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Cervical (carotid) artery dissection

artery dissection

Cervical (carotid) artery dissection (CAD) is a rupture of a layer of the artery wall, in which blood begins to seep and spread between the layers. It is responsible for 20% of ischemic strokes in adults diagnosis under 45 years old, accounting for 2% of all IS. 

CAD is rare – the frequency of dissection of the cervical artery is 2.5-3 cases per 100 thousand population per year, vertebral artery dissection (VAD) – 1-1.5 cases per 100 thousand population per year. In the course of aging, many other factors contribute to the development of IS. Therefore, it is believed that CAD is the cause of only 2-3% of all IS in elderly patients; however, in this population, spontaneous CAD is usually rarely diagnosed unreasonably. 

In fact, in stroke, arterial dissection was the most relevant cause of headache; a recent study found that up to 8% of patients with spontaneous ASD experience headache or neck pain as the first symptoms of a stroke.

There are no significant sex differences, but the condition develops on average about 5 years earlier in women than in men. Most often, dissection occurs in the most mobile areas of the carotid and vertebral arteries, which emphasizes the importance of accompanying mechanical factors in the pathogenesis of spontaneous CAD. 

  1. Recurrent spontaneous CAD is a rare phenomenon and, according to previous studies, is observed in 3–8% of cases.
  2. It is noteworthy that, according to new evidence, delayed relapses are more frequent than previously thought and may develop at the level of the previous stratification. 
  3. Among patients with spontaneous cervical artery dissection, the risk of re-dissection was reported to be 3% during a mean follow-up of 36 months and reached 8% in a study with a mean follow-up of 7.4 years with the highest relapse rate (2%) during the first months after the primary event. 

However, relapse rates are difficult to estimate, as relapse is sometimes asymptomatic, especially if it occurs within a few weeks, and dissections with isolated local symptoms are likely to be unreasonably rare to be diagnosed.

According to a large multicenter study, the incidence of symptomatic recurrence of CAD is 0.3% per year, which is slightly less than reported in earlier studies, in which relapses were most common among patients with connective tissue diseases or family history of CAD.

artery dissection causes

Cervical artery dissection causes and diagnostics

Causes

The main provoking factors for dissection are: 

  • head or neck trauma (primarily as a result of accidents), usually mild; 
  • physical activity with muscle tension in the shoulder girdle and neck; 
  • tilts and turns of the head; 
  • alcohol intake; 
  • current or previous infection; 
  • taking contraceptives;
  • the postpartum period in women.

Diagnosis

Diagnosis of cervical artery dissection is mainly based on the results of angiographic methods: 

  • magnetic resonance imaging (MRI);
  • spiral computed angiography (SCT-AG);
  • radiopaque angiography (RA);
  • ultrasound by color duplex scanning (CDS). 

Dissection by intramural hematoma with hemodynamically significant stenosis of the ICA at the extracranial level, thrombosis of the ICA distal to the dissection area, and “candle flame symptom” – CDS, Doppler curve, and DSA. 

  1. MRI of the neck vessels in the area of ​​the internal carotid artery dissection shows a high signal from the vessel wall, no signal, and bending of the vessel. With MRI of the brain, the consequences of dissection of the carotid arteries, territorial extensive strokes, are clearly visible.
  2. SCT-AG combines two methods: slip ring CT scanning and computerized three-dimensional (3D) reconstruction.
  3. Radiopaque angiography is a method for diagnosing vascular diseases, in which a contrast agent is injected into them, staining its lumen. The passage of contrast through the vessels is monitored on a special apparatus – an angiograph.
  4. Thanks to CDS, you can obtain information about the quality of blood flow, as well as the presence of anatomical or postoperative abnormalities, the appearance of blood clots, the geometry of the vascular lumen, wall thickness, channel tortuosity, and atherosclerotic plaques.

cervical artery dissection

Carotid (cervical) artery dissection treatment

Treatment of a cervical artery is not definitively defined, as there are no randomized, placebo-controlled trials involving large numbers of patients. In this regard, there are no clearly established methods of treatment of a cervical artery in the acute period of stroke. 

  1. Most often, it is recommended to introduce direct anticoagulants, followed by a switch to indirect anticoagulants, used for 3–6 months:
  • their purpose is to prevent arterio-arterial embolism;
  • people should bear in mind that the appointment of large doses of anticoagulants can lead to a deterioration in the blood supply to the brain. 
  1. As an alternative to these drugs in the acute period of stroke, the use of antiplatelet agents is recommended, while there are no differences in stroke outcomes, according to preliminary data: 
  • to assess the safety of treatment with low molecular weight heparin and aspirin in the acute period of dissection, French researchers measured the volume and extent of IMH during the 1st week of treatment of a cervical artery;
  • a slight increase in these parameters was observed in one-third of patients, but in none of the cases was there an increase in the degree of stenosis or the development of repeated dissection;
  • the use of anticoagulants and antiplatelet agents is limited to 2-3 months; 
  • further prophylactic use of these drugs is inappropriate since the cause of dissection of the cervical artery is not hypercoagulation but the weakness of the arterial wall. 

