Hostname: page-component-8448b6f56d-mp689 Total loading time: 0 Render date: 2024-04-18T00:27:51.468Z Has data issue: false hasContentIssue false
  • English
  • Français

Extracranial Carotid and Vertebral Artery Dissection: A Review

Published online by Cambridge University Press:  02 December 2014

Gary John Redekop
Gary John Redekop*
Affiliation:
Division of Neurosurgery, Vancouver General Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

Dissection of the extracranial carotid and vertebral arteries is increasingly recognized as a cause of transient ischemic attacks and stroke. The annual incidence of spontaneous carotid artery dissection is 2.5 to 3 per 100,000, while the annual incidence of spontaneous vertebral artery dissection is 1 to 1.5 per 100,000. Traumatic dissection occurs in approximately 1% of all patients with blunt injury mechanisms, and is frequently initially unrecognized. Overall, dissections are estimated to account for only 2% of all ischemic strokes, but they are an important factor in the young, and account for approximately 20% of strokes in patients less than 45 years of age. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe stenosis or occlusion. Available evidence strongly favors embolism as the most common cause. Both anticoagulation and antiplatelet agents have been advocated as treatment methods, but there is limited evidence on which to base these recommendations. A Cochrane review on the topic of antithrombotic drugs for carotid dissection did not identify any randomized trials, and did not find that anticoagulants were superior to antiplatelet agents for the primary outcomes of death and disability. Healing of arterial dissections occurs within three to six months, with resolution of stenosis seen in 90%, and recanalization of occlusions in as many as 50%. Dissecting aneurysms resolve on follow-up imaging in 5- 40%, decrease in size in 15-30%, and remain unchanged in 50-65%. Resolution is more common in vertebral dissections than in carotid dissections. Aneurysm enlargement occurs rarely. The uncommon patient presenting with acute hemodynamic insufficiency should be managed with measures to increase cerebral blood flow, and in this setting emergency stent placement to restore cerebral perfusion may be considered, provided that irreversible infarction has not already occurred.

Résumé:

<span class='bold'>RÉSUMÉ</span>:

On reconnaît de plus en plus que la dissection de la portion extracrânienne de la carotide et de l’artère vertébrale peut être une cause d’ischémie cérébrale transitoire (ICT) et d’accident vasculaire cérébral (AVC). L’incidence annuelle de la dissection spontanée de la carotide est de 2,5 à 3 par 100,000 alors qu’elle est de 1 à 1,5 par 100,000 pour la dissection spontanée de l’artère vertébrale. La dissection traumatique survient chez à peu près 1% de tous les patients qui subissent une contusion et passe souvent inaperçue lors de l’évaluation initiale. On estime que les dissections sont responsables de seulement 2% de tous les accidents ischémiques, mais elles constituent un facteur important chez les jeunes et elles sont la cause d’à peu près 20% des accidents vasculaires chez les patients de moins de 45 ans. La dissection artérielle peut causer un accident ischémique soit par thromboembolie à l’endroit du traumatisme ou à cause de l’insuffisance hémodynamique due à une sténose sévère ou à une occlusion. Selon les données actuelles, la cause la plus fréquente serait l’embolie. Les anticoagulants et les antiplaquettaires ont été proposés comme traitement, mais il existe peu de données pour étayer ces recommandations. Une revue systématique (Cochrane Library) portant sur l’administration d’antithrombotiques dans la dissection carotidienne n’a pas identifié d’essai randomisé et n’a pas déterminé si les anticoagulants étaient supérieurs aux agents antiplaquettaires quand le critère d’évaluation principal était le décès et l’invalidité. Une dissection artérielle guérit en 3 à 6 mois, avec résolution de la sténose dans 90% des cas et recanalisation de l’occlusion dans 50% des cas. Le suivi par imagerie des anévrismes disséquant démontre une résolution dans 5 à 40% des cas, une diminution de la taille de l’anévrisme dans 15 à 30% des cas et aucun changement dans 50 à 65% des cas. La résolution est plus fréquente dans les dissections vertébrales que dans les dissections carotidiennes. On observe rarement une augmentation de la taille de l’anévrisme. Chez les rares patients qui présentent une insuffisance hémodynamique aiguë, le traitement en phase aiguë vise à augmenter la perfusion cérébrale et on peut envisager la mise en place d’un stent d’urgence en l’absence d’infarctus irréversible.

