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Volume 2024, Issue 1
  • ISSN: 0253-8253
  • EISSN: 2227-0426

Abstract

Introduction: Cervicocephalic arterial dissections (CADs) occur in 3 cases per 100,000 individuals across all ages. Multiple simultaneous CADs are found in 13 to 22% of cases, and three or more dissections occur in approximately 2%. CADs might result from multifactorial intrinsic deficiencies of vessel wall integrity and extrinsic factors, e.g., minor trauma.

Case Presentation: A young gentleman presented to the emergency department with a sudden onset of a spinning sensation of surrounding, left side arm weakness, blurring of vision, and an NIHSS score of 4. An urgent CT scan of the head and intracranial angiogram showed bilateral severe stenosis of the distal cervical segment of internal carotid arteries (ICAs) and right vertebral artery moderate stenosis at the V2 segment. He had been given IV TPA (Alteplase) within the 4.5-hour window. After 4 hours, the patient’s GCS dropped from 15 to 10, and the NIHSS score increased from 4 to 24, followed by witnessed a generalized tonic-clonic seizure. Repeat urgent CT head showed no evidence of intracerebral hemorrhage (ICH). The patient was arranged for cerebral angiographic catheterization that showed bilateral flame-shaped occlusion of cervical ICA dissection. There is a mild focal narrowing of the right cervical vertebral artery, likely dissection. Routine laboratory blood workup for vasculitis was negative. During MICU admission, he had witnessed the right arm hemichorea-ballism spectrum abnormal movement. After the 6th-month follow-up, intracranial CT angiogram showed reduced caliber of the bilateral distal cervical course of the internal carotid arteries seen with residual dissection and focal outpouching of the right ICA representing pseudoaneurysm.

Discussion: The occurrence of multiple CADs suggests the presence of an underlying intrinsic arteriopathy, such as FMD, the presence of pseudoaneurysm, environmental triggers, cervical manipulation, and remote history of head or neck surgery. A study of the most extensive case series of patients with cervical artery dissection showed 15.2% of patients with multiple CAD. In most patients with multiple cervical artery dissections, antithrombotic treatment is effective, complete recanalization, and the outcome is favorable. Outside the window period of acute ischemic stroke, either anticoagulation or antiplatelet therapy is a recognized treatment for secondary ischemic stroke prevention due to extracranial artery dissection. For acute stroke or TIA patients caused by intracranial artery dissection, experts recommend antiplatelet therapy rather than anticoagulation.

Conclusion: Simultaneous triple-vessel cervicocephalic arterial dissections are rarely reported condition. Multiple CADs are associated with underlying vasculopathy and environmental triggers, and a majority are recanalized with antithrombotic treatment with favorable outcomes. Antithrombotic treatment is effective in most patients with multiple CADs, and most expect complete recanalization. This case report guides physicians in the treatment and outcome of acute stroke due to multiple CAD.

© 2024 Ali, Haroon, Akhtar, Zammar, Meer, Abualrob, Eltazi, Noorain, Baniamer, Yasin, Licensee HBKU Press.
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2024-02-15
2024-11-07
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References

