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Cervical artery dissections
Insights
Cervical artery dissection (CAD) is a significant cause of stroke in young adults, often presenting with pain or neurological deficits. Early noninvasive detection and monitoring are crucial for managing this condition.
Area of Science:
- Neurology
- Vascular Medicine
- Radiology
Background:
- Cervical artery dissection (CAD) is a leading cause of ischemic stroke in individuals under 45.
- It is increasingly recognized due to heightened clinical awareness, particularly in patients experiencing painful ischemic events.
- The internal carotid artery is the most frequently affected vessel, with cerebral ischemia being the most severe complication.
Purpose of the Study:
- To summarize the current understanding of cervical artery dissection (CAD).
- To highlight the importance of noninvasive diagnostic and monitoring approaches.
- To discuss the clinical presentation, incidence, and prognosis of CAD.
Main Methods:
- Review of existing literature on cervical artery dissection (CAD).
- Discussion of diagnostic modalities including CT scan, MRI, MRA, and ultrasonography.
- Analysis of clinical presentation, predisposing factors, and treatment approaches.
Main Results:
- CAD typically affects young adults (mean age 40) with a male predominance.
- Incidence is estimated at 2.6 per 100,000 annually, likely underestimated.
- Clinical presentations vary, including cerebral ischemia, pain (cervical, cranial, occipital), Horner's syndrome, and cranial nerve palsy.
Conclusions:
- CAD has a favorable natural history, supporting noninvasive detection and follow-up.
- While angiography is the gold standard, noninvasive imaging plays a key role.
- The efficacy of heparin treatment in the acute stage remains unproven by randomized trials.
Abstract:
Cervical artery dissection (CAD) accounts for up to one fifth of ischemic strokes occurring before 45 years. Their increasing recognition is probably due to an increased clinical awareness of this condition in patients with painful ischemic events. The internal carotid artery is the most commonly affected vessel. Cerebral ischemia is the most serious consequence of a CAD. It may be due to hemodynamic factors or emboli. The enlargement of the artery may lead to a direct compression of the lower cranial nerves. CAD typically occurs in young adults with a mean age of 40 years with a male:female ratio of 1.5. After exclusion of traumatic cases, the average annual incidence rate of CAD is 2.6 per 100,000, but the reported incidence figures in the literature are likely to be an underestimation of the incidence of CAD. A spontaneous dissection is assumed when no or only minor trauma preceded the onset. However, the differentiation between spontaneous and traumatic dissections is artificial because of a continuum between both forms. The pathogenesis of dissections remains unknown in most cases. However, traumas and primary diseases of the arterial wall are the main predisposing factors. The clinical presentation of spontaneous dissections of the internal carotid artery includes cerebral ischemia, cervical or cranial pain, Horner's syndrome and cranial nerve palsy; CAD may also be silent. Brainstem ischemic deficits and occipital pain are the most common findings in vertebral artery dissections, but these features may be biased because the most benign and the most severe cases may escape detection. The favorable natural history of CAD emphasizes the need for a noninvasive approach to the detection, monitoring and follow-up. This noninvasive approach can be obtained by means of CT scan, MRI, magnetic resonance angiography and ultrasonography, although angiography remains the gold standard for the diagnosis of arterial dissections. Follow-up studies suggest a fairly good overall prognosis in adults and in children. In many centers, CAD are treated by heparin at the acute stage, although the benefit of such a potentially dangerous treatment has never been proven by a randomized trial.