Type
Review Article
Information
Canadian Journal of Neurological Sciences , Volume 35 , Issue 2 , May 2008 , pp. 146 - 152
Copyright
Copyright © The Canadian Journal of Neurological 2008

References

1. Lee, V, Brown, R, Mandrekar, J, Mokri, B. Incidence and outcome of cervical artery dissection; a population-based study. Neurology. 2006; 67:1809–12.CrossRefGoogle ScholarPubMed
2. Caplan, L, Biousse, V. Cervicocranial arterial dissections. J Neuroophthalmol. 2004; 24:299–305.Google Scholar
3. Schievink, W. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001; 344:898–906.CrossRefGoogle ScholarPubMed
4. Dziewas, R, Konrad, C, Drager, B, Evers, S, Besselmann, M, Ludemann, P, et al. Cervical artery dissection - clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003; 250:1179–84.CrossRefGoogle ScholarPubMed
5. Rubinstein, S, Peerdeman, S, van Tulder, M, Riphagen, I, Haldeman, S. A systematic review of the risk factors for cervical artery dissection. Stroke. 2005; 36:1575–80.CrossRefGoogle ScholarPubMed
6. Norris, J. Extracranial arterial dissection - anticoagulation is the treatment of choice: for. Stroke. 2005; 36:2041–2.Google Scholar
7. Lyrer, P. Extracranial arterial dissection - anticoagulation is the treatment of choice: against. Stroke. 2005; 36:2042–3.Google Scholar
8. Georgiadis, D, Caso, V, Baumgartner, R. Acute therapy and prevention of stroke in spontaneous carotid dissection. Clin Exp Hypertens. 2006; 28:365–70.Google Scholar
9. Lyrer, P, Engelter, S. Antithrombotic drugs for carotid artery dissection. Stroke. 2004; 35:613–4.Google Scholar
10. Lyrer, P, Engelter, S. Antithrombotic drugs for carotid artery dissection (Cochrane Review). Oxford, UK: Cochrane Library; 2006; Volume 1.Google Scholar
11. Beletsky, V, Nadareishvili, Z, Lynch, J, Shuaib, A, Woolfenden, A, Norris, J. Cervical arterial dissection; time for a therapeutic trial? Stroke. 2003; 34:2856–60.Google Scholar
12. Flis, C, Jager, H, Sidhu, P. Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol. 2007; 17:820–34.Google Scholar
13. Kremer, C, Mosso, M, Georgiadis, D, Stockli, E, Benninger, D, Arnold, M, et al. Carotid dissection with permanent and transient occlusion or severe stenosis: long term outcome. Neurology. 2003; 60:271–5.CrossRefGoogle ScholarPubMed
14. Biffl, W, Moore, E, Elliott, J, Ray, C, Offner, P, Franciose, R, et al. The devastating potential of blunt vertebral artery injuries. Ann Surg. 2000; 231:672–81.CrossRefGoogle Scholar
15. Carillo, E, Osborne, D, Spain, D, Miller, F, Senler, S, Richardson, J. Blunt carotid artery injuries: difficulties with the diagnosis prior to the neurologic event. J Trauma. 1999; 46:1120–5.CrossRefGoogle Scholar
16. Fabian, T, Patton, J, Croce, M, Minard, G, Kudsk, K, Pritchard, F. Blunt carotid injury: the importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996; 223:513–25.Google Scholar
17. Inamasu, J, Guiot, B. Vertebral artery injury after blunt cervical trauma: an update. Surg Neurol. 2006; 65:238–46.CrossRefGoogle ScholarPubMed
18. McKevitt, E, Kirkpatrick, A, Vertesi, L, Granger, R, Simons, R. Blunt vascular neck injuries: diagnosis and outcomes of extracranial vessel injury. J Trauma. 2002; 53:472–6.Google Scholar
