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Concept: Vertebral artery dissection

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To evaluate the incidence and predictors of ischaemic recurrent stroke and the adverse events of antithrombotic therapy in patients with first intra- or extracranial vertebral artery dissection (VAD) who were treated with aspirin or oral anticoagulation (OA).

Concepts: Myocardial infarction, Stroke, Thrombosis, Warfarin, Aspirin, Vertebral artery dissection, Vertebral artery

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There are no reliable data from randomised trials to decide whether anticoagulants or antiplatelet agents are better to prevent further thromboembolic events after cervical arterial dissection. Most neurologists favour anticoagulants based on the underlying pathology and the likely course of acute post-dissection thromboembolism.

Concepts: Thrombosis, Antiplatelet drug, Vertebral artery dissection, Coronary artery dissection, Carotid artery dissection

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BACKGROUND: Stroke in patients with acute cervical artery dissection may be anticipated by initial transient ischemic or nonischemic symptoms. AIM: Identifying risk factors for delayed stroke upon cervical artery dissection. METHODS: Cervical artery dissection patients from the multicenter Cervical Artery Dissection and Ischemic Stroke Patients study were classified as patients without stroke (n = 339), with stroke preceded by nonstroke symptoms (delayed stroke, n = 244), and with stroke at onset (n = 382). Demographics, clinical, and vascular findings were compared between the three groups. RESULTS: Patients with delayed stroke were more likely to present with occlusive cervical artery dissection (P < 0·001), multiple cervical artery dissection (P = 0·031), and vertebral artery dissection (P < 0·001) than patients without stroke. No differences were observed in age, smoking, arterial hypertension, hypercholesterolemia, migraine, body mass index, infections during the last week, and trauma during the last month, but patients with delayed stroke had less often transient ischemic attack (P < 0·001) and local signs (Horner syndrome and cranial nerve palsy; P < 0·001). CONCLUSIONS: Occlusive cervical artery dissection, multiple cervical artery dissection, and vertebral artery dissection were associated with an increased risk for delayed stroke. No other risk factors for delayed stroke were identified. Immediate cervical imaging of cervical artery dissection patients without ischemic stroke is needed to identify patients at increased risk for delayed ischemia.

Concepts: Myocardial infarction, Atherosclerosis, Coronary artery disease, Stroke, Transient ischemic attack, Blood pressure, Vertebral artery dissection, Hypercholesterolemia

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BACKGROUND: Cerebellar infarction is easily misdiagnosed or underdiagnosed. In this study, we investigated factors leading to misdiagnosis of cerebellar infarction in patients with acute ischemic stroke. METHODS: Data on neurological and radiological findings from 114 consecutive patients with acute cerebellar infarction were analyzed. We investigated factors associated with misdiagnosis from the data on clinical findings. RESULTS: Thirty-two (28%) patients were misdiagnosed on admission. Misdiagnosis was significantly more frequent in patients below 60 years of age and in patients with vertebral artery dissection, and significantly less frequent in patients with dysarthria. It tended to be more frequent in patients with the medial branch of posterior inferior cerebellar artery territory infarction, and infrequent in patients with the medial branch of the superior cerebellar artery territory infarction. Thirty out of 32 (94%) misdiagnosed patients were seen by physicians that were not neurologists at the first visit. Twenty-four of 32 (75%) misdiagnosed patients were screened only by brain CT. However, patients were not checked by brain MRI or follow-up CT until their conditions worsened. CONCLUSIONS: Patients below 60 years of age and patients with vertebral artery dissection are more likely to have a cerebellar infarction misdiagnosed by physicians other than neurologists.

Concepts: Central nervous system, Medicine, Brain, Stroke, Cerebellum, Posterior inferior cerebellar artery, Vertebral artery dissection, Anterior inferior cerebellar artery

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INTRODUCTION: Previous reports have suggested that endovascular parent artery occlusion is an effective and safe procedure for the treatment of vertebral artery dissection (VAD). However, the results of long-term outcomes are still unclear. This study reviewed the clinical and imaging outcomes of patients with VAD treated by endovascular internal trapping. METHODS: A total of 73 patients were treated for VAD by endovascular internal trapping between March 1998 and March 2011. Patients were regularly followed up by magnetic resonance imaging, magnetic resonance angiography, and clinical examinations. Clinical outcomes were evaluated using the modified Rankin Scale. RESULTS: Forty-five patients had ruptured VADs, and 28 had unruptured VADs. Clinical follow-up of at least 6 months data was obtained for 61 patients (83.6 %). The follow-up period ranged from 6 to 145 months (mean ± SD, 55.6 ± 8.9 months). Two patients with ruptured VADs had recurrence (2.74 %). Cranial nerve paresis (CNP) was observed in six patients (8.21 %), spinal cord infarction in two patients (2.74 %), and a perforating artery ischemia was diagnosed in seven patients (9.59 %); all patients with CNP and five of the patients with partial Wallenberg syndrome experienced only temporary symptoms; two of the patients with partial Wallenberg syndrome had permanent neurological deficits. Despite their symptoms, most patients were in good general condition, as shown by their clinical scores. CONCLUSIONS: The results of this study have proven that endovascular internal trapping is a stable and durable treatment for closure of VADs. Recanalization is rather rare and occurred only in ruptured cases, both within 3 months after initial treatment without rupture. CNPs were observed in 8.21 %, perforating ischemia in 9.59 %, and spinal cord infarction in 2.74 %. The former two are temporary, while the last can be a factor that affects the modified Rankin Scale. Patients rated their quality of life as good, as corroborated by their posttreatment clinical score. Endovascular internal trapping for VAD is a therapy with a satisfactory long-term outcome.

Concepts: Stroke, Medical imaging, Nuclear magnetic resonance, Magnetic resonance imaging, Modified Rankin Scale, Radiology, Vertebral artery dissection, Medulla oblongata

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Cervical artery dissection (CAD) and stroke are serious harms that are sometimes associated with cervical spinal manipulation therapy (cSMT). Because of the relative rarity of these adverse events, studying them prospectively is challenging. As a result, systematic review of reports describing these events offers an important opportunity to better understand the relation between adverse events and cSMT. Of note, the quality of the case report literature in this area has not yet been assessed.

Concepts: Myocardial infarction, Atherosclerosis, Blood pressure, Galen, Vertebral artery dissection, Coronary artery dissection, Pseudoaneurysm, Carotid artery dissection

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Cervical spine manipulation (CSM) is a commonly spinal manipulative therapies for the relief of cervical spine-related conditions worldwide, but its use remains controversial. CSM may carry the potential for serious neurovascular complications, primarily due to vertebral artery dissection (VAD) and subsequent vertebrobasilar stroke. Here, we reported a rare case of locked-in syndrome (LIS) due to bilaterial VAD after CSM treated by arterial embolectomy.A 36-year-old right-handed man was admitted to our hospital with numbness and weakness of limbs after treating with CSM for neck for half an hour. Gradually, although the patient remained conscious, he could not speak but could communicate with the surrounding by blinking or moving his eyes, and turned to complete quadriplegia, complete facial and bulbar palsy, dyspnea at 4 hours after admission. He was diagnosed with LIS. Then, the patient was received cervical and brain computed tomography angiography that showed bilateral VAD. Aortocranial digital subtraction angiography showed vertebrobasilar thrombosis, blocking left vertebral artery, and stenosis of right vertebral artery. The patient was treated by using emergency arterial embolectomy and followed by antiplatelet therapy and supportive therapy in the intensive care unit and a general ward. Twenty-seven days later, the patient’s physical function gradually improved and discharged but still left neurological deficit with muscle strength grade 3/5 and hyperreflexia of limbs.Our findings suggested that CSM might have potential severe side-effect like LIS due to bilaterial VAD, and arterial embolectomy is an important treatment choice. The practitioner must be aware of this complication and should give the patients informed consent to CSM, although not all stroke cases temporally related to SCM have pre-existing craniocervical artery dissection.

Concepts: Atherosclerosis, Vertebral column, Angiography, Vertebral artery dissection, Vertebral artery, Digital subtraction angiography, Intravenous digital subtraction angiography, Subclavian artery

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For patients and health care providers who are considering spinal manipulative therapy of the neck, it is crucial to establish if it is a trigger for cervical artery dissection and/or stroke, and if it is, the magnitude of the risk.

Concepts: Health care, Health care provider, Medicine, Vertebral column, Vertebral artery dissection, Joint manipulation, Subclavian artery, Carotid artery dissection

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The purported relationship between cervical manipulative therapy (CMT) and stroke related to vertebral artery dissection (VAD) has been debated for several decades. A large number of publications, from case reports to case-control studies, have investigated this relationship. A recent article suggested that case misclassification in the case-control studies on this topic resulted in biased odds ratios in those studies.

Concepts: Epidemiology, Case-control study, Vertebral artery dissection, Joint manipulation

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Although sparse observational studies have suggested a link between migraine and cervical artery dissection (CEAD), any association between the 2 disorders is still unconfirmed. This lack of a definitive conclusion might have implications in understanding the pathogenesis of both conditions and the complex relationship between migraine and ischemic stroke (IS).

Concepts: Observational study, Stroke, Transient ischemic attack, Vertebral artery dissection, Carotid artery dissection