Skip to main content Accessibility help
×
Home

Extracranial Carotid and Vertebral Artery Dissection: A Review

  • Gary John Redekop (a1)

Abstract

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.

<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.

    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Extracranial Carotid and Vertebral Artery Dissection: A Review
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Extracranial Carotid and Vertebral Artery Dissection: A Review
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Extracranial Carotid and Vertebral Artery Dissection: A Review
      Available formats
      ×

Copyright

References

Hide All
1. Lee, V, Brown, R, Mandrekar, J, Mokri, B. Incidence and outcome of cervical artery dissection; a population-based study. Neurology. 2006; 67:180912.
2. Caplan, L, Biousse, V. Cervicocranial arterial dissections. J Neuroophthalmol. 2004; 24:299305.
3. Schievink, W. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001; 344:898906.
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; 250:117984.
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; 36:157580.
6. Norris, J. Extracranial arterial dissection - anticoagulation is the treatment of choice: for. Stroke. 2005; 36:20412.
7. Lyrer, P. Extracranial arterial dissection - anticoagulation is the treatment of choice: against. Stroke. 2005; 36:20423.
8. Georgiadis, D, Caso, V, Baumgartner, R. Acute therapy and prevention of stroke in spontaneous carotid dissection. Clin Exp Hypertens. 2006; 28:36570.
9. Lyrer, P, Engelter, S. Antithrombotic drugs for carotid artery dissection. Stroke. 2004; 35:6134.
10. Lyrer, P, Engelter, S. Antithrombotic drugs for carotid artery dissection (Cochrane Review). Oxford, UK: Cochrane Library; 2006; Volume 1.
11. Beletsky, V, Nadareishvili, Z, Lynch, J, Shuaib, A, Woolfenden, A, Norris, J. Cervical arterial dissection; time for a therapeutic trial? Stroke. 2003; 34:285660.
12. Flis, C, Jager, H, Sidhu, P. Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol. 2007; 17:82034.
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; 60:2715.
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; 231:67281.
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; 46:11205.
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; 223:51325.
17. Inamasu, J, Guiot, B. Vertebral artery injury after blunt cervical trauma: an update. Surg Neurol. 2006; 65:23846.
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; 53:4726.
19. Miller, P, Fabian, T, Bee, T, Timmons, S, Chamsuddin, A, Finkle, R, et al. Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma. 2001; 51:27986.
20. Kraus, R, Bergstein, J, DeBord, J Diagnosis., treatment, and outcome of blunt carotid arterial injuries. Am J Surg. 1999; 178:1903.
21. Cloft, H, Jensen, M, Kallmes, D, Dion, J. Arterial dissections complicating cerebral angiography and cerebrovascular interventions. Am J Neuroradiol. 2000; 21:5415.
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; 69:4867.
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; 53:11722.
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; 32:41823.
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; 60:20916.
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; 45:84566.
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; 139:5406.
28. Engelter, S, Brandt, T, Debette, S, Caso, V, Lichy, C, Pezzini, A, et al. Antiplatelets versus anticoagulation in cervical artery dissection. Stroke. 2007; 38:260511.
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; 31:9808.
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; 95:4129.
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; 34:2547.
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; 19:14.
33. Edgell, R, Abou-Chebl, A, Yadav, J. Endovascular management of spontaneous carotid artery dissection. J Vasc Surg. 2005; 42: 85460.
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: 232835.
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; 190:84954.

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed