Challenges in diagnosis and treatment of cervico-cephalic arterial dissections

Abstract

I n this number of Arquivos de Neuro-psiquiatria, Fragoso and colleagues reported a series of fourty-one cases of cervical or intracranial arterial dissections. Clinical information was retrospectively collected for dissections considered to have occurred in close temporal association with practice of physical activity, ranging from brisk walks to bungee-jumping. One patient presented an isolated Horner´s syndrome while the other forty subjects presented anterior or posterior circulation infarct syndromes 1 . Exclusively cervical dissections were identified in twenty-nine patients while exclusively intracranial dissections were observed in eight, and combined cervical/intracranial dissections, in four cases.Spontaneous cervical artery dissections have been associated with mechanical triggers including, but not restricted to, minor traumas that can happen in the context of physical activity. It has been hypothesized that an underlying arteriopathy leading to ultrastructural abnormalities and arterial weakness is likely present, increasing susceptibility to dissections in affected subjects 2,3,4 . However, cervical dissections are often diagnosed in the absence of prior mechanical triggers. Case series cannot establish cause-effect relations between possible triggers and dissections. Still, results of an observational study suggested that mechanical triggers may indeed have a role in cervical artery dissections. In this study, Engelter et al.2 systematically evaluated the presence and type of prior cervical trauma in patients with cervical artery dissection (n = 966) as well as in two other groups: age-and sex-matched patients with ischemic strokes with etiologies diferent from cervical artery dissection, (n = 651) and healthy subjects (n = 280). Prior mechanical triggers were more common in patients with cervical artery dissection than in patients with stroke due to other causes (adjusted odds ratio, 7.6 [95%CI 5.6 -10.2]), or in healthy subjects (adjusted odds ratio, 3.7 [95%CI 2.4 -5.6]). Strokes were less common and neck pain was more common in patients with dissections plus history of prior mechanical triggers than in those without. This study only included patients with cervical artery dissections. It still remains to be determined whether mechanical triggers play a role in patients with intracranial artery dissections 4 .