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Occlusion due to carotid artery dissection: a more severe disease than previously suggested
Didier Milhaud1, Gabriel R de Freitas, Guy van Melle
1Department of Neurology, University Hospital Lausanne, rue du Bugnon 46, Lausanne 1011, Switzerland.
Insights
Internal carotid artery dissection (ICAD) stroke patients present with fewer risk factors but experience worse outcomes than those with atherothrombosis. Large infarcts in the middle cerebral artery territory contribute to the poorer prognosis in ICAD.
Area of Science:
- Neurology
- Vascular Medicine
- Radiology
Background:
- Stroke due to internal carotid artery dissection (ICAD) is traditionally considered to have a favorable prognosis.
- This study challenges that notion by comparing ICAD with atherothrombotic occlusion (AO).
Purpose of the Study:
- To compare the characteristics and prognosis of acute ischemic stroke patients with internal carotid artery occlusion due to dissection (DO) versus atherothrombosis (AO).
- To determine if the prognosis of DO is worse than classically reported.
Main Methods:
- Retrospective analysis of 3502 patients admitted to a population-based primary care center.
- DO (n=73) and AO (n=81) diagnosed via angiography or MRI.
- Univariate and multivariate analyses compared patient characteristics and outcomes.
Main Results:
- DO patients were younger (44.6 vs. 60.1 years), had fewer vascular risk factors, and presented with more global middle cerebral artery territory infarcts (42% vs. 17%).
- DO patients exhibited more severe clinical impairment, including decreased consciousness, and a poorer 1-month outcome.
- Independent predictors for DO included age <55, non-smoker, no hypertension, headache, and global aphasia.
Conclusions:
- Despite younger age and fewer risk factors, patients with DO have worse clinical features and prognosis than those with AO.
- Extensive middle cerebral artery territory infarcts, potentially due to poor collateral circulation, underlie the adverse prognosis in DO.
Background:
Stroke due to internal carotid artery dissection is considered to have a good prognosis.
Objective:
To determine whether the prognosis of internal carotid artery dissection is worse than classically reported by comparing the characteristics of patients who had an acute ischemic stroke admitted to a population-based primary care center with internal carotid artery occlusion due to either dissection (DO) or atherothrombosis (AO).
Patients And Methods:
Among 3502 patients admitted to our population-based primary care center, DO (n = 73) was diagnosed by angiography or magnetic resonance imaging, while AO (n = 81) was diagnosed by angiography. The characteristics of patients with DO or AO were compared using univariate and multivariate analysis.
Results:
Patients with DO were younger (mean [SD] age, 44.6 [10] vs. 60.1 [10] years, P<.001), had fewer vascular risk factors, and presented more frequently with global middle cerebral artery territory involvement (42% vs. 17%, P<.05) and less frequently with watershed infarcts (3% vs. 19%, P<.05) than patients with AO. Unexpectedly, patients with DO were noted to have more severe clinical impairment, with an increased frequency of decreased consciousness, and a poorer outcome at 1 month. Multivariate analysis showed that the independent factors associated with DO were age younger than 55 years, nonsmoker, no history of hypertension, headache at presentation, and global aphasia.
Conclusions:
Patients with DO are younger and are initially seen with fewer risk factors than patients with AO, but their clinical features and prognosis are worse. Large infarcts involving the whole middle cerebral artery territory that may be due to the lack of collateral circulation are responsible for the bad prognosis of patients with DO.