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Carotid dissection with permanent and transient occlusion or severe stenosis: Long-term outcome
C Kremer1, M Mosso, D Georgiadis
1Department of Neurology, University Hospitals of Zürich (Drs. Kremer, Mosso, Georgiadis, Benninger, Baumgartner, Bern, Switzerland. christine.kremer@nos.usz.ch
Insights
Internal carotid artery dissection (ICAD) has a favorable long-term prognosis. The persistence of severe stenosis or occlusion does not increase stroke risk, questioning the need for revascularization procedures.
Area of Science:
- Neurology
- Vascular Surgery
- Cardiology
Background:
- Spontaneous internal carotid artery dissection (ICAD) can lead to severe stenosis or occlusion.
- Long-term outcomes and the impact of stenosis persistence in ICAD are not fully understood.
Purpose of the Study:
- To compare ischemic events and intracranial hemorrhage rates in patients with persistent versus transient severe internal carotid artery stenosis/occlusion after ICAD.
- To evaluate the long-term prognosis of ICAD.
Main Methods:
- Retrospective analysis of 161 patients with unilateral ICAD.
- Comparison of 46 patients with persistent severe stenosis/occlusion and 46 matched patients with transient stenosis/occlusion.
- Annual clinical follow-ups, excluding patients who received surgical, endovascular, or fibrinolytic therapy.
Main Results:
- Similar antithrombotic therapy and follow-up durations in both groups (permanent: 6.2 years, transient: 7.2 years).
- Permanent stenosis/occlusion showed annual rates of 0.7% for ipsilateral stroke and 1.4% for any stroke.
- Transient stenosis/occlusion showed lower annual rates of 0.3% for ipsilateral stroke and 0.6% for any stroke.
Conclusions:
- ICAD generally has a benign long-term prognosis with low stroke rates.
- Stroke risk in ICAD is not significantly associated with the persistence of severe carotid stenosis or occlusion.
- Findings challenge the routine use of surgical or catheter-based revascularization for ICAD.
Objective:
To compare the rate of ischemic events and intracranial hemorrhage in the long-term follow-up of patients with persistent and transient severe stenosis or occlusion of the internal carotid artery (ICA) due to spontaneous dissection (ICAD).
Methods:
One hundred and sixty-one consecutive patients with unilateral ICAD causing severe stenosis or occlusion were examined clinically and by ultrasound 1 year after symptom onset. Forty-six cases with persistent and 46 age- and latency-matched cases with transient (recanalization complete or less than 50% stenosis) severe stenosis or occlusion of the ICA were enrolled. Nine patients with surgical, endovascular, or fibrinolytic therapy for ICAD or associated stroke were excluded. Antithrombotic therapy was given at the discretion of the treating physician. Clinical follow-ups were done annually.
Results:
Antithrombotic therapy and follow-up were similar in patients with permanent (6.2 +/- 3.4 years) and transient (7.2 +/- 4.3 years) severe stenosis or occlusion of the ICA. Cases with permanent carotid stenosis or occlusion showed annual rates of 0.7% for ipsilateral carotid territory stroke and of 1.4% for any stroke. Cases with transient carotid stenosis or occlusion showed annual rates of 0.3% for ipsilateral carotid territory stroke and of 0.6% for any stroke.
Conclusions:
This study suggests that ICAD has a benign long-term prognosis with low rates of ipsilateral carotid territory and any stroke and that the stroke rate in ICAD is not related to the persistence of severe carotid stenosis or occlusion. These results question the rationale of surgical or catheter-based revascularization in patients with ICAD.