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Outcome of extracranial cervicocephalic arterial dissections: a follow-up study
Fernando Gonzales-Portillo1, Askiel Bruno, José Biller
1Department of Neurology, The University of Arizona Health Sciences Center, Tucson 85724-5023, USA.
Insights
Cervicocephalic arterial dissections (CCAD) in young adults often lead to ischemic stroke. Medical management with anticoagulants or antiplatelets generally yields favorable outcomes, making it the recommended initial approach.
Area of Science:
- Neurology
- Vascular Medicine
- Stroke Research
Background:
- Cervicocephalic arterial dissections (CCAD) are a significant cause of ischemic stroke, particularly in younger populations.
- Current treatment strategies lack robust evidence from controlled trials, with options including medical therapy and surgical or endovascular interventions.
Purpose of the Study:
- To review the management and outcomes of extracranial CCAD in a cohort of patients treated and followed by a dedicated Stroke Service.
- To evaluate the effectiveness of different treatment modalities, focusing on medical management.
Main Methods:
- Retrospective review of 27 patients with extracranial CCAD diagnosed between September 1995 and August 2001.
- Data collection included clinical presentation, diagnostic methods (cerebral angiography, MRI/MRA), management strategies (anticoagulation, antiplatelet therapy), and patient outcomes.
- Follow-up duration ranged from 2 to 115 months.
Main Results:
- The majority of patients (85%) experienced favorable outcomes with no or minor disability (modified Rankin score 0-1).
- Internal carotid artery (ICA) was the most frequently affected vessel (63%).
- Anticoagulant therapy was administered to 18 patients, and nine received antiplatelet agents, both showing generally positive short- and long-term results.
Conclusions:
- Extracranial CCAD, predominantly involving the ICA, presents variably but often results in ischemic stroke or TIAs.
- Medical management, including anticoagulation or antiplatelet therapy, is recommended as the initial approach for most patients due to favorable outcomes.
- While interventions like angioplasty and stenting are used, their long-term efficacy requires further investigation.
Abstract:
Cervicocephalic arterial dissections (CCAD) are an increasingly recognized cause of ischemic stroke in young adults. Various treatments have been suggested but no controlled trial has ever been performed. Medical treatment has included anticoagulant or platelet antiaggregant therapy. Surgical correction has been proposed for selected patients who have failed medical therapy. Percutaneous balloon angioplasty and stenting have been increasingly used in some patients, although long-term results are unknown. The objective of the study was to review our recent experience with the management and outcome of extracranial CCAD. We identified 27 patients with extracranial CCAD who were evaluated, treated and/or followed by our Stroke Service from September 1995 to August 2001. Clinical presentation, diagnostic evaluation, management, and outcome were reviewed. There were 15 men (56%) and 12 women (44%) with mean ages of 38 and 43 years respectively. Diagnosis was made by cerebral angiography in 15 (56%) patients and by MRI/MRA only in 12 (44%) patients. Twenty-two patients had spontaneous and five had traumatic extracranial CCAD. Most common associated disorders were arterial hypertension (37%) and migraine (26%). One patient presented only with a painful post-ganglionic Horner syndrome, another patient with neck pain and post-ganglionic Horner syndrome, another patient solely with protracted unilateral headaches, three with transient ischemic attacks (TIA), and 21 with ischemic strokes. The internal carotid artery (ICA) was the most frequently involved vessel (63%), followed by the vertebral artery (30%, and multivessel involvement in two patients (7%). Eighteen patients received anticoagulant therapy and nine platelet anti-aggregants. Follow-up extended from 2 to 115 months, with a mean of 58 months. At the end of follow-up, 23 (85%) patients had either no disability or only minor sequelae (modified Rankin score: 0 to 1), and four (15%) patients had moderate limitations (modified Rankin score: 2 to 3). Two patients had a recurrent ischemic stroke, one unrelated to recurrent CCAD, and the other following percutaneous balloon angioplasty/stenting for treatment of a persistent vertebral artery pseudoaneurysm. Most CCAD involved the extracranial ICA. The clinical presentation is variable, most patients having an ischemic stroke or TIAs. The short- and long-term outcome are usually favorable with either anticoagulant or platelet antiaggregant therapy. A medical initial approach to the management of extracranial CCAD is recommended for most patients.