Clinical Characteristics of Symptomatic Vertebral Artery Dissection

Gottesman, Rebecca F.; Sharma, Priti; Robinson, Karen A.; Arnan, Martinson; Tsui, Megan; Ladha, Karim; Newman‐Toker, David E.

doi:10.1097/nrl.0b013e31826754e1

Cited by 132 publications

(109 citation statements)

References 78 publications

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“…26,178 The absence of an external elastic lamina and a thinner adventitia results in intracranial arteries being prone to subadventitial dissection and resultant SAH, reported more commonly in intracranial VADs. 5,171,172,[179][180][181][182][183][184] Histological studies of CDs typically show tearing in the intima and media and hemorrhagic dissection within the outer layers of the tunica media, which may result in severe stenosis. The dissection tract typically contains fibrovascular granulation tissue with collections of red blood cells, fibrin, proliferating fibroblasts, early neovascularization changes, and hemosiderin-containing macrophages.…”

Section: Pathologymentioning

confidence: 99%

“…In such patients and under some circumstances, endovascular or surgical intervention, in addition to limiting the use of antithrombotic agents, particularly among those with aneurysmatic intracranial vertebrobasilar artery dissection, may be considered. 171,172,179,[194][195][196][197][198][199][200][201][202] Treatment can be categorized as acute management and secondary prevention. Acutely, treatment is focused on the re-establishment of blood flow to brain tissue at risk.…”

Section: Treatment Of Cdsmentioning

confidence: 99%

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Cervical Arterial Dissections and Association With Cervical Manipulative Therapy

Biller¹,

Sacco²,

Albuquerque³

et al. 2014

Stroke

179

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3155Purpose-Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults.The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional. Methods-Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. Results-Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.

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Section: Pathologymentioning

confidence: 99%

Section: Treatment Of Cdsmentioning

confidence: 99%

Cervical Arterial Dissections and Association With Cervical Manipulative Therapy

Biller¹,

Sacco²,

Albuquerque³

et al. 2014

Stroke

179

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“…21 Furthermore, risk factor stratification might tend to miss younger stroke patients presenting with dizziness, who often lack traditional vascular risk factors, having vertebral artery dissection rather than atherosclerosis as the cause for posterior fossa infarction. 23,24 A well-studied expert approach relies on differentiating transient from persistent dizziness and then examining eye movements. 8,18,[25][26][27] Most stroke patients present with persistent symptoms.…”

mentioning

confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

Self Cite

316

351

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ObjectivesDizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).MethodsThis was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.ResultsA total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.ConclusionsHINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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“…As of 2 years after onset, no neck pain has recurred and the patient had returned to her previous work. In Japan, 232 (82%) and 30 (11%) of 283 cases diagnosed as VAD were IVAD and EVAD, respectively [2], whereas 378 (74%) and 134 (26%) of 512 cases were IVAD and EVAD, respectively, in a systematic review of cases in western countries [3]. These data demonstrate that the frequency of EVAD in Japan is less than half that in western countries.…”

Section: Case Reportmentioning

confidence: 98%

Spontaneous Extracranial Vertebral Artery Dissociation: A Case Report and Review of the Literature

Kamakura¹,

Iida²,

Hasegawa³

et al. 2018

OJO

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We encountered a 36-year-old female who developed extracranial vertebral artery dissociation (EVAD), which is a rare condition in Japan. The disease developed with sudden severe right side neck pain and right upper arm pain. No abnormality was observed in the spinal canal, intervertebral discs, spinal cord, or nerve roots on MRI of the cervical spine, but dilation and double lumen were noted in the vertebral artery (VA) at the C4/5 level. The presence of aneurysm was confirmed by VA angiography, and EVAD was diagnosed. The symptoms were resolved by conservative treatment of pain, and the aneurysm shrank and disappeared with time on VA angiography. Even though neck and upper limb pain are the only clinical symptom and there is no brain dysfunction, such as disturbance of consciousness and vertigo, when symptoms develop acutely, this pathology should be included in differential diagnosis and orthopedists should carefully observe the vertebral artery, as well as the spinal canal, in evaluating cervical MRI.

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Clinical Characteristics of Symptomatic Vertebral Artery Dissection

Cited by 132 publications

References 78 publications

Cervical Arterial Dissections and Association With Cervical Manipulative Therapy

Cervical Arterial Dissections and Association With Cervical Manipulative Therapy

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Spontaneous Extracranial Vertebral Artery Dissociation: A Case Report and Review of the Literature

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