Gender and cervical artery dissection

Background and purpose: To analyze previously established gender differences in cervical artery dissection (CeAD). Methods: This case–control study is based on the CADISP (Cervical Artery Dissection and Ischemic Stroke Patients) population comprising 983 consecutive CeAD patients (mean age: 44.1 ± 9.9 years) and 658 control patients with a non‐CeAD ischemic stroke (IS) (44.5 ± 10.5 years). Results: Cervical artery dissection was more common in men (56.7% vs. 43.3%, P < 0.001) and men were older (46.4 vs. 41.0 years, P < 0.001). We assessed putative risk factors for CeAD including vascular risk factors, recent cervical trauma, pregnancies, and infections. All gender differences in the putative risk factors and outcome were similar in the CeAD and the non‐CeAD IS groups. Conclusion: Our analysis of the largest collection of CeAD patients to date confirms male predominance and differences in age at dissection between men and women. Gender differences in putative risk factors may explain the higher frequency of CeAD in men and their older age, but the putative risk factors are probably not specific for CeAD.     

Elevated inflammatory laboratory parameters in spontaneous cervical artery dissection as compared to traumatic dissection

Several studies have reported infection as a possible risk factor for cervical artery dissection (CAD). We retrospectively analyzed several inflammatory parameters of CAD patients with the aim of detecting differences between spontaneous (n = 25) and traumatic (n = 18) CAD. In this case-control study, we observed significantly higher absolute leucocyte values (10.3 versus 8.1 G/L; p = 0.02) as well as an elevated frequency of leucocytosis (64% versus 28%; p = 0.02) and elevated CRP (60% versus 28%; p = 0.04) in patients without a history of trauma ("spontaneous" CAD) compared with patients with trauma-related CAD. As the elevated inflammatory laboratory parameters were not associated with an elevated infection rate, these findings imply a role of an acute inflammation as a pathogenetic factor in spontaneous CAD. The cause and mechanism of the inflammatory process remain unknown.     

Diagnosing intra-cranial and cervical artery dissection using MRI as the initial modality

Dissection of cranial and cervical arteries is a relatively frequent clinical condition. However, it is difficult to diagnose a dissection when patients present with relatively mild symptoms. Various radiological techniques are used as diagnostic tools. This study analyzed retrospectively the characteristics of cranial and cervical artery dissections using “MR first concept”, with MRI as the first-choice diagnostic modality for all new patients with neurological symptoms. The patients who were admitted in Ohnishi neurological center between January 2001 and December 2014 were included. MRI was used as the initial investigation for all new patients, including those with mild symptoms such as headache or vertigo only. The patients were divided into carotid group and vertebral group. The statistical comparison was performed between these two groups. A total of 164 patient cases were analyzed. In 44 (26.8%) and 120 (73.2%) patients, dissection occurred in the carotid group and vertebral group, respectively. Concerning the type of onset, 52 patients presented with only subjective symptoms accompanied with ischemic or hemorrhagic lesions, 97 patients with ischemic symptoms and 15 patients with subarachnoid hemorrhage. There were statistically significant differences between the carotid and vertebral groups in terms of hemiparesis, aphasia, history of trauma, headache and vertigo. Patients with only a headache and those with no ischemic features had no worsening symptoms. The symptom of headache or neck pain only is more frequent than previously reported. The “MR first concept” would prove useful for early diagnosis of dissections and early treatment.     

Spontaneous dissection of the cervical internal carotid artery

We studied 36 patients (21 women and 15 men) with spontaneous dissection of the internal carotid arteries. The ages of these patients ranged from 21 to 63 years. Focal unilateral headache was the most common symptom. Other common clinical manifestations (in decreasing order of frequency) included focal cerebral ischemic symptoms, oculosympathetic paresis, bruits, light-headedness, and neck pain. Less common symptoms were syncope, amaurosis fugax, scalp tenderness, swelling in the neck, and dysgeusia. Common angiographic manifestations (in decreasing order of frequency) were elongated, irregular, and frequently tapered narrowing of the lumen; abrupt luminal reconstitution (often at the carotid canal); aneurysms; intimal flaps; slow internal carotid artery--middle cerebral artery flow; tapered occlusion; and distal branch occlusions. The incidence of hypertension in these patients was considerably higher than that in the general population. Angiographic evidence of fibromuscular dysplasia was found in 14% of the patients, but atherosclerotic changes were uncommon. Follow-up ranged from 14 to 140 months (mean, 58.5 months). Twenty-three patients with 29 dissected internal carotid arteries were also restudied angiographically. The stenosis of the internal carotid artery either completely resolved or substantially improved in more than 85% of the dissected vessels. About two-thirds of the dissecting aneurysms either resolved or decreased in size. Clinically more than 85% of the patients had an excellent or complete recovery. Recurrence of the dissection or rupture of a dissecting aneurysm was not noted. Despite their disconcerting appearance on angiography, spontaneous dissections of the internal carotid arteries are often associated with a good prognosis.     

