Diagnosis and Treatment of Arterial Dissections

  • Ricky Medel
  • Robert M. Starke
  • Edison P. Valle-Giler
  • Sheryl Martin-Schild
  • Ramy El Khoury
  • Aaron S. Dumont
Stroke (H Adams, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Stroke

Abstract

Dissections of the cervical and intracranial vessels represent an important source of stroke in those less than 50 years of age. This can occur spontaneously or following trauma, minor or major. Rapid diagnosis is essential to limit subsequent sequelae and modern computed tomographic angiography represents an appropriately sensitive modality. Treatment must be individualized to the patient and can consist of an antiplatelet regimen, anticoagulation, or endovascular intervention. No evidence demonstrates superiority of either medical modality and even aspirin alone may be efficacious. Consideration should be given to this in the multi-trauma population in which more aggressive anticoagulation is contraindicated. In addition, thrombolytic administration should not be withheld would it otherwise be indicated. Endovascular intervention is reserved for those with hemodynamically significant narrowing, enlarging pseudoaneurysms, fistulas formation, or subarachnoid hemorrhage.

Keywords

Carotid artery Dissection Vertebral artery Stroke TIA SAH Trauma Anticoagulation Antiplatelet 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Putaala J, Metso AJ, Metso TM, et al. Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: the Helsinki Young Stroke Registry. Stroke. 2009;40:1195–203. doi:10.1161/STROKEAHA.108.529883.PubMedCrossRefGoogle Scholar
  2. 2.
    Stence NV, Fenton LZ, Goldenberg NA, et al. Craniocervical arterial dissection in children: diagnosis and treatment. Curr Treat Options Neurol. 2011;13:636–48. doi:10.1007/s11940-011-0149-2.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Lee VH, Brown Jr RD, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006;67:1809–12. doi:10.1212/01.wnl.0000244486.30455.71.PubMedCrossRefGoogle Scholar
  4. 4.
    Schievink WI, Mokri B, Whisnant JP. Internal carotid artery dissection in a community. Rochester, Minnesota, 1987-1992. Stroke. 1993;24:1678–80.PubMedCrossRefGoogle Scholar
  5. 5.
    Giroud M, Fayolle H, Andre N, et al. Incidence of internal carotid artery dissection in the community of Dijon. J Neurol Neurosurg Psychiatry. 1994;57:1443.PubMedCrossRefGoogle Scholar
  6. 6.
    Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60:1424–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Albuquerque FC, Hu YC, Dashti SR, et al. Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011;115:1197–205. doi:10.3171/2011.8.JNS111212.PubMedCrossRefGoogle Scholar
  8. 8.
    Engelter ST, Grond-Ginsbach C, Metso TM, et al. Cervical artery dissection: trauma and other potential mechanical trigger events. Neurology. 2013;80:1950–7. doi:10.1212/WNL.0b013e318293e2eb.PubMedCrossRefGoogle Scholar
  9. 9.
    Grau AJ, Buggle F, Ziegler C, et al. Association between acute cerebrovascular ischemia and chronic and recurrent infection. Stroke. 1997;28:1724–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Ringer AJ, Matern E, Parikh S, Levine NB. Screening for blunt cerebrovascular injury: selection criteria for use of angiography. J Neurosurg. 2010;112:1146–9. doi:10.3171/2009.6.jns08416.PubMedCrossRefGoogle Scholar
  11. 11.
    Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP Study. Neurology. 2011;77:1174–81. doi:10.1212/WNL.0b013e31822f03fc.PubMedCrossRefGoogle Scholar
  12. 12.
    von Babo M, De Marchis GM, Sarikaya H, et al. Differences and similarities between spontaneous dissections of the internal carotid artery and the vertebral artery. Stroke. 2013;44:1537–42. doi:10.1161/STROKEAHA.113.001057.CrossRefGoogle Scholar
  13. 13.
    Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18:245–54. doi:10.1097/NRL.0b013e31826754e1.PubMedCrossRefGoogle Scholar
  14. 14.
