Cervical Carotid Artery Dissection

Patel, Raj Ramabhai; Adam, Richard; Maldjian, Catherine; Lincoln, Christie M.; Yuen, Annie; Arneja, Amrita

doi:10.1097/crd.0b013e318247cd15

Cited by 103 publications

(35 citation statements)

References 136 publications

(335 reference statements)

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“…There is one meta-analysis of retrospective cases in which patients had received thrombolysis after experiencing a CAD-related stroke [29]; this reported that 3.1% suffered SICH, and in these patients, mortality was 9.0%, which are similar rates as found in our meta-analysis and also in the European Cooperative Acute Stroke Study III studies and SITS-ISTR [27,31]. In addition, we found that patients with intracranial extension of dissection had a high SICH rate and mortality in a multicenter study [32], in agreement with the view of some clinicians, fearing that sub-adventitial dissections with intracranial extension especially in posterior circulation treated with tPA could cause bleeding into the adjacent tissue, resulting in SICH or subarachnoid hemorrhage [22,33,34]. However, 3 earlier studies indicated that thrombolysis was not any more likely to adversely affect patients with intracranial extension of dissection more than other patients [35,36,37].…”

Section: Discussionsupporting

confidence: 69%

Safety and Efficacy of Thrombolysis in Cervical Artery Dissection-Related Ischemic Stroke: A Meta-Analysis of Observational Studies

Lin¹,

Sun²,

Zhao³

et al. 2016

Cerebrovasc Dis

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Background: Although thrombolysis is considered to be the first-line treatment for ischemic stroke, there remains an ongoing controversy on the safety and efficacy of thrombolysis in cervical artery dissection (CAD). The aim of this meta-analysis was to assess observational data related to the safety and efficacy of thrombolysis in CAD-related ischemic stroke. Methods: We performed a systematic search of the efficacy of thrombolysis treatment in CAD-related ischemic stroke with appropriate observational studies identified for the study. The meta-analysis models in Comprehensive Meta-Analysis V2 software were applied to calculate the merged rates of favorable outcome (modified Rankin Scale, mRS 0-2), excellent outcome (mRS 0-1), intracranial hemorrhage (ICH), symptomatic ICH (SICH), mortality and recurrent stroke between thrombolysis and non-thrombolysis in CAD-related stroke. The difference of outcomes and adverse events between the 2 groups was compared by analyzing the pooled OR value and chi-square test using the software SPSS. Results: A total of 846 patients were identified from 10 studies (174 with thrombolysis; 672 with non-thrombolysis). The meta-analysis detected no significant statistical difference in the proportion of CAD-related stroke patients enjoying a favorable outcome at the 3 months' follow-up between the thrombolysis and non-thrombolysis groups (53.7 vs. 58.2%, OR 0.782, χ² = 0.594, p > 0.05); non-thrombolysis was slightly superior than thrombolysis in terms of excellent outcome (52.4 vs. 34.4%, OR 0.489, χ² = 9.143, p = 0.002). There was no significant difference in SICH, mortality and recurrent stroke rates between the 2 groups (all p > 0.05). ICH rate was higher in the thrombolysis group of CAD-related stroke patients compared to that in the non-thrombolysis group (12.3 vs. 7.4%, OR 2.647, χ² = 4.127, p = 0.042). Conclusion: Thrombolysis seems to be equally safe and will achieve an efficacy similar to the efficacy of non-thrombolysis in patients with acute ischemic stroke due to CAD. It is also as effective as thrombolysis in stroke from miscellaneous causes. Therefore, CAD patients experiencing a stroke should not be denied thrombolysis therapy. However, this will need to be confirmed in large-scale randomized studies, especially involving intravenous thrombolysis treatment.

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Section: Discussionsupporting

confidence: 69%

Safety and Efficacy of Thrombolysis in Cervical Artery Dissection-Related Ischemic Stroke: A Meta-Analysis of Observational Studies

Lin¹,

Sun²,

Zhao³

et al. 2016

Cerebrovasc Dis

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“…brain injuries, fractures, etc.) [1, 6, 13, 14]. But it also has certain limits, especially during the diagnostic of critically injured patients in the trauma room.…”