  1. GBD 2019 Stroke Collaborators . Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021 Oct; 20:(10):795-820. doi: [Crossref].
     https://doi.org/10.1016/S1474-4422(21)00252-0 [Google Scholar]
  2. Lee VH, Brown RD Jr, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006 Nov 28; 67:(10):1809-12. doi: [Crossref].
     https://doi.org/10.1212/01.wnl.0000244486.30455.71 [Google Scholar]
  3. Touzé E, Gauvrit JY, Moulin T, Meder JF, Bracard S, Mas JL, et al.. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology. 2003 Nov 25; 61:(10):1347-51. doi: [Crossref].
     https://doi.org/10.1212/01.wnl.0000094325.95097.86 [Google Scholar]
  4. Atalay YB, Piran P, Chatterjee A, Murthy S, Navi BB, Liberman AL, et al.. Prevalence of Cervical Artery Dissection Among Hospitalized Patients With Stroke by Age in a Nationally Representative Sample From the United States. Neurology. 2021 Feb 16; 96:(7):e1005-e1011. doi: [Crossref].
     https://doi.org/10.1212/WNL.0000000000011420 [Google Scholar]
  5. Kim BM, Kim SH, Kim DI, Shin YS, Suh SH, Kim DJ, et al.. Outcomes and prognostic factors of intracranial unruptured vertebrobasilar artery dissection. Neurology. 2011 May 17; 76:(20):1735-41. doi: [Crossref].
     https://doi.org/10.1212/WNL.0b013e31821a7d94 [Google Scholar]
  6. Debette S, Compter A, Labeyrie MA, Uyttenboogaart M, Metso TM, Majersik JJ, et al.. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol. 2015 Jun; 14:(6):640-54. doi: [Crossref].
     https://doi.org/10.1016/S1474-4422(15)00009-5 [Google Scholar]
  7. Downer J, Nadarajah M, Briggs E, Wrigley P, McAuliffe W. The location of origin of spontaneous extracranial internal carotid artery dissection is adjacent to the skull base. J Med Imaging Radiat Oncol. 2014 Aug; 58:(4):408-14. doi: [Crossref].
     https://doi.org/10.1111/1754-9485.12170 [Google Scholar]
  8. Arnold M, Bousser MG, Fahrni G, Fischer U, Georgiadis D, Gandjour J, et al.. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke. 2006 Oct; 37:(10):2499-503. doi: [Crossref].
     https://doi.org/10.1161/01.STR.0000240493.88473.39 [Google Scholar]
  9. Arauz A, Hoyos L, Espinoza C, Cantú C, Barinagarrementeria F, Román G. Dissection of cervical arteries: Long-term follow-up study of 130 consecutive cases. Cerebrovasc Dis. 2006; 22:(2-3):150-4. doi: [Crossref].
     https://doi.org/10.1159/000093244 [Google Scholar]
  10. Markus HS, Levi C, King A, Madigan J, Norris J; Cervical Artery Dissection in Stroke Study (CADISS) Investigators. Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection: The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA Neurol. 2019 Jun 1; 76:(6):657-664. doi: [Crossref].
     https://doi.org/10.1001/jamaneurol.2019.0072 [Google Scholar]
  11. Maruyama H, Nagoya H, Kato Y, Deguchi I, Fukuoka T, Ohe Y, et al.. Spontaneous cervicocephalic arterial dissection with headache and neck pain as the only symptom. J Headache Pain. 2012 Apr; 13:(3):247-53. doi: [Crossref].
     https://doi.org/10.1007/s10194-012-0420-2 [Google Scholar]
  12. Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol. 2009 Oct; 193:(4):1167-74. doi: [Crossref].
     https://doi.org/10.2214/AJR.08.1688 [Google Scholar]
  13. Vertinsky AT, Schwartz NE, Fischbein NJ, Rosenberg J, Albers GW, Zaharchuk G. Comparison of multidetector CT angiography and MR imaging of cervical artery dissection. AJNR Am J Neuroradiol. 2008 Oct; 29:(9):1753-60. doi: [Crossref].
     https://doi.org/10.3174/ajnr.A1189 [Google Scholar]
  14. Provenzale JM. MRI and MRA for evaluation of dissection of craniocerebral arteries: lessons from the medical literature. Emerg Radiol. 2009 May; 16:(3):185-93. doi: [Crossref].
     https://doi.org/10.1007/s10140-008-0770-x [Google Scholar]
  15. Hassan AE, Zacharatos H, Mohammad YM, Tariq N, Vazquez G, Rodriguez GJ, et al.. Comparison of single versus multiple spontaneous extra- and/or intracranial arterial dissection. J Stroke Cerebrovasc Dis. 2013 Jan; 22:(1):42-8. doi: [Crossref].
     https://doi.org/10.1016/j.jstrokecerebrovasdis.2011.06.004 [Google Scholar]
  16. Arnold M, De Marchis GM, Stapf C, Baumgartner RW, Nedeltchev K, Buffon F, et al.. Triple and quadruple spontaneous cervical artery dissection: presenting characteristics and long-term outcome. J Neurol Neurosurg Psychiatry. 2009 Feb; 80:(2):171-4. doi: [Crossref].
     https://doi.org/10.1136/jnnp.2008.155226 [Google Scholar]
  17. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul; 8:(7):668-78. doi: [Crossref].
     https://doi.org/10.1016/S1474-4422(09)70084-5 [Google Scholar]
  18. Béjot Y, Aboa-Eboulé C, Debette S, Pezzini A, Tatlisumak T, Engelter S, et al.. Characteristics and outcomes of patients with multiple cervical artery dissection. Stroke. 2014 Jan; 45:(1):37-41. doi: [Crossref].
     https://doi.org/10.1161/STROKEAHA.113.001654 [Google Scholar]
  19. Janquli M, Selvarajah L, Moloney MA, Kavanagh E, O’Neill DC, Medani M. Long-term outcome of cervical artery dissection. J Vasc Surg. 2023 Jul; 78:(1):158-165. doi: [Crossref].
     https://doi.org/10.1016/j.jvs.2023.03.020 [Google Scholar]
  20. Bernardo F, Nannoni S, Strambo D, Bartolini B, Michel P, Sirimarco G. Intravenous thrombolysis in acute ischemic stroke due to intracranial artery dissection: a single-center case series and a review of literature. J Thromb Thrombolysis. 2019 Nov; 48:(4):679-684. doi: [Crossref].
     https://doi.org/10.1007/s11239-019-01918-6 [Google Scholar]
  21. Brott TG, Halperin JL, Abbara S, et al.. 2011. ASA guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. Circulation. 2011 Jul 26; 124:(4):489-532. doi: [Crossref].
     https://doi.org/10.1161/CIR.0b013e31820d8d78 [Google Scholar]
  22. Ono H, Nakatomi H, Tsutsumi K, Inoue T, Teraoka A, Yoshimoto Y, et al.. Symptomatic recurrence of intracranial arterial dissections: follow-up study of 143 consecutive cases and pathological investigation. Stroke. 2013 Jan; 44:(1):126-31. doi: [Crossref].
     https://doi.org/10.1161/STROKEAHA.112.670745 [Google Scholar]
  23. Bond KM, Krings T, Lanzino G, Brinjikji W. Intracranial dissections: A pictorial review of pathophysiology, imaging features, and natural history. J Neuroradiol. 2021 May; 48:(3):176-188. doi: [Crossref].
     https://doi.org/10.1016/j.neurad.2020.03.007 [Google Scholar]
/content/journals/10.5339/qmj.2024.6
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Spontaneous triple vessel cervicocephalic artery dissection in a young gentleman: A case report
Qatar Medical Journal 2024, 6 (2024); https://doi.org/10.5339/qmj.2024.6
/content/journals/10.5339/qmj.2024.6
/content/journals/10.5339/qmj.2024.6
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  • Article Type: Research Article
Keyword(s): dissecting aneurysm (pseudoaneurysm), fibromuscular dysplasia (FMD), intracranial hemorrhage (ICH) and Multiple simultaneous cervicocephalic dissections

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