    Yaghi S, Maalouf N, Keyrouz SG. Cervical artery dissection: risk factors, treatment, and outcome: a 5-year experience from a tertiary care center. Int J Neurosci. 2012;122:40–4. doi:10.3109/00207454.2011.622453.PubMedCrossRefGoogle Scholar
  15. 15.
    Debette S, Metso T, Pezzini A, et al. Association of Vascular risk factors with cervical artery dissection and ischemic stroke in young adults. Circulation. 2011;123:1537–44. doi:10.1161/CIRCULATIONAHA.110.000125.PubMedCrossRefGoogle Scholar
  16. 16.
    Chandra A, Suliman A, Angle N. Spontaneous dissection of the carotid and vertebral arteries: the 10-year USCD experience. Ann Vasc Surg. 2007;21:178–85. doi:10.1016/j.avsg.2006.10.020.PubMedCrossRefGoogle Scholar
  17. 17.
    Sarraj A, Medrek S, Albright K, et al. Posterior circulation stroke is associated with prolonged door-to-needle time. Int J Stroke. 2013. doi:10.1111/j.1747-4949.2012.00952.x.Google Scholar
  18. 18.
    Arnold M, Kurmann R, Galimanis A, et al. Differences in demographic characteristics and risk factors in patients with spontaneous vertebral artery dissections with and without ischemic events. Stroke. 2010;41:802–4. doi:10.1161/STROKEAHA.109.570655.PubMedCrossRefGoogle Scholar
  19. 19.
    Jauch EC, Saver JL, Adams Jr HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947. doi:10.1161/STR.0b013e318284056a.PubMedCrossRefGoogle Scholar
  20. 20.
    Berne JD, Reuland KS, Villarreal DH, et al. Sixteen-slice multi-detector computed tomographic angiography improves the accuracy of screening for blunt cerebrovascular injury. J Trauma. 2006;60:1204–9. doi:10.1097/01.ta.0000220435.55791.ce. discussion 1209–10.PubMedCrossRefGoogle Scholar
  21. 21.
    Hoit DA, Schirmer CM, Weller SJ, et al. Angiographic detection of carotid and vertebral arterial injury in the high-energy blunt trauma patient. J Spinal Disord Tech. 2008;21:259–66. doi:10.1097/BSD.0b013e318141fce8.PubMedCrossRefGoogle Scholar
  22. 22.
    Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236:386–93. doi:10.1097/01.SLA.0000027174.01008.A0. discussion 393–385.PubMedCrossRefGoogle Scholar
  23. 23.
    Biffl WL, Egglin T, Benedetto B, et al. Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries. J Trauma. 2006;60:745–51. doi:10.1097/01.ta.0000204034.94034.c4. discussion 751–42.PubMedCrossRefGoogle Scholar
  24. 24.
    Biffl WL, Moore EE, Elliott JP, et al. The devastating potential of blunt vertebral arterial injuries. Ann Surg. 2000;231:672–81.PubMedCrossRefGoogle Scholar
  25. 25.
    Griessenauer CJ, Fleming JB, Richards BF, et al. Timing and mechanism of ischemic stroke due to extracranial blunt traumatic cerebrovascular injury. J Neurosurg. 2013;118:397–404. doi:10.3171/2012.11.JNS121038.PubMedCrossRefGoogle Scholar
  26. 26.
    Mayberry JC, Brown CV, Mullins RJ, Velmahos GC. Blunt carotid artery injury: the futility of aggressive screening and diagnosis. Arch Surg. 2004;139:609–12. doi:10.1001/archsurg.139.6.609. discussion 612–603.PubMedCrossRefGoogle Scholar
  27. 27.
    Stein DM, Boswell S, Sliker CW, et al. Blunt cerebrovascular injuries: does treatment always matter? J Trauma. 2009;66:132–43. doi:10.1097/TA.0b013e318142d146. discussion 143–134.PubMedCrossRefGoogle Scholar
  28. 28.
    Chen CJ, Tseng YC, Lee TH, et al. Multisection CT angiography compared with catheter angiography in diagnosing vertebral artery dissection. Am J Neuroradiol. 2004;25:769–74.PubMedGoogle Scholar
  29. 29.