Since the main reason predisposing to the development of dissection is the weakness of the arterial wall, therapeutic measures both in the acute and in the long-term period of stroke should be aimed at strengthening it. If we take into account the data on mitochondrial cytopathy, which leads to energy deficiency of cells of the arterial wall and its dysplasia, which contributes to the onset of dissection, the use of drugs with energotropic action can be considered justified. 

  1. One of these drugs is Actovegin, which is used both in the acute and in the long-term period of stroke caused by dissection. It is a biologically active substance of natural origin – a deproteinized derivative of calf blood. The main action of Actovegin is to activate cellular metabolism by facilitating the flow of oxygen and glucose into the cell, which provides an additional influx of energy substrates and increases by 18 times a universal donor of energy necessary for the vital activity and functioning of the cell. 
  2. Other drugs with a neurometabolic effect are also used to restore functions impaired due to a stroke: cerebrolysin, piracetam, gliatilin, ceraxon.

In the acute period of dissection, in addition to drug treatment, it is of great importance to observe the following rules:

  • avoid sudden head movements; 
  • avoid injuries;
  • avoid physical stress;
  • avoid straining, which can lead to an increase in dissection.

Carotid artery dissection endovascular therapy presenting  with ischemic stroke

Endovascular treatment is widely used to treat cardiovascular and cerebrovascular diseases. 

  •  Endovascular therapy can effectively improve vascular stenosis caused by coronary artery disease and reduce the incidence of ischemic stroke; 
  • Also, multiple overlapping stents can effectively reduce blood flow velocity in pseudoaneurysms and promote thrombosis, thereby reducing or causing pseudoaneurysms to disappear. 

Endovascular therapy:

  1. Is mainly used in patients with coronary artery disease with ineffective antithrombotic treatment with contraindications for anticoagulation and pseudoaneurysm, as well as when stent implantation is the main procedure for vascular intervention. 
  2. Endovascular/surgical treatment of cervical artery disease should be limited because patients with coronary artery disease have a lower risk of recurrent ischemic stroke. 
  3. There is no significant correlation between coronary artery disease-induced vascular stenosis and pseudoaneurysm, and endovascular/surgical treatments are traumatic. Endovascular treatment can be considered the preferred treatment option for patients with coronary artery disease, especially when the patient has both embolism and obvious hypoperfusion. In this case, endovascular therapy can effectively reduce stenosis, increase blood flow, and improve low perfusion. 
  4. In a retrospective study, 140 patients with coronary artery disease underwent stenting, and angiographic observation was carried out for an average of 12.8 months. The results showed that vascular stenosis caused by dissection was significantly reduced and that secondary strokes accounted for only 1.4% of cases. 
  5. Previous studies have shown that dissection stenosis in patients with coronary artery disease undergoing stent therapy can be significantly reduced – from 71% to complete remission. 

endovascular therapy

Carotid artery dissection prognosis

The prognosis for life in most cases is favorable. Fatality, according to our information and data literature, is observed in about 5% of cases. Usually, it occurs with extensive cerebral infarctions caused by dissection of the intracranial part of the Internal Carotid Artery (ICA) with the transition to the Middle cerebral artery (MCA) and the cervical artery

  1. In most patients the prognosis for life is favorable and there is a good recovery of the impaired functions. 
  2. When there is the involvement of the intracranial part of the ICA and dissection spread to the  MCA or with embolism of the last restoration of impaired functions, the prognosis is much worse:
  • dissection recurs infrequently and is usually present in the 1st month after the onset of the disease. They can appear both intact and already dissected arteries; 
  • the main mechanism of IS development is hemodynamic under conditions of an increasing stenosing-occlusive process in the ICA due to myocardial infarction;
  • less commonly, an intrauterine device (IUD) develops by the mechanism of arterial embolism;
  • its source is blood clots that form in a dissecting aneurysm, thrombosed imaging fragments that enter the bloodstream with a secondary breakthrough of the intima, or thrombotic layers at the site of rupture of the intima.

The available data stimulates researchers to better understand the pathological physiology of CAD and to focus on environmental and genetic risk factors. Modern methods of treatment and prevention are likely to be effective in modifying the natural course of this disease.

FAQ

  • Is a car accident an important risk factor for cervical (carotid) artery dissections?

Yes, it is a dangerous factor for cervical (carotid) artery dissections. The injured people of car accidents should be examined.

  • What is carotid dissection?

Dissection is the penetration of blood through the intimal gap from the lumen of the artery into its wall with the formation of an intramural hematoma (IMH), which stenoses / occludes the lumen of the artery or is a source of arterio-arterial embolism, which in turn leads to ischemic stroke.

  • What is the main reason of cervical (carotid) artery dissection?

Since the main reason predisposing to the development of dissection is the weakness of the arterial wall, therapeutic measures both in the acute and in the long-term period of stroke should be aimed at strengthening it. 

  • Can you die from cervical artery syndrome?

Cervical artery syndrome is a life-threatening emergency requiring urgent medical attention. Even if the illness lasts for decades, you should not wait and test your luck. 80% of patients can be cured of pathology, the remaining 20% get better.

  • What is cervical artery stenosis?

Stenosis of the cervical spine is a process of reducing the lumen of the spinal canal due to the development of various pathological structures. As a rule, the tendency to form stenosis is most often manifested in people over 55 years of age.

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Lone Star Neurology
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Daneisha Johnson
Daneisha Johnson
22:20 19 May 22
Dr. Askari was very kind and explained everything so I could understand. The other staff were nice as well. I would... have gave 5 stars but I was a little taken aback when I checked in and had to pay 600.00 upfront. I think that should have been discussed in a appointment confirmation call or email just so I could have been prepared.read more
Jean Cooper
Jean Cooper
16:54 29 Apr 22
I love the office staff they are friendly and very helpful. Dr. JODIE is very caring and understanding to your needs... and wants to help you. I will go back. would recommend Dr. Dr. Jodie to other Patients in a heart beat. The team works well together.read more
Linda M
Linda M
19:40 02 Apr 22
I was obviously stressed, needing to see a neurologist. The staff was so patient and Dr. Ansari was so kind. At one... point he told me to relax, we have time, when I was relaying my history of my condition. That helped ease my stress. I have seen 3 other neurologists and he was the only one who performed any assessment tests on my cognitive and physical skills. At one point I couldn't complete two assessments and got upset and cried. I was told, it's OK. That's why you're here. I was truly impressed, and super pleased with the whole experience!read more
Leslie Durham
Leslie Durham
15:05 01 Apr 22
I've been coming here for about 5 years. The staff are ALWAYS friendly and knowledgeable. The Doctors are the absolute... best!! Jodie Moore is always in such a great mood which is a plus when you are already stressed. Highly recommendedread more
Monica Del Bosque
Monica Del Bosque
14:13 25 Mar 22
Since my first post my thoughts have changed here. It's unfortunate. My doctor and PA were great, but the office staff... is horrible. They never call you back when they say they will, they misinform you, they cause you too much stress wondering what's going on, they don't keep you posted. They never answer the phone. At this point I've left four messages in the last week, and I have sent three messages. Twice from their portal and one direct email. No response. My appointment is on Monday morning at 8:30am, no confirmation on my insurance and what's going on. What the heck is going on, this is ridiculous!I've given up... the stress her office staff has put me through is just not worth it. You can do so much better, please clean house, either change out your office staff, or find a way for them to be more efficient please. You have to do something. This is not how you want to run your practice. It leaves a very bad impression on your business.read more
Ron Buckholz
Ron Buckholz
23:32 23 Mar 22
I was actually pleasantly surprised with this visit! It took me a long time to get the appointment scheduled because no... one answers your phones EVER! After a month, I finally got in, and your staff was warm, friendly, and I was totally impressed! I feel like you will take care of my needs!read more
Steve Nabavi
Steve Nabavi
16:28 16 Mar 22
It was a nice visit. Happy staff doing all they can do to comfort the patients in a very calming environment. You ask... me they are earned a big gold star on the fridge. My only complaint they didn't give me any cookies.read more
Katie Lewis
Katie Lewis
16:10 10 Feb 22
Had very positive appointments with Jodie and Dr. Sheth for my migraine care. Jodie was so fast with the injections and... has so much valuable info. I started to feel light headed during checkout and the staff was SO helpful—giving me a chair, water, and taking me into a private room until I felt better. Highly recommend this practice for migraine patients, they know what they’re doing!!read more
Joshua Martinez
Joshua Martinez
16:02 10 Dec 21
I was scheduled to be checked and just want to say that the staff was fantastic. They were kind and helpful. I was... asked many questions related to what was going on and not once did I feel as though I was being brushed off. The front desk staff was especially great in assisting me. I'm scheduled to go back for a mri and am glad that I'll be going there.read more
Isabel Ivy
Isabel Ivy
21:42 03 Nov 21