Section: Discussionmentioning

confidence: 99%

Traumatic bilateral carotid artery dissection following severe blunt trauma: a case report on the difficulties in diagnosis and therapy of an often overlooked life-threatening injury

et al. 2015

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BackgroundTraumatic carotid artery dissections are very rare, often overlooked and life-threatening injuries. Diagnosis and treatment are difficult especially in multiple injured patients.Case presentationWe report on a 28-year-old female major trauma patient (injury severity score, ISS 50) who was involved in a motor vehicle accident. She was primarily transferred to a level II trauma center. After initial assessment and operative management, an anisocoria was diagnosed on the intensive care unit. Subsequent CT angiography and extracranial duplex sonography revealed a bilateral internal carotid artery dissection. The patient was transferred to our level I trauma center where conservative treatment with high-dose heparin therapy was started at day two after trauma. Outcome after 6 months was very good.ConclusionBesides presenting the case and outcome of this patient, the article discusses the diagnostic and therapeutic management of this extremely rare and often overlooked dangerous injury. To avoid overlooking carotid artery dissections, CT angiography of the neck region should be generously included into the initial multislice CT whole-body scan, when the injury results from an according trauma. For the best outcome, sites of hemorrhage should be abolished quickly and the anticoagulative therapy should be initiated as soon as possible. Interdisciplinary treatment of trauma surgeons and neurologists is crucial.

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“…Despite many prospective observational studies, there remains much debate over the treatment choice in CAD [12,13,14,15,16,17,18]. Therefore, the decision to choose an antithrombotic agent and duration of treatment for CAD remains empiric and requires customizing to patient-specific risks and benefits.…”

Section: Discussionmentioning

confidence: 99%

Efficacy and Safety of Novel Oral Anticoagulants in Patients with Cervical Artery Dissections

Caprio¹,

Bernstein²,

Alberts³

et al. 2014

Cerebrovasc Dis

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Background: American and European guidelines support antiplatelet agents and anticoagulants as reasonable treatments of cervical artery dissection (CAD), though randomized clinical trials are lacking. The utility of novel oral anticoagulants (NOAC), effective in reducing embolic stroke risk in non-valvular atrial fibrillation (NVAF), has not been reported in patients with CAD. We report on the use, safety, and efficacy of NOACs in the treatment of CAD. Methods: We retrospectively identified patients diagnosed with CAD at a single academic center between January 2010 and August 2013. Patients were categorized by their antithrombotic treatment at hospital discharge with a NOAC (dabigatran, rivaroxaban, or apixaban), traditional anticoagulant (AC: warfarin or treatment dose low-molecular weight heparin), or antiplatelet agent (AP: aspirin, clopidogrel, or aspirin/extended-release dypyridamole). Using appropriate tests, we compared the baseline medical history, presenting clinical symptoms and initial radiographic characteristics among patients in the 3 treatment groups. We then evaluated for the following outcomes: recurrent stroke, vessel recanalization, and bleeding complications. p values <0.05 were considered significant. Results: Of the 149 included patients (mean age 43.4 years; 63.1% female; 70.5% vertebral artery CAD), 39 (26.2%), 70 (47.0%), and 40 (26.8%) were treated with a NOAC, AC, and AP, respectively. More patients with severe stenosis or occlusion were treated with NOAC than with AC or AP (61.8 vs. 60.0 vs. 22.5%, p = 0.002). Other baseline clinical and radiographic findings, including the presence of acute infarction and hematoma, did not differ between the 3 treatment groups. One hundred and thirty-five (90.6%) patients had clinical follow-up (median time 7.5 months) and 125 (83.9%) had radiographic follow-up (median time 5 months) information. There were 2 recurrent strokes in the NOAC group and 1 in each of the AC and AP groups (p = 0.822). There were more major hemorrhagic events in the AC group (11.4%) compared to the NOAC (0.0%) and AP (2.5%) groups (p = 0.034). Three patients treated with NOAC and none treated with AC or AP had a worsened degree of stenosis on follow-up imaging (8.6 vs. 0.0 vs. 0.0%, p = 0.019). Conclusion: Compared to traditional anticoagulants for CAD, treatment with NOACs is associated with similar rates of recurrent stroke, fewer hemorrhagic complications, but greater rates of radiographic worsening. These data suggest that NOACs may be a reasonable alternative in the management of CAD. Prospective validation of these findings is needed.

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Cervical Carotid Artery Dissection

Cited by 103 publications

References 136 publications

Safety and Efficacy of Thrombolysis in Cervical Artery Dissection-Related Ischemic Stroke: A Meta-Analysis of Observational Studies

Safety and Efficacy of Thrombolysis in Cervical Artery Dissection-Related Ischemic Stroke: A Meta-Analysis of Observational Studies

Traumatic bilateral carotid artery dissection following severe blunt trauma: a case report on the difficulties in diagnosis and therapy of an often overlooked life-threatening injury

Efficacy and Safety of Novel Oral Anticoagulants in Patients with Cervical Artery Dissections

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