19. Miller, P, Fabian, T, Bee, T, Timmons, S, Chamsuddin, A, Finkle, R, et al. Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma. 2001; 51:279–86.Google Scholar
20. Kraus, R, Bergstein, J, DeBord, J Diagnosis., treatment, and outcome of blunt carotid arterial injuries. Am J Surg. 1999; 178:190–3.Google Scholar
21. Cloft, H, Jensen, M, Kallmes, D, Dion, J. Arterial dissections complicating cerebral angiography and cerebrovascular interventions. Am J Neuroradiol. 2000; 21:541–5.Google Scholar
22. Benninger, D, Gandjour, J, Georgiadis, D, Stockli, E, Arnold, M, Baumgartner, R. Benign long-term outcome of conservatively treated cervical aneurysms due to carotid dissection. Neurology. 2007; 69:486–7.CrossRefGoogle ScholarPubMed
23. Guillon, B, Brunereau, L, Biousse, V, Djouhri, H, Levy, C, Bousser, M-G. Long-term follow-up of aneurysms developed during extracranial internal carotid artery dissection. Neurology. 1999; 53:117–22.Google Scholar
24. Touźe, E, Randoux, B, Meary, E, Arquizan, C, Meder, J, Mas, J. Aneurysmal forms of cervical artery dissection - associated factors and outcome. Stroke. 2001; 32:418–23.Google Scholar
25. Schneidereit, N, Simons, R, Nicolau, S, Graeb, D, Brown, D, Kirkpatrick, A, et al. Utility of screening for blunt vascular neck injuries with computed Tomographic angiography. J Trauma. 2006; 60:209–16.Google Scholar
26. Biffl, W, Moore, E, Offner, P, Brega, K, Franciose, R, Burch, J. Blunt carotid injuries: implications of a new grading scale. J Trauma. 1999; 45:845–66.CrossRefGoogle Scholar
27. Cothren, C, Moore, E, Biffl, W, Ciesla, D, Ray, C, Johnson, J, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004; 139:540–6.Google Scholar
28. Engelter, S, Brandt, T, Debette, S, Caso, V, Lichy, C, Pezzini, A, et al. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke. 2007; 38:2605–11.Google Scholar
29. Müller, B, Luther, B, Hort, W, Neumann-Haefelin, T, Aulich, A, Sandmann, W. Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg. 2000; 31:980–8.Google Scholar
30. Redekop, G, Marotta, T, Weill, A. Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents. J Neurosurg. 2001; 95:412–9.Google Scholar
31. Cohen, J, Leker, R, Gotkine, M, Gomori, M, Ben-Hur, T. Emergency stenting to treat patients with carotid artery dissection - clinically and radiologically directed therapeutic decision making. Stroke. 2003; 34:254–7.CrossRefGoogle ScholarPubMed
32. Fateri, F, Groebli, Y, Rüfenacht, D. Intra-arterial thrombolysis and stent placement in the acute phase of blunt internal carotid artery trauma with subocclusive dissection and thromboembolic complication: case report and review of the literature. Ann Vasc Surg. 2005; 19:1–4.CrossRefGoogle Scholar
33. Edgell, R, Abou-Chebl, A, Yadav, J. Endovascular management of spontaneous carotid artery dissection. J Vasc Surg. 2005; 42: 854–60.CrossRefGoogle ScholarPubMed
34. Kadkhodayan, Y, Jeck, D, Moran, C, Derdeyn, C, Cross, D. Angioplasty and stenting in carotid dissection with or without associated pseudoaneurysm. Am J Neuroradiol. 2005; 26: 2328–35.Google ScholarPubMed
35. Cothren, C, Moore, E, Ray, C, Ciesla, D, Johnson, J, Moore, J, et al. Screening for blunt cerebrovascular injuries is cost-effective. Am J Surg. 2005; 190:849–54.Google Scholar