I had such a good experience with Lone Star Neurology, Brent my MRI Tech was so awesome and made sure I was very... comfortable during the appointment. He gave me ear plugs, a pillow, leg support and blanket, easiest MRI ever lol 🤣 My 72 hour EEG nurse Amanda was also so awesome. She made sure I was take care of over the 3 days and took her time with the electrodes to make sure it was comfortable for me! Paige was also a huge help in answering all my questions when it came to my test results, and letting me know her honest opinions about how I should go forth with my treatment.read more
Leslie Luce
Leslie Luce
17:37 20 Oct 21
The professionalism and want to help attitude of this office was present from the moment I contacted them. The follow... up and follow through as well as their willingness to find a way to schedule my dad was above and beyond. We visited two offices in the same day with the same experience. I am appreciative of this—we spend a lot of time with doctors and this was top notch start to finish.read more
robert Parker
robert Parker
16:38 16 Apr 21
I love going to this office. The staff is friendly and helpful. The doctor is great. I am getting the best... neurological tests and treatment I have ever had. The only reason I did not give them a 5 star rating is because it is impossible to reach a live person at the office to reschedule appointments. Every time I have tried to get through to the office it says all people are busy and I am sent to a voicemail. If they could get their phone answering fixed, I would give them a strong 5 stars.read more
MaryAnn Hornbaker
MaryAnn Hornbaker
00:26 25 Feb 21
Dr. Harney is an excellent Dr. I found him friendly , personable and thorough. I evidently am an unusual case. ... Therefore he spent a Hugh amount of time educating me. He even gave me literature to further explain my condition and how to follow up. This is something you rarely get from your doctors. So I am more than please with my doctor and his staff.read more
Roger Arguello
Roger Arguello
03:05 29 Jan 21
Always courteous, professional. The staff is very friendly and always work with you to find the best appointment time.... The care team has been great. Always taking the time to listen to your concerns and to find the best treatment.read more
Margaret Rowland
Margaret Rowland
01:12 27 Jan 21
I have been a patient at Lone Star Neurology for several years. Now both my adult daughters also are patients there. I... love Jodie. She is always so prompt whether it is a teleamed call are a visit in the office. She takes the time to explain everything to me and answers all my questions. I am so blessed to have Jodie as my doctor.read more
Susan Miller
Susan Miller
03:01 13 Jan 21
My husband had an accident 5 years ago and Lone Star Neurology has been such a blessing to us with my husbands care.... Jodie Moore is his provider and she is amazing! Jodie is very knowledgeable, caring, and thorough. She takes her time with you, making sure your needs are met and she is happy to answer any questions you may have. Lone Star Neurology’s patients are very lucky to have Jodie providing their care. Thank you Lone Star Neurology and especially Jodie for everything you have done for us. Jodie, you are the best!read more
Windalyn C
Windalyn C
01:32 09 Jan 21
Jodie is wonderful. She is very caring and knowledgeable. I have been to over a dozen neurologists, and none were able... to help me as much as they have here. Thanks!read more
Katie Kordel
Katie Kordel
00:40 09 Jan 21
Jodi Moore, nurse practitioner, is amazing. I have suffered from frequent, debilitating headaches for almost 20 years.... She has provided the best proactive and responsive care I have ever received. My quality of life has been greatly improved by her caring approach and tenacity in finding solutions.read more
Ellie Natsis
Ellie Natsis
15:41 07 Jan 21
I have had the best experience at this neurologist's office! For over a year I have been receiving iv treatments here... each month and my nurse, Bobbie is beyond wonderful!! She's so attentive, knowledgeable, caring, and detail oriented. She makes an otherwise uncomfortable experience much more pleasant and definitely puts me at ease! She also helps me with my insurance,ordering this specialty medication and dealing with the ordering process which is no easy feat.Needless to say, she goes above a beyond in every way and I'm so grateful to this office and to Bobbie for all they do for me!read more
Matt Morris
Matt Morris
15:39 07 Jan 21
Let me start by saying that I have been coming here for years. Due to my autoimmune disease, I am in this office... once every three weeks for multiple hours at a time. The office is very clean and the staff very friendly. My only complaint would be there communication via phone. They aren't the best at responding if you leave a voicemail and expect a call back. I understand that this is prob just due to the sheer number of alls they receive daily. What I can say I like the best about the office are the people. Bobby who handles my infusions is great. I never have any issues with her setting up my infusions. She is very quick to reply to messages sent via text and if she were to leave then my whole opinion of the office may change. I also enjoy people like Matt, Lauren, and Jodi. I appreciate all that they do for me and without this team I'm not sure I would be as happy as I am to visit the office as frequently as I have to. Please ensure that these folks are recognized as they are what makes my visit to this office so tolerable :).read more
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