    Elijovich L, Kazmi K, Gauvrit JY, Law M. The emerging role of multidetector row CT angiography in the diagnosis of cervical arterial dissection: preliminary study. Neuroradiology. 2006;48:606–12. doi:10.1007/s00234-006-0100-5.PubMedCrossRefGoogle Scholar
  30. 30.
    Houser OW, Mokri B, Sundt Jr TM, et al. Spontaneous cervical cephalic arterial dissection and its residuum: angiographic spectrum. Am J Neuroradiol. 1984;5:27–34.PubMedGoogle Scholar
  31. 31.
    Sliker CW, Shanmuganathan K, Mirvis SE. Diagnosis of blunt cerebrovascular injuries with 16-mdct: accuracy of whole-body MDCT compared with neck MDCT angiography. Am J Roentgenol. 2008;190:790–9. doi:10.2214/AJR.07.2378.CrossRefGoogle Scholar
  32. 32.
    Zuber M, Meary E, Meder JF, Mas JL. Magnetic resonance imaging and dynamic CT scan in cervical artery dissections. Stroke. 1994;25:576–81.PubMedCrossRefGoogle Scholar
  33. 33.
    Eastman AL, Muraliraj V, Sperry JL, Minei JP. CTA-based screening reduces time to diagnosis and stroke rate in blunt cervical vascular injury. J Trauma. 2009;67:551–6. doi:10.1097/TA.0b013e3181b84408. discussion 555–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Chen WL, Chern CH, Wu YL, Lee CH. Vertebral artery dissection and cerebellar infarction following chiropractic manipulation. Emerg Med J. 2006;23:e1. doi:10.1136/emj.2004.015636.PubMedCrossRefGoogle Scholar
  35. 35.
    Cothren CC, Biffl WL, Moore EE, et al. Treatment for blunt cerebrovascular injuries: equivalence of anticoagulation and antiplatelet agents. Arch Surg. 2009;144:685–90. doi:10.1001/archsurg.2009.111.PubMedCrossRefGoogle Scholar
  36. 36.
    Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139:540–5. doi:10.1001/archsurg.139.5.540. discussion 545–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Engelter ST, Brandt T, Debette S, et al. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke. 2007;38:2605–11. doi:10.1161/STROKEAHA.107.489666.PubMedCrossRefGoogle Scholar
  38. 38.
    Georgiadis D, Arnold M, von Buedingen HC, et al. Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients. Neurology. 2009;72:1810–5. doi:10.1212/WNL.0b013e3181a2a50a.PubMedCrossRefGoogle Scholar
  39. 39.
    •• Kennedy F, Lanfranconi S, Hicks C, et al. Antiplatelets vs anticoagulation for dissection: CADISS nonrandomized arm and meta-analysis. Neurology. 2012;79:686–9. doi:10.1212/WNL.0b013e318264e36b. Demonstrates equal effectiveness of both antiplatelet and anticoagulation in arterial dissections.PubMedCrossRefGoogle Scholar
  40. 40.
    Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev. 2010; CD000255. doi: 10.1002/14651858.CD000255.pub2.
  41. 41.
    Harrigan MR, Hadley MN, Dhall SS, et al. Management of vertebral artery injuries following nonpenetrating cervical trauma. Neurosurgery. 2013;72 Suppl 2:234–43. doi:10.1227/NEU.0b013e31827765f5.PubMedCrossRefGoogle Scholar
  42. 42.
    • Engelter ST, Dallongeville J, Kloss M, et al. Thrombolysis in cervical artery dissection--data from the cervical artery dissection and ischaemic stroke patients (CADISP) database. Eur J Neurol. 2012;19:1199–206. doi:10.1111/j.1468-1331.2012.03704.x. Demonstrates safety of thrombolysis in this patient population.PubMedCrossRefGoogle Scholar
  43. 43.
    Engelter ST, Rutgers MP, Hatz F, et al. Intravenous thrombolysis in stroke attributable to cervical artery dissection. Stroke. 2009;40:3772–6. doi:10.1161/STROKEAHA.109.555953.PubMedCrossRefGoogle Scholar
  44. 44.
    Georgiadis D, Lanczik O, Schwab S, et al. IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection. Neurology. 2005;64:1612–4. doi:10.1212/01.WNL.0000159548.45013.C1.PubMedCrossRefGoogle Scholar
  45. 45.
    Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42:2515–20. doi:10.1161/STROKEAHA.111.617282.PubMedCrossRefGoogle Scholar
  46. 46.
    Cohen JE, Ben-Hur T, Rajz G, et al. Endovascular stent-assisted angioplasty in the management of traumatic internal carotid artery dissections. Stroke. 2005;36:e45–7. doi:10.1161/01.STR.0000158910.08024.7f.PubMedCrossRefGoogle Scholar
  47. 47.
    Cohen JE, Gomori JM, Grigoriadis S, et al. Intra-arterial thrombolysis and stent placement for traumatic carotid dissection with subsequent stroke: a combined, simultaneous endovascular approach. J Neurol Sci. 2008;269:172–5. doi:10.1016/j.jns.2007.12.013.PubMedCrossRefGoogle Scholar
  48. 48.
    Cohen JE, Gomori JM, Itshayek E, et al. Single-center experience on endovascular reconstruction of traumatic internal carotid artery dissections. J Trauma Acute Care Surg. 2012;72:216–21. doi:10.1097/TA.0b013e31823f630a.PubMedGoogle Scholar
  49. 49.
    Cohen JE, Gomori JM, Umansky F. Endovascular management of symptomatic vertebral artery dissection achieved using stent angioplasty and emboli protection device. Neurol Res. 2003;25:418–22.PubMedCrossRefGoogle Scholar
  50. 50.
    Edgell RC, Abou-Chebl A, Yadav JS. Endovascular management of spontaneous carotid artery dissection. J Vasc Surg. 2005;42:854–60. doi:10.1016/j.jvs2005.06.029. discussion 860.PubMedCrossRefGoogle Scholar
  51. 51.
    Fava M, Meneses L, Loyola S, et al. Carotid artery dissection: endovascular treatment. report of 12 patients. Catheter Cardiovasc Interv. 2008;71:694–700.PubMedCrossRefGoogle Scholar
  52. 52.
    Lavallee PC, Mazighi M, Saint-Maurice JP, et al. Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion. Stroke. 2007;38:2270–4. doi:10.1161/STROKEAHA.106.481093.PubMedCrossRefGoogle Scholar
  53. 53.
    • Seth R, Obuchowski AM, Zoarski GH. Endovascular repair of traumatic cervical internal carotid artery injuries: a safe and effective treatment option. Am J Neuroradiol. 2013;34:1219–26. doi:10.3174/ajnr.A3337. Demonstrates safety and efficacy of endovascular repair of arterial dissections in a select population.PubMedCrossRefGoogle Scholar
  54. 54.
    Ansari SA, Thompson BG, Gemmete JJ, Gandhi D. Endovascular treatment of distal cervical and intracranial dissections with the neuroform stent. Neurosurgery. 2008;62:636–46. doi:10.1227/01.NEU.0000311350.25281.6B. discussion 636–46.PubMedCrossRefGoogle Scholar
  55. 55.
    Kansagra AP, Cooke DL, English JD, et al. Current trends in endovascular management of traumatic cerebrovascular injury. J Neurointervention Surg. 2013. doi:10.1136/neurintsurg-2012-010605.Google Scholar
  56. 56.
    Hassan AE, Zacharatos H, Rodriguez GJ, et al. Long-term clinical and angiographic outcomes in patients with spontaneous cervico-cranial arterial dissections treated with stent placement. J Neuroimaging. 2012;22:384–93. doi:10.1111/j.1552-6569.2012.00724.x.PubMedCrossRefGoogle Scholar
  57. 57.
    Pham MH, Rahme RJ, Arnaout O, et al. Endovascular stenting of extracranial carotid and vertebral artery dissections: a systematic review of the literature. Neurosurgery. 2011;68:856–66. doi:10.1227/NEU.0b013e318209ce03. discussion 866.PubMedGoogle Scholar
  58. 58.
    de Barros Faria M, Castro RN, Lundquist J, et al. The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms. Am J Neuroradiol. 2011;32:2192–5. doi:10.3174/ajnr.A2671.PubMedCrossRefGoogle Scholar
  59. 59.
    Ducruet AF, Crowley RW, Albuquerque FC, McDougall CG. Reconstructive endovascular treatment of a ruptured vertebral artery dissecting aneurysm using the pipeline embolization device. J Neurointervention Surg. 2013;5:e20. doi:10.1136/neurintsurg-2012-010358.CrossRefGoogle Scholar
  60. 60.
    Fields JD, Lutsep HL, Rymer MR, et al. Endovascular mechanical thrombectomy for the treatment of acute ischemic stroke due to arterial dissection. Interv Neuroradiol. 2012;18:74–9.PubMedCentralPubMedGoogle Scholar
  61. 61.
    Ioannidis I, Nasis N, Andreou A. Endovascular treatment of ruptured dissecting posterior inferior cerebellar artery aneurysms. Interv Neuroradiol. 2012;18:442–8.PubMedCentralPubMedGoogle Scholar
  62. 62.
    Ishihara H, Tateshima S, Jahan R, et al. Endovascular treatment of ruptured dissecting aneurysms of the posterior inferior cerebellar artery. J Neurointervention Surg. 2012;5:557–561. doi:10.1136/neurintsurg-2012-010500.Google Scholar
  63. 63.
    Kashiwazaki D, Ushikoshi S, Asano T, et al. Long-term clinical and radiological results of endovascular internal trapping in vertebral artery dissection. Neuroradiology. 2013;55:201–6. doi:10.1007/s00234-012-1114-9.PubMedCrossRefGoogle Scholar
  64. 64.
    Kim BM, Shin YS, Kim SH, et al. Incidence and risk factors of recurrence after endovascular treatment of intracranial vertebrobasilar dissecting aneurysms. Stroke. 2011;42:2425–30. doi:10.1161/strokeaha.111.617381.PubMedCrossRefGoogle Scholar
  65. 65.
    Kocak B, Tureci E, Kizilkilic O, et al. Dissecting aneurysms of posterior communicating artery itself: anatomical, diagnostic, clinical, and therapeutical considerations. Neuroradiology. 2013;55:1103–12. doi:10.1007/s00234-013-1212-3.PubMedCrossRefGoogle Scholar
  66. 66.
    Lama S, Dolati P, Sutherland GR. Controversy in the management of lenticulostriate artery dissecting aneurysm: a case report and review of the literature. World Neurosurg. 2012. doi:10.1016/j.wneu.2012.12.006.Google Scholar
  67. 67.
    Wang H, Du R, Stary J, et al. Dissecting aneurysms of the posterior cerebral artery: current endovascular/surgical evaluation and treatment strategies. Neurosurgery. 2012;70:1581–8. doi:10.1227/NEU.0b013e31824c00f4. discussion 1588.PubMedCrossRefGoogle Scholar
  68. 68.
    Yeung TW, Lai V, Lau HY, et al. Long-term outcome of endovascular reconstruction with the pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery. J Neurosurg. 2012;116:882–7. doi:10.3171/2011.12.JNS111514.PubMedCrossRefGoogle Scholar
  69. 69.
    Ali MS, Amenta PS, Starke RM, et al. Intracranial vertebral artery dissections: evolving perspectives. Interv Neuroradiol. 2012;18:469–83.PubMedCentralPubMedGoogle Scholar
  70. 70.
    Narata AP, Yilmaz H, Schaller K, et al. Flow-diverting stent for ruptured intracranial dissecting aneurysm of vertebral artery. Neurosurgery. 2012;70:982–8. doi:10.1227/NEU.0b013e318236715e. discussion 988–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Ricky Medel
    • 1
  • Robert M. Starke
    • 2
  • Edison P. Valle-Giler
    • 1
  • Sheryl Martin-Schild
    • 3
  • Ramy El Khoury
    • 3
  • Aaron S. Dumont
    • 1
  1. 1.Department of NeurosurgeryTulane University School of MedicineNew OrleansUSA
  2. 2.Department of NeurosurgeryUniversity of Virginia School of MedicineCharlottesvilleUSA
  3. 3.Department of NeurologyTulane University School of MedicineNew OrleansUSA

Personalised recommendations