Abstract:Objective:To test the hypothesis that the prevalence of cervical artery dissection remains constant across age groups, we evaluated the relationship between age and cervical artery dissection in patients with stroke using a Nationally Representative Sample from the United States.Methods:We used inpatient claims data included in the 2012-2015 releases of the National Inpatient Sample (NIS). We used validated ICD-9-CM codes to identify adults hospitalized with ischemic stroke and a concomitant diagnosis of carot… Show more
“…10 The incidence is slightly higher in men, 11 but the age at onset and the peak age prevalence of dissection-related stroke are lower in women (30-49 years) compared with men (50-89 years). 10,11 The pathogenesis of cervical artery dissection is multifactorial and involves the interplay of comorbidities, environmental triggers, genetic or congenital factors, including connective tissue disorders, and anatomic factors such as elongated styloid process (>30 mm; Eagle syndrome) or increased vascular tortuosity (Figure S1). 1,[12][13][14] Furthermore, risk factors may differ according to dissection location; recent systemic infection is more common in carotid artery dissection, and history of minor trauma is more common in vertebral artery dissection.…”
Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members’ approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.
“…10 The incidence is slightly higher in men, 11 but the age at onset and the peak age prevalence of dissection-related stroke are lower in women (30-49 years) compared with men (50-89 years). 10,11 The pathogenesis of cervical artery dissection is multifactorial and involves the interplay of comorbidities, environmental triggers, genetic or congenital factors, including connective tissue disorders, and anatomic factors such as elongated styloid process (>30 mm; Eagle syndrome) or increased vascular tortuosity (Figure S1). 1,[12][13][14] Furthermore, risk factors may differ according to dissection location; recent systemic infection is more common in carotid artery dissection, and history of minor trauma is more common in vertebral artery dissection.…”
Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members’ approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.
“…An interesting study utilizing nationwide inpatient data revealed that the prevalence of dissection among stroke hospitalizations was around 7% between age 18–40. 79 Figure 5 Right cervical internal carotid artery (ICA) dissecting pseudoaneurysm (white arrow) (reconstructed images from MRA) (figure on the left) and ipsilateral stroke on the ICA territory. …”
Section: Immediate Complicationsmentioning
confidence: 99%
“…An interesting study utilizing nationwide inpatient data revealed that the prevalence of dissection among stroke hospitalizations was around 7% between age 18-40. 79 As with other ischemic strokes, the management of neurologic ischemic due to CeAD has two components: hyperacute treatment and secondary stroke prevention. The degree of luminal stenosis, presence of occlusion, intraluminal thrombus formation on the dissection sites, the amount of tissue at risk, and the intracranial extension of CeAD are essential factors.…”
Cervical Artery Dissection (CeAD) is a frequent stroke etiology for patients younger than 50 years old. The most common immediate complications related to CeAD are headache and neck pain (65–95%), TIA/ischemic stroke (>50%), and partial Horner’s syndrome (25%). The prevailing hypothesis regarding the pathogenesis of sCeAD is that the underlying constitutional vessel wall weakness of patients with sCeAD is genetically determined and that environmental factors could act as triggers. The stroke prevention treatment of CeAD remains controversial, involving anticoagulation or antiplatelet therapy and potentially emergent stenting and/or thrombectomy or angioplasty for selected cases of carotid artery dissection with occlusion. The treatment of headache associated with CeAD depends on the headache phenotype and comorbidities. Radiographically, more than 75% of CeAD cases present with occlusion or non-occlusive stenosis. Many patients demonstrate partial and complete healing, more commonly in the carotid arteries. One-fifth of the patients develop dissecting pseudoaneurysm, but this is a benign clinical entity with an extremely low rupture and stroke recurrence risk. Good recovery is achieved in many CeAD cases, and mortality remains low. Family history of CeAD, connective tissue disorders like Ehlers-Danlos syndrome type IV, and fibromuscular dysplasia are risk factors for recurrent CeAD, which can occur in 3–9% of the cases. This review serves as a comprehensive, updated overview of CeAD, emphasizing etiopathogenesis and management.
“…A large epidemiologic study utilizing data from the National Inpatient Sample found that while CeAD accounted for a higher proportion of hospitalization for ischemic stroke in younger age groups, the actual prevalence of CeAD related stroke hospitalization increased with age. 21 As such, rigorous examination of the potential relationship between CSM and CeAD in older Medicare beneficiaries seems warranted. In this study, to better inform US policymakers, providers, and patients, we evaluated the association between CSM and CeAD among Medicare beneficiaries.…”
Background
Cervical artery dissection and subsequent ischemic stroke is the most serious safety concern associated with cervical spinal manipulation.
Methods
We evaluated the association between cervical spinal manipulation and cervical artery dissection among older Medicare beneficiaries in the United States. We employed case-control and case-crossover designs in the analysis of claims data for individuals aged 65+, continuously enrolled in Medicare Part A (covering hospitalizations) and Part B (covering outpatient encounters) for at least two consecutive years during 2007–2015. The primary exposure was cervical spinal manipulation; the secondary exposure was a clinical encounter for evaluation and management for neck pain or headache. We created a 3-level categorical variable, (1) any cervical spinal manipulation, 2) evaluation and management but no cervical spinal manipulation and (3) neither cervical spinal manipulation nor evaluation and management. The primary outcomes were occurrence of cervical artery dissection, either (1) vertebral artery dissection or (2) carotid artery dissection. The cases had a new primary diagnosis on at least one inpatient hospital claim or primary/secondary diagnosis for outpatient claims on at least two separate days. Cases were compared to 3 different control groups: (1) matched population controls having at least one claim in the same year as the case; (2) ischemic stroke controls without cervical artery dissection; and (3) case-crossover analysis comparing cases to themselves in the time period 6–7 months prior to their cervical artery dissection. We made each comparison across three different time frames: up to (1) 7 days; (2) 14 days; and (3) 30 days prior to index event.
Results
The odds of cervical spinal manipulation versus evaluation and management did not significantly differ between vertebral artery dissection cases and any of the control groups at any of the timepoints (ORs 0.84 to 1.88; p > 0.05). Results for carotid artery dissection cases were similar.
Conclusion
Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups.
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