Management of Spontaneous Dissection of the Cervical Carotid Artery

Abstract

This manuscript reviews the management of patients with spontaneous dissection of the cervical internal carotid artery (sICAD). Recommendations are not based on controlled-randomized trials, but on case-control and observational, hospital-based studies, and case reports. Vascular risk factors seem to be as prevalent in patients with sICAD as in age-matched, healthy volunteers. Stroke prevention includes the treatment of vascular risk factors and the administration of oral aspirin, which may be as effective as anticoagulation. The few available data indicate that most patients with sICAD causing severe stenosis or occlusion, or an aneurysm can be treated conservatively. Patients with sICAD were not excluded in the intravenous controlled-randomized thrombolysis trials with tissue plasminogen activator, but were excluded in the intraarterial controlled-randomized thrombolysis trials. Taking the few published case series and reports on thrombolysis in patients with sICAD into consideration, intravenous thrombolysis may be beneficial, whereas it remains unclear whether intraarterial thrombolysis is useful. This manuscript reviews the management of patients with spontaneous dissection of the cervical internal carotid artery (sICAD). The first part will deal with stroke prevention, in particular the vascular risk factors, antithrombotic therapy, and the treatment of severe stenosis or occlusion, and dissecting aneurysm. The second part will discuss thrombolytic treatment of acute ischemic stroke due to sICAD. Management of Spontaneous Dissection of the Cervical Carotid Artery

Common Carotid Dissection following a Bike Injury—Unusual Cause of Carotid Bruit

“…Risk of stroke with traumatic dissections is reported as 3–44%, and most victims suffer permanent neurologic deficits. 6 Our patient was asymptomatic and her pathology was an incidental finding. It was only in retrospect that the mechanism of injury was identified.…”

“…Coumadin is initiated to reduce the risk of embolic or thrombotic events, and is generally converted to lifelong aspirin therapy after 3–12 months. 6 A small case series describe catheter-directed tissue plasminogen activator thrombolysis and Merci catheter clot extraction, but generally these techniques have been applied only when other efforts fail. There are no designated criteria for use of carotid stenting in this setting, but the technique has been used when there is an expanding dissecting aneurysm, bilateral dissections, or persistent symptoms from low flow state.…”

Non-atherosclerotic Vascular Disease, Biological and Pathological Basis

“…There is no general consensus regarding optimal management of internal carotid artery dissection, but the choice among medical, endovascular, and surgical options may depend on the type of and anatomic location of dissection; while surgery has a limited role, candidates for angioplasty and stent placement include patients with persistent ischemic symptoms despite adequate anticoagulation, patients with a contraindication to anticoagulant therapy, and patients with significantly compromised cerebral blood flow [36,37]. Overall, the prognosis for spontaneous internal carotid artery dissection is favorable, with about 75 % of patients making a good recovery; the reported mortality is less than 5 %.…”

Differenzialdiagnostik seltener Schlaganfallursachen

“…früher beendet werden [36]. Allerdings gibt es Hinweise, dass auch die thrombozytenfunktionshemmende Therapie ausreicht [37][38][39]. Bei rezidivierenden ischämischen Ereignissen unter Therapie kann eine akute Stentversorgung erwogen werden.…”