevalent in both CAD and VAD patients, whereas tobacco smoking, physical inactivity, obesity and a family history of cerebrovascular diseases were found less frequently in CAD patients, but not in VAD patients. A history of migraine was observed at a similar frequency in patients with CAD (31%), VAD (27.8%) and in those without CeAD (25.8%). Conclusions: We identified clinical features and risk factor profiles that are specific to young patients with CeAD, and to subgroups with either CAD or VAD compared to patients without CeAD. Therefore, our data support the concept that certain vascular risk factors differentially affect the risk of CAD and VAD.

Vertebral artery dissection (VAD) is among the most common identifiable etiologies of stroke in young adults and poses a diagnostic challenge due to nonspecific symptoms and substantial variability of imaging results. Here, we present a case of unspecific neck pain as isolated symptom of VAD with unusually compelling evidence on duplex ultrasound. This observation has clinical relevance as the absence of any neurological symptoms in our patient highlights the necessity of considering cervical artery dissection in patients presenting with unspecific symptoms such as neck pain, even if isolated. Furthermore, our image of intramural hematoma on duplex ultrasound has been captured in an unusual, clear and distinct fashion and might therefore be a useful reference image in the clinical assessment of patients with a suspicion of cervical artery dissection.

The incidence of cervical artery dissection (CeAD) in the general population is as low as 2.6 to 3.0 per 100 000 inhabitants per year and accounts for only a small proportion of all ischemic stroke, but it is a major cause of stroke among young and middle-aged adults.1–3 Cervicocerebral dissection was the second common cause (15%) preceded by cardioembolism (20%) in 1008 Finnish patients with ischemic stroke aged 15 to 49 years.4 The current guidelines recommend antithrombotic treatment at the acute phase of CeAD, especially in patients presenting with ischemic stroke or transient ischemic attack.5 However, the optimal strategy for prevention of stroke in patients with acute CeAD is controversial, and there is a lively debate around choice of antithrombotic drugs (anticoagulation versus antiplatelet therapy), duration of antithrombotic treatment, and indications for endovascular and surgical treatments. The recent Cervical Artery Dissection in Stroke Study (CADISS) trial6 published in the Lancet Neurology aimed to address one of these questions, namely, which antithrombotic therapy, out of anticoagulation or antiplatelet agents, should be preferred at the acute phase of CeAD. Many practitioners routinely treat CeAD patients with anticoagulants, and some guidelines are supporting this practice,5 mainly based on the empirical argument that the mechanism of ischemic stroke in CeAD is thromboembolic in the vast majority of cases (an assumption derived from the neuroimaging distribution of ischemic lesions).7 The CADISS trial was planned as a phase 2 feasibility trial.8 Patients with CeAD (extracranial carotid or vertebral artery dissection) with onset of symptom within the past 7 days and imaging evidence of definite or probable dissection were included. The sample size required for this feasibility phase was estimated at 250 based on the rates of recurrence reported in observational studies9–11 (details on the …

Background and purpose The management of cervical artery occlusions in hyperacute stroke with tandem cervical/intracranial occlusions has not yet become standardized, especially when the circle of Willis is effective. Methods We retrospectively analyzed the safety and accuracy of current approaches to manage the cervical occlusion in consecutive patients with tandem occlusions addressed for intracranial mechanical thrombectomy (MT) in our department from January 2012 to May 2017. The different approaches that could be performed in a same patient during the same procedure or hospitalization were analyzed separately. Results We reported 64 approaches to manage the cervical occlusion in 49 patients with tandem occlusion (14% of MT): medical treatment alone in 16/64 (25%), stenting/angioplasty in 16/64 (25%), occlusion with coils in 12/64 (19%), angioplasty alone in 9/64 (14%), stent-retriever in 8/64 (12%), and/or thromboaspiration in 3/64 (5%). Early ipsilateral embolic recurrence occurred after 9/64 (14%) of them. It was strongly associated with the presence of a cervical intraluminal thrombus (P = 0.001) and was then lower after occlusion with coils and stent-retriever compared to medical treatment alone and thromboaspiration (P = 0.002). Occlusion with coils had a lower rate of radiological intracranial hemorrhage at 48-hour compared to other approaches (P = 0.009). The 3-month rates of favorable outcome (P = 0.806) and mortality (P = 0.878) were similar. One delayed stroke was imputable to an occlusion with coils, for a median (Q1–Q3) follow-up of 10 (3–20) months. Conclusions Cervical occlusion with coils and thrombectomy with stent-retrievers may be relevant to prevent early embolic recurrence in cervical occlusions with intraluminal thrombus. Stent-retrievers should be further assessed as a first-line approach, since delayed stroke may occur following occlusion with coils. Medical treatment alone may be sufficient when no cervical intraluminal thrombus is present, the Willis polygon is effective, and the cervical occlusion can be crossed easily to perform the intracranial thrombectomy.

Cervical artery dissections (CeAD) include both internal carotid and vertebral artery dissections. They are rare but important causes of stroke, especially in younger patients. CeAD should be considered in patients with strokelike symptoms, a new-onset headache and/or neck pain, and/or other risk factors. Early imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is key to making the diagnosis. Treatment may vary depending on the extent of the dissection, timing of the dissection, and other comorbidities. The overall prognosis is good, but does depend on the initial severity of symptoms.