Spontaneous dissection of the cervical internal carotid artery

Five patients with spontaneous dissection of the cervical internal carotid artery (CICA) are reported. The different patterns of clinical and radiological presentation are described and the frequently benign outcome is underlined. The need for diagnostic angiography is emphasized.     

Age-dependent differences in cervical artery dissection

The goal of this work was to explore age-dependent differences in cervical artery dissection (CeAD). This study is based on the Cervical Artery Dissection and Ischemic Stroke Patients population comprising 983 consecutive CeAD patients and 658 control patients with a non-CeAD ischemic stroke (IS), frequency-matched for age and gender. Patients were divided into three age categories: ≤33 (for CeAD, n?=?150), 34–54 (n?=?688), and ≥55 (n?=?145) years, and the youngest and oldest groups were compared. The youngest patients were mostly women and the oldest men. The frequency of internal carotid artery dissection (ICAD) versus vertebral artery dissection (VAD) increased with age from 44 to 75?%. This age-related shift remained significant after adjustment for sex. The frequency of a transient ischemic event as the CeAD symptom declined from 33?% in the youngest age group, to 19?% in the oldest. Vascular risk factors increased in frequency with advancing age in both groups, but for hypertension the increase was steeper for non-CeAD IS patients. For CeAD patients, but not for patients with non-CeAD IS, preceding infection was more common in the oldest group. The youngest non-CeAD IS patients had better functional outcome (modified Rankin Scale 0–1) than the oldest, while the similar trend was not statistically significant among CeAD patients. Younger age seems to be associated with VAD and female gender, and older age with ICAD and male gender. Age-related changes in the frequencies of hypertension and recent infection were different between the CeAD and non-CeAD IS groups. Age does not seem to be an important outcome predictor in CeAD strokes.     

University education and cervical artery dissection

Background and purpose

We investigated whether university education is more likely in cervical artery dissection (CeAD)-patients than in age- and sex-matched patients with ischemic stroke (IS) due to other causes (non-CeAD-IS-patients).

Methods

Patients from the Cervical Artery Dissection and Ischemic Stroke Patients study with documented self-reported profession before onset of IS due to CeAD (n = 715) or non-CeAD causes (n = 631) were analyzed. In the reported profession, the absence or presence of university education was assessed. Professions could be rated as academic or non-academic in 518 CeAD and 456 non-CeAD patients. Clinical outcome at 3 months was defined as excellent if modified Rankin Scale was 0–1.

Results

University education was more frequent in CeAD-patients (100 of 518, 19.3%) than in non-CeAD-IS-patients (61 of 456, 13.4%, p = 0.008). CeAD-patients with and without university education differed significantly with regard to smoking (39 vs. 57%, p = 0.001) and excellent outcome (80 vs. 66%, p = 0.004). In logistic regression analysis, university education was associated with excellent outcome in CeAD-patients (OR 2.44, 95% CI 1.37–5.38) independent of other outcome predictors such as age (OR 0.97, 95% CI 0.84–0.99), NIHSS (OR 0.80, 95% CI 0.76–0.84) and local signs (OR 2.77, 95% CI 1.37–5.57).

Conclusion

We observed a higher rate of university education in patients with CeAD compared with non-CeAD patients in our study population. University education was associated with favorable outcome in CeAD-patients. The mechanism behind this association remains unclear.

