Spontaneous cerebral and cervical artery dissection: Treatment and prognosis
- David S Liebeskind, MD
David S Liebeskind, MD
- Professor of Neurology
- University of California, Los Angeles
Arterial dissections are a common cause of stroke in the young, but may occur at any age. Dissection occurs when structural integrity of the arterial wall is compromised, allowing blood to collect between layers as an intramural hematoma.
This topic will review the treatment and prognosis of spontaneous cerebral and cervical artery dissection. Other aspects of this disorder are reviewed separately. (See "Spontaneous cerebral and cervical artery dissection: Clinical features and diagnosis".)
The available evidence suggests that treatment with thrombolytic therapy should not be withheld for eligible patients with very early acute ischemic stroke due to extracranial cervical artery dissection (see 'Thrombolysis' below). Beyond the hyperacute period, antithrombotic therapy with either anticoagulation or antiplatelet drugs is accepted treatment for ischemic stroke and transient ischemic attack (TIA) caused by extracranial artery dissection, although there is controversy regarding the choice between the two (see 'Antithrombotic therapy' below). In addition, there is controversy regarding the use of thrombolytics and antithrombotic agents for ischemic symptoms in patients with either intracranial dissection alone or intracranial extension of extracranial dissection because of the presumed increased risk of subarachnoid hemorrhage.
Less often, endovascular methods or surgical repair have been used to treat dissection, mainly for patients who have recurrent ischemia despite antithrombotic therapy (see 'Endovascular and surgical therapy' below).
Optimal treatment of dissection remains a challenge due to limitations in rapidly establishing a definitive diagnosis, the overall low incidence, low recurrence rate, and marked variation in patient characteristics .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kasner SE. CADISS: a feasibility trial that answered its question. Lancet Neurol 2015; 14:342.
- Engelter ST, Rutgers MP, Hatz F, et al. Intravenous thrombolysis in stroke attributable to cervical artery dissection. Stroke 2009; 40:3772.
- Georgiadis D, Baumgartner RW. Thrombolysis in cervical artery dissection. Front Neurol Neurosci 2005; 20:140.
- 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.
- Qureshi AI, Chaudhry SA, Hassan AE, et al. Thrombolytic treatment of patients with acute ischemic stroke related to underlying arterial dissection in the United States. Arch Neurol 2011; 68:1536.
- 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.
- Arnold M, Nedeltchev K, Sturzenegger M, et al. Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature. Arch Neurol 2002; 59:549.
- 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.
- CADISS trial investigators, Markus HS, Hayter E, et al. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol 2015; 14:361.
- Kennedy F, Lanfranconi S, Hicks C, et al. Antiplatelets vs anticoagulation for dissection: CADISS nonrandomized arm and meta-analysis. Neurology 2012; 79:686.
- Chowdhury MM, Sabbagh CN, Jackson D, et al. Antithrombotic treatment for acute extracranial carotid artery dissections: a meta-analysis. Eur J Vasc Endovasc Surg 2015; 50:148.
- Nedeltchev K, Bickel S, Arnold M, et al. R2-recanalization of spontaneous carotid artery dissection. Stroke 2009; 40:499.
- Donas KP, Mayer D, Guber I, et al. Endovascular repair of extracranial carotid artery dissection: current status and level of evidence. J Vasc Interv Radiol 2008; 19:1693.
- Ansari SA, Thompson BG, Gemmete JJ, Gandhi D. Endovascular treatment of distal cervical and intracranial dissections with the neuroform stent. Neurosurgery 2008; 62:636.
- Ecker RD, Levy EI, Hopkins LN. Acute neuroform stenting of a symptomatic petrous dissection. J Invasive Cardiol 2007; 19:E137.
- Cohen JE, Leker RR, Gotkine M, et al. Emergent stenting to treat patients with carotid artery dissection: clinically and radiologically directed therapeutic decision making. Stroke 2003; 34:e254.
- Biondi A, Katz JM, Vallabh J, et al. Progressive symptomatic carotid dissection treated with multiple stents. Stroke 2005; 36:e80.
- Kadkhodayan Y, Jeck DT, Moran CJ, et al. Angioplasty and stenting in carotid dissection with or without associated pseudoaneurysm. AJNR Am J Neuroradiol 2005; 26:2328.
