Prognostic significance of pulsatile tinnitus in cervical artery dissection

Kellert, Lars; Kloß, Manja; Pezzini, Alessandro; Debette, Stéphanie; Leys, Didier; Caso, Valeria; Thijs, Vincent; Bersano, Anna; Touzé, Emmanuel; Tatlısumak, Turgut; Traenka, Christopher; Lyrer, Philippe; Engelter, Stefan T.; Metso, Tiina M.; Grond‐Ginsbach, Caspar

doi:10.1111/ene.13031

Cited by 18 publications

(11 citation statements)

References 13 publications

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“…In a third step, we performed the following sensitivity analyses using favorable outcome as outcome measure: (1) multivariable logistic regression as performed in the primary outcome analyses separately in patients with ICAD or VAD; (2) including presence of Horner syndrome and tinnitus, both known to predict favorable outcome in patients with CeAD, 5,6 in our primary multivariable logistic regression model in patients with ICAD; and (3) separate multivariable logistic regression analyses including age, sex, and DAO as covariates in patients with (1) no signs of cerebral ischemia, (2) TIA, or (3) ischemic stroke at baseline. All statistical analyses were performed using SPSS version 25 (IBM; Armonk, NY).…”

Section: Primary Outcome Analysesmentioning

confidence: 99%

“…Its enlargement or local thrombosis at the site of dissection can lead to dissected artery occlusion (DAO), which was found in about one-third of patients with CeAD in prior studies. [2][3][4][5] In contrast to the reported prognostic significance of Horner syndrome or pulsatile tinnitus as local signs of CeAD, 5,6 little is known about the prognostic importance of DAO in CeAD. One observational study suggests worse outcome for patients with CeAD with DAO of the internal carotid artery compared to patients with artery occlusion due to atherothrombotic disease.…”

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confidence: 99%

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Artery occlusion independently predicts unfavorable outcome in cervical artery dissection

Traenka

Grond‐Ginsbach²,

Simonetti³

et al. 2020

Neurology

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ObjectiveTo assess the impact of dissected artery occlusion (DAO) on functional outcome and complications in patients with cervical artery dissection (CeAD).MethodsWe analyzed combined individual patient data from 3 multicenter cohorts of consecutive patients with CeAD (the Cervical Artery Dissection and Ischemic Stroke Patients [CADISP]–Plus consortium dataset). Patients with data on DAO and functional outcome were included. We compared patients with DAO to those without DAO. Primary outcome was favorable functional outcome (i.e., modified Rankin Scale [mRS] score 0–1) measured 3–6 months from baseline. Secondary outcomes included delayed cerebral ischemia, major hemorrhage, recurrent CeAD, and death. We performed univariate and multivariable binary logistic regression analyses and calculated odds ratios (OR) with 95% confidence intervals (CI), with adjustment for potential confounders.ResultsOf 2,148 patients (median age 45 years [interquartile range (IQR) 38–52], 43.6% women), 728 (33.9%) had DAO. Patients with DAO more frequently presented with cerebral ischemia (84.6% vs 58.5%, p < 0.001). Patients with DAO were less likely to have favorable outcome when compared to patients without DAO (mRS 0–1: 59.6% vs 80.1%, punadjusted < 0.001). After adjustment for age, sex, and initial stroke severity, DAO was independently associated with less favorable outcome (mRS 0–1: OR 0.65, CI 0.50–0.84, p = 0.001). Delayed cerebral ischemia occurred more frequently in patients with DAO than in patients without DAO (4.5% vs 2.9%, p = 0.059).ConclusionDAO independently predicts less favorable functional outcome in patients with CeAD. Further research on vessel patency, collateral status and effects of revascularization therapies particularly in patients with DAO is warranted.

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Section: Primary Outcome Analysesmentioning

confidence: 99%

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confidence: 99%

Artery occlusion independently predicts unfavorable outcome in cervical artery dissection

Traenka

Grond‐Ginsbach²,

Simonetti³

et al. 2020

Neurology

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“…The Horner Syndrome that occurred with recanalization of ICAD in one of the patients of our study population might be the consequence of the irritation of peri-vascular sympathetic nerve fibers [25] due to change of external diameter of the affected artery with reorganization of the mural hematoma. Pulsatile tinnitus ipsilateral to the affected artery is common in CeAD [26] and may reflect the auditable turbulences in case recanalization is incomplete, as it was the case in one of our patients. However, it remains unclear why 1 patient in our study reported the occurrence of a tinnitus contralateral to a recanalized CeAD.…”

Section: Discussionmentioning

confidence: 53%

Clinical Usefulness of Serial Duplex Ultrasound in Cervical Artery Dissection Patients

et al. 2020

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Purpose: To study the clinical usefulness of serial color-coded duplex ultrasound (DUS) examinations in cervical artery dissection (CeAD) patients. Methods: Single-center, CeAD registry-based re-review of serial, routine DUS exams in consecutive CeAD patients treated at the Stroke Center Basel, Switzerland (2009. Two experienced raters reassessed all DUS for the occurrence of new arterial findings during follow-up, that is. (i) recanalization of the dissected artery (if occluded at baseline), (ii) delayed occlusion of a patent dissected artery, and (iii) recurrent CeAD. We studied whether these new arterial findings were associated with clinical symptoms. Results: In 94 CeAD patients (n = 40 female [42.6%], median age 46 years [interquartile range (IQR) 36.2-53]), 506 DUS examinations were reviewed covering a median length of follow-up of 54.1 weeks (IQR 30.5-100.5). In total, 105 dissected arteries were detected, of which 27 (25.7%) were occluded. In 28/94 patients (29.8%), 31 new arterial findings were recorded, which were associated with clinical symptoms in 9/31 (30%) patients. Recanalization of occluded CeAD was observed in 22/27 (81.5%) arteries and occurred in 20/22 arteries within 3 months. In 4/22 patients (18.2%), recanalization was associated with clinical symptoms (ischemic events [n = 2], pure local symptoms [n = 2]). Delayed occlusions were observed in 4/78 (5.1%) dissected arteries patent at baseline. All were clinically asymptomatic and occurred within 14 days from baseline. Recurrent CeAD (all symptomatic) occurred in 5 previously non-dissected arteries. Conclusion: In CeAD patients, follow-up DUS identified new arterial findings, of which several were associated with clinical symptoms: we found that about 1 of 5 recanalizations were associated with clinical symptoms, of whom half were ischemic symptoms. Further, delayed occlusions occurred in patients with no or mild stenosis at baseline and were asymptomatic. This study emphasizes the potential importance of repeated DUS in CeAD particularly in the early phase of up to 4 weeks.

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“…stenosis or aneurysm) at the site of dissection, which can then be perceived as ipsilateral pulsatile murmurs by the patients. 13 Local symptoms mostly resolve throughout the healing process of the affected artery. However, the prevention or treatment of cerebral ischemia is our primary and most important therapeutic target.…”

Section: Introductionmentioning

confidence: 99%

Cervical and intracranial artery dissections

Engelter

Lyrer

Traenka

2021

Ther Adv Neurol Disord

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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.

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Prognostic significance of pulsatile tinnitus in cervical artery dissection

Abstract: The presence of PT in CeAD is associated with a benign clinical course and predicts a favourable outcome.

Cited by 18 publications

References 13 publications

Artery occlusion independently predicts unfavorable outcome in cervical artery dissection

Artery occlusion independently predicts unfavorable outcome in cervical artery dissection

Clinical Usefulness of Serial Duplex Ultrasound in Cervical Artery Dissection Patients

Cervical and intracranial artery dissections

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