Background Cervical artery dissection is one of the most important causes of ischemic stroke in young age patients. However, multiple cervical artery dissection simultaneously involving the anterior and posterior circulation is uncommon. Here, we would like to report a case of a patient with bilateral vertebral artery (VA) and internal carotid artery dissection (ICA) after a use of systemic steroid due to peripheral facial palsy. Case presentation A 44-year-old man with hypertension visited emergency department due to recurrent vertigo. He was receiving methyl prednisolone for two weeks for the treatment of right peripheral type facial palsy which occurred after retro-orbital headache. Neurologic examination revealed severe ataxia at left side. Sensory for pain and temperature was declined in the right arm and leg. Diffusion-weighted image showed an acute ischemic lesion at the whole territory of posterior-inferior cerebellar artery. Severe stenosis was observed from bilateral VAs and ICAs on conventional magnetic resonance angiography. Intramural hematoma and intimal flap was observed from the high-resolution MRI. Conclusions Peripheral type facial palsy is an unusual presentation of carotid dissection. Steroids aggravate arterial dissection by increasing blood pressure and blood vessel fragility by its negative effect on connective tissue strength. Use of steroid in patients with peripheral type facial palsy with severe headache may need caution.

Cervical artery dissection (CAD) is an important etiology of ischemic stroke and early recognition is vital to protect patients from the major complication of cerebral embolization by administration of anticoagulants. The etiology of arterial dissections differ and can be either spontaneous or traumatic. Even though the historical gold standard is still catheter angiography, recent studies suggest a good performance of computed tomography angiography (CTA) for detection of CAD. We conducted this research to evaluate the variety and frequency of possible imaging signs of spontaneous and traumatic CAD and to guide neuroradiologists’ decision making. Retrospective review of the database of our multiple injured patients admitted to the Department of Trauma, Hand, and Reconstructive Surgery of the University Hospital Munster in Germany (a level 1 trauma center) for patients with traumatic CAD (tCAD) and of our stroke database (2008–2015) for patients with spontaneous CAD (sCAD) and CT/CTA on initial clinical work-up. All images were evaluated concerning specific and sensitive radiological features for dissection by two experienced neuroradiologists. Imaging features were compared between the two etiologies. This study included 145 patients (99 male, 46 female; 45 ± 18.8 years of age), consisting of 126 dissected arteries with a traumatic and 43 with spontaneous etiology. Intimal flaps were more frequently observed after traumatic etiology (58.1% tCADs, 6.9% sCADs; p

Background Cerebral hyperperfusion syndrome (CHS) is known to be a rare but devastating complication of carotid artery revascularization. Because patients with acute ischemic stroke due to acute major cerebral and/or cervical artery occlusion treated with endovascular reperfusion therapy may have impaired autoregulation in the cerebral vasculature, these patients may also develop CHS. Despite the growing number of endovascular reperfusion procedures for acute ischemic stroke, this complication has only rarely been reported. Case Description A 77-year-old man developed acute cerebral infarction as the result of occlusions of the right internal carotid artery and right middle cerebral artery. After systemic intravenous injection of recombinant tissue-type plasminogen activator, endovascular reperfusion therapy was initiated. The occluded arteries were successfully recanalized with thrombectomy by using a stent retriever for the middle cerebral artery and stent placement for the origin of the internal carotid artery. However, head computed tomography obtained 12 hours after treatment showed acute intracranial hemorrhage that did not involve the ischemic lesions. Under evaluation with transcranial near-infrared spectroscopy and single-photon emission computed tomography, the hemorrhage was considered to have been caused by CHS after reperfusion therapy. Conclusions CHS may lead to unfavorable outcomes after reperfusion therapy for acute ischemic stroke. Recognizing clinical deterioration caused by CHS can be challenging in patients with neurologic disorders of acute ischemic stroke. Therefore, it is important to perform routine monitoring of regional cerebral oxygen saturation by using near-infrared spectroscopy, perform single-photon emission computed tomography promptly to evaluate cerebral blood flow, and maintain strict antihypertensive therapy to prevent CHS after reperfusion therapy.

ObjectiveTo explore the recurrence of cervical artery dissection (CeAD).MethodsA single-center consecutive series of 282 CeAD patients was prospectively recruited during first admission from 1995 to 2012. Patients with a follow-up of at least 1 year (n = 238) were eligible for the current analysis. All patients with clinical symptoms or signs of recurrent CeAD on ultrasound were examined by MRI. Dermal connective tissue morphology was studied in 108 (45.4%) patients.ResultsMedian follow-up was 52 months (range 12–204 months). In all, 221 (92.8%) patients presented with monophasic CeAD, including 188 (79.0%) patients with a single CeAD event, 11 (4.6%) with simultaneous dissections in multiple cervical arteries, and 22 (9.2%) with subsequent events within a single phase of 4 weeks. Seventeen patients (7.1%) had late (>1 month after the initial event) recurrent CeAD events, including 5 (2.1%) with multiple recurrences. Patients with late recurrences were younger (37.5 ± 6.9 years) than those without (43.8 ± 9.9; p = 0.011). Ischemic stroke occurred in 164 (68.9%) patients at first diagnosis, but only 4 of 46 (8.7%) subsequent events caused stroke (p < 0.0001), while 19 (41.3%) were asymptomatic. Connective tissue abnormalities were found in 54 (56.3%) patients with monophasic and 8 (66.7%) with late recurrent dissections (p = 0.494).ConclusionTwenty-two (9.2%) patients had new CeAD events within 1 month and 17 (7.1%) later recurrences. The risk for new events was significantly higher (about 60-fold) during the acute phase than during later follow-up. Connective tissue abnormalities were not more frequent in patients with late recurrent events than in those with monophasic CeAD.