- Edgell RC, Abou-Chebl A, Yadav JS. Endovascular management of spontaneous carotid artery dissection. J Vasc Surg 2005; 42:854.
- 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.
- Ono H, Nakatomi H, Tsutsumi K, et al. Symptomatic recurrence of intracranial arterial dissections: follow-up study of 143 consecutive cases and pathological investigation. Stroke 2013; 44:126.
- Debette S, Compter A, Labeyrie MA, et al. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol 2015; 14:640.
- Mizutani T, Aruga T, Kirino T, et al. Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 1995; 36:905.
- Müller BT, Luther B, Hort W, et al. Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg 2000; 31:980.
- Chiche L, Praquin B, Koskas F, Kieffer E. Spontaneous dissection of the extracranial vertebral artery: indications and long-term outcome of surgical treatment. Ann Vasc Surg 2005; 19:5.
- Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.
- National Institute for Health and Clinical Excellence. Stroke: The diagnosis and acute management of stroke and transient ischaemic attacks. Royal College of Physicians, London 2008. http://www.nice.org.uk/CG068 (Accessed on February 01, 2011).
- Lansberg MG, O'Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e601S.
- Metso TM, Metso AJ, Helenius J, et al. Prognosis and safety of anticoagulation in intracranial artery dissections in adults. Stroke 2007; 38:1837.
- Paciaroni M, Bogousslavsky J. Cerebrovascular complications of neck manipulation. Eur Neurol 2009; 61:112.
- Reuter U, Hämling M, Kavuk I, et al. Vertebral artery dissections after chiropractic neck manipulation in Germany over three years. J Neurol 2006; 253:724.
- Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology 2011; 77:1174.
- Arauz A, Hoyos L, Espinoza C, et al. Dissection of cervical arteries: Long-term follow-up study of 130 consecutive cases. Cerebrovasc Dis 2006; 22:150.
- Arnold M, Bousser MG, Fahrni G, et al. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke 2006; 37:2499.
- Milhaud D, de Freitas GR, van Melle G, Bogousslavsky J. Occlusion due to carotid artery dissection: a more severe disease than previously suggested. Arch Neurol 2002; 59:557.
- Dziewas R, Konrad C, Dräger B, et al. Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003; 250:1179.
- Fischer U, Ledermann I, Nedeltchev K, et al. Quality of life in survivors after cervical artery dissection. J Neurol 2009; 256:443.
- Arauz A, Márquez JM, Artigas C, et al. Recanalization of vertebral artery dissection. Stroke 2010; 41:717.
- Baracchini C, Tonello S, Meneghetti G, Ballotta E. Neurosonographic monitoring of 105 spontaneous cervical artery dissections: a prospective study. Neurology 2010; 75:1864.
- Manabe H, Yonezawa K, Kato T, et al. Incidence of intracranial arterial dissection in non-emergency outpatients complaining of headache: preliminary investigation with MRI/MRA examinations. Acta Neurochir Suppl 2010; 107:41.
- Larsson SC, King A, Madigan J, et al. Prognosis of carotid dissecting aneurysms: Results from CADISS and a systematic review. Neurology 2017; 88:646.
- Touzé E, Gauvrit JY, Moulin T, et al. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology 2003; 61:1347.
- Schievink WI, Mokri B, Piepgras DG, Kuiper JD. Recurrent spontaneous arterial dissections: risk in familial versus nonfamilial disease. Stroke 1996; 27:622.
- Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009; 8:668.
- Dittrich R, Nassenstein I, Bachmann R, et al. Polyarterial clustered recurrence of cervical artery dissection seems to be the rule. Neurology 2007; 69:180.
- Martin JJ, Hausser I, Lyrer P, et al. Familial cervical artery dissections: clinical, morphologic, and genetic studies. Stroke 2006; 37:2924.
- ACUTE ISCHEMIA
- Endovascular methods
- ANTITHROMBOTIC THERAPY
- Duration of antithrombotic therapy
- Endovascular and surgical therapy
- Choosing therapy for primary and secondary prevention of ischemia
- MANAGEMENT OF LOCAL SYMPTOMS
- MANAGEMENT OF SUBARACHNOID HEMORRHAGE
- RISK REDUCTION
- Vessel healing
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS