Cervical and intracranial artery dissections

Abstract

This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.

Antithrombotic therapy in the postacute phase of cervical artery dissection: the Italian Project on Stroke in Young Adults Cervical Artery Dissection

“…Therefore, inhibiting platelet aggregation with antiplatelet agents or the coagulation cascade with anticoagulants is likely to stabilise the thrombus, reduce further thrombus formation and thereby reduce stroke risk. This supports the recommendation to start antithrombotic treatment immediately without any delay, whatever type of antithrombotic treatment is chosen in the individual case 6 15. Evidence from follow-up imaging studies16–18 indicates that resolution and healing of the initial blood vessel damage take place approximately 6 months after the acute event, regardless of whether the dissected vessel progresses towards complete recanalisation, residual stenosis or persistent occlusions, which, in turn, translates into the very low risk of ischaemic recurrence observed afterwards 1.…”

Biological Properties and Clinical Significance of Lipoprotein-Associated Phospholipase A2 in Ischemic Stroke

“…Small vessel disease damages the tiny blood vessels deep inside the brain, reducing blood flow and preventing brain cells from obtaining oxygen and nutrients [13,14]. Other conditions associated with the pathogenesis of ischemic stroke include atrial fibrillation, patent foramen ovale (PFO), and arterial dissection (Figure 2(a)) [15][16][17].…”

“…Blood clots may form in PFO-containing patients when blood flows from one side of the heart to the other and up to the brain [16]. Cervical artery dissection is the most common cause of ischemic stroke in young adults [17]. Arterial dissection occurs after a tear, as blood enters the vessel wall, where it forms a clot and restricts the flow of blood to the brain, causing stroke [17].…”

“…Cervical artery dissection is the most common cause of ischemic stroke in young adults [17]. Arterial dissection occurs after a tear, as blood enters the vessel wall, where it forms a clot and restricts the flow of blood to the brain, causing stroke [17].…”

Primary stent implantation for bilateral spontaneous cervical ICA dissections with hypoperfusion after 72 h from onset: a case report

“…Endovascular treatment (EVT) restores the vessel caliber and normal circulation, repairing the arterial defect and thus preventing the formation of emboli. Previous studies show that EVT is crucial for those patients who do not respond to antithrombotic treatment, have clinical deterioration due to hypoperfusion, or experience acute occlusion in an intracranial large vessel (Engelter et al 2015 ; Moon et al 2017 ; Engelter et al 2021 ). However, the EVT brings challenges: 1) to secure true lumen during the whole procedure; 2) to prevent downstream embolism from thrombus migration; 3) multiple stents are serially implanted using partially overlapping techniques to reconstruct the entire dissected segment, creating a restriction for the type of stent for deployment (Cohen et al 2003 ; Ansari et al 2017 ).…”