     

Seasonal variability in spontaneous cervical artery dissection

We examined the seasonal variability of spontaneous cervical artery dissection (sCAD) by analysing prospectively collected data from 352 patients with 380 sCAD (361 symptomatic sCAD; 305 carotid and 75 vertebral artery dissections) admitted to two university hospitals with a catchment area of 2,200,000 inhabitants between 1985 and 2004. Presenting symptoms and signs of the 380 sCAD were ischaemic stroke in 241 (63%), transient ischaemic attack in 40 (11%), retinal ischemia in seven (2%), and non-ischaemic in 73 (19%) cases; 19 (5%) were asymptomatic sCAD. A seasonal pattern, with higher frequency of sCAD in winter (31.3%; 95% confidence interval (CI): 26.5 to 36.4; p=0.021) compared to spring (25.5%; 95% CI: 21.1 to 30.3), summer (23.5%; 95% CI: 19.3 to 28.3), and autumn (19.7%; 95% CI: 15.7 to 24.1) was observed. Although the cause of seasonality in sCAD is unclear, the winter peaks of infection, hypertension, and aortic dissection suggest common underlying mechanisms.     

Gender differences in spontaneous cervical artery dissection

We analyzed sex differences in 696 patients with spontaneous cervical artery dissection. There were more men (n = 399; p < 0.0001), and men showed a higher frequency of hypertension (31% vs 15%; p < 0.0001). Women were younger (42.5 +/- 9.9 vs 47.5 +/- 9.3 years; p < 0.0001), had more often multiple dissections (18 vs 10%; p = 0.001), migraine (47 vs 20%; p < 0.0001), and tinnitus (16 vs 8%; p = 0.001). Outcome and mortality were similar in both sexes.     

Antiplatelets versus anticoagulation in cervical artery dissection

BACKGROUND AND PURPOSE: The widespread preference of anticoagulants over antiplatelets in patients with cervical artery dissection (CAD) is empirical rather than evidence-based. Summary of Review- This article summarizes pathophysiological considerations, clinical experiences, and the findings of a systematic metaanalysis about antithrombotic agents in CAD patients. As a result, there are several putative arguments in favor as well as against immediate anticoagulation in CAD patients. CONCLUSIONS: A randomized controlled trial comparing antiplatelets with anticoagulation is needed and ethically justified. However, attributable to the large sample size which is required to gather meaningful results, such a trial represents a huge venture. This comprehensive overview may be helpful for the design and the promotion of such a trial. In addition, it could be used to encourage both participation of centers and randomization of CAD patients. Alternatively, antithrombotic treatment decisions can be customized based on clinical and paraclinical characteristics of individual CAD patients. Stroke severity with National Institutes of Health Stroke Scale score > or =15, accompanying intracranial dissection, local compression syndromes without ischemic events, or concomitant diseases with increased bleeding risk are features in which antiplatelets seem preferable. In turn, in CAD patients with (pseudo)occlusion of the dissected artery, high intensity transient signals in transcranial ultrasound studies despite (dual) antiplatelets, multiple ischemic events in the same circulation, or with free-floating thrombus immediate anticoagulation is favored.     

Pain as heralding symptom in multiple sclerosis

Neurological Sciences - It is becoming recognised that neuropathic pain is among the major burdens of patients affected by multiple sclerosis (MS). Neuropathic pain may be an early symptom of the...     

Epidemiology and pathophysiology of spontaneous cervical artery dissection

Spontaneous cervical artery dissections are produced by the penetration of circulating blood into the vessel wall of one or more cervical arteries, without a preceding major trauma. Dissection is one of the most frequent etiologies of ischemic stroke in young patients. Its annual incidence is about 3 per 100,000. Pathophysiology of cervical artery dissection remains misunderstood. Triggering factors such as minor trauma and infection have been identified. However, they are too trivial to explain alone the occurrence of a mural hematoma. Several abnormalities suggesting an underlying arteriopathy related to an extracellular matrix defect which could predispose to dissection have been reported: arterial redundancies, intracranial aneurysms, aortic root dilatation, common carotid artery distensibility increase, fibromuscular dysplasia, inherited connective tissue disorders, ultrastructural dermal connective tissue abnormalities. Other factors associated with dissection, such as migraine, hyperhomocysteinemia and alpha-1 antitrypsin deficiency, suggest arterial wall fragility secondary to hyperactivity of some proteases. If an underlying arteriopathy is likely, its nature remains unidentified to date and does not seem to be unique.