Rodolfo Pini
Università di bologna
Alma Mater Studiorum
Chirurgia Vascolare
Oltre la terapia medica nelle
dissezioni carotidee
What we know from the literature
Epidemiology
Clinical presentation in the real world
Carotid and Vertebral Artery Dissection
What we know from the literature
Epidemiology
Clinical presentation in the real world
Carotid and Vertebral Artery Dissection
Common types:
ICDs (80%)
VADs (15%)
ICD+VAD (5%)
ICD: 2.5% of strokes
20% of strokes in patients < 45 yo
Aethiopathogenesis not clear
Carotid and Vertebral Artery Dissection
Common types:
ICDs (80%)
VADs (15%)
ICD+VAD (5%)
ICD: 2.5% of strokes
20% of strokes in patients < 45 yo
Aethiopathogenesis not clear
Carotid and Vertebral Artery Dissection
Clinical Manifestations
Intracranial
SAH
TIA
Major/Minor stroke
Extracranial
Neck/ jaw/ face sharp pain
Headache
Partial Horner syndrome
Ipsilateral cranial palsiesICD and VAD pain localization
Diagnosis of ICD
US
MRI/MRA
CT Angiography
Catheter Angiography
Diagnosis of ICD
US
MRI/MRA
CT Angiography
Catheter Angiography
Diagnosis of ICD
US
MRI/MRA
CT Angiography
Catheter Angiography
ICD Treatment
Antiplatelets vs Anticoagulants for the Treatment of
Cervical Artery Dissection: Bayesian Meta-Analysis
Antiplatelets Anticoagulants
Relative Risk
Sarikaya et al, Plos One 2014
ICD Treatment
Antiplatelets vs Anticoagulants for the Treatment of
Cervical Artery Dissection: Bayesian Meta-Analysis
Antiplatelets Anticoagulants
Relative Risk
Sarikaya et al, Plos One 2014
Antiplatelets should be given precedence over
anticoagulants as a first line treatment
in patients with cervical artery dissection
ICD Treatment
Antiplatelet treatment compared with anticoagulation treatment for cervical
artery dissection (CADISS): a randomised trial
CADISS investigators, Lancet Neurol 2015
126 antiplatelet
124 anticoagulant
ICD Treatment
Antiplatelet treatment compared with anticoagulation treatment for cervical
artery dissection (CADISS): a randomised trial
CADISS investigators, Lancet Neurol 2015
126 antiplatelet
124 anticoagulant
No difference in efficacy of antiplatelet and anticoagulant drugs at
preventing stroke and death
ICD Treatment
Surgical reconstruction
ICD Treatment
Stenting
Not recommended (low-rate of event in medical therapy)
Recurrent event in BMT: hemodynamic
Efficacy and durability: not demonstrated
Class IIb, level of evidence C
ICD Treatment
Stenting
Not recommended in asymptomatic or stable cases(low-rate of event in medical therapy)
Recurrent event in BMT: hemodynamic
Efficacy and durability: not demonstrated
Class IIb, level of evidence C
ICD Treatment
Stenting
Not recommended in asymptomatic or stable cases(low-rate of event in medical therapy)
Recurrent event in BMT: hemodynamic
Efficacy and durability: not demonstrated
Class IIb, level of evidence C
?
ICD Treatment
Stenting
Not recommended in asymptomatic or stable cases(low-rate of event in medical therapy)
Recurrent event in BMT: hemodynamic
Efficacy and durability: not demonstrated
Class IIb, level of evidence C
??
ICD Treatment
Level of Recommendation
Treatment
Asymptomatic or with unrepeated symptoms
Class IIa Medical Therapy
With symptoms recurrence
Class IIbCAS
CEA
ASA/AHA/AANN/AANS/ACR/ASNR/CNS/
SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline
What we know from the literature
Epidemiology
Clinical presentation in the real world
Carotid and Vertebral Artery Dissection
ICD VAD TOT
SIDE
Left 17 6 23
Right 9 4 13
Bilateral 2 1 3
AETHIOLOGY
Unknown 22 8 30
Traumatic 4 3 7
Iatrogenic 2 - 2
CLINICAL MANIFESTATIONS
Stroke 14 8 22
TIA 4 1 5
Horner Sd. 2 - 2
Others 5 - 5
None 4 1 5
Carotid and Vertebral Artery Dissection
Policlinico
S. Orsola, Bo
aa. 2012-15
Tot N 39
ICD VAD TOT
Antiplatelets 2 4 6
Anticoagulants 13 4 17
Both 3 2 5
Thrombolysis 2 - 2
Stenting 1 - 1
Surgery 1 - 1
None 6 1 7
Carotid and Vertebral Artery Dissection
What we know from the literature
Epidemiology
Clinical presentation in the real world
Carotid and Vertebral Artery Dissection
59yo female
Dyslipidemia
History of headache
GCS 15/15
NIHSS 0
ICD # 1
8:00
Neurologic event:
Right arm Parestesia and
Ipostenia
ICD # 1
8:00 11:45
E.R:
Symptoms regression
ICD # 1
New event
Aphasia
E.R.
11:45 12:00
Neurologic event
8:00
ICD # 1
Symptoms regression
No thrombolysis
Neurologic event
8:00
E.R.
11:45
Aphasia
12:00 12:30
ICD # 1
Imaging
Cerebral CT
Supra-aortic vessels CTA
Neurologic event
8:00
E.R.
11:45
Aphasia
12:00
Regression
12:30 13:00
ICD # 1
Imaging
Neurologic event
8:00
E.R.
11:45
Aphasia
12:00
Regression
12:30 13:00
No ischemic or hemorrhagic lesions
ICD # 1
Neurologic event
8:00
E.R.
11:45
Aphasia
12:00
Regression
12:30 13:00
Focal extracranial left internal carotid dissection
Patency from the intrapetrosus section
ICD # 1
Neurologic event
8:00
E.R.
11:45
Aphasia
12:00
Regression
12:30
Imaging
13:00
Vascular Surgeon Evaluation
Internal left carotid dissection
Patency from the intrapetrosus section
No neurological deficit, stable last hour
13:30
ICD # 1
Medical therapy: anticoagulation
New neurologic symptoms
Right arm ipostenia Aphasia
1 hour duration
DAY 2
10:00
ICD # 1
New cerebral CT2 new ischemic frontal lesions
New event
10:00 12:30
9 mm
10 mm
ICD # 1
10:00 12:30
New event CT
13:00
Vascular Surgeon Evaluation
Distal internal left carotid dissecation
Neurologic symptoms “in crescendo”
Small cerebral lesions
ICD # 1
Revascularization: stenting
Filterwire: no
progression
Command 0.014
Wallstent 7x40
10:00 12:30
New event CT Surg Evaluation
13:00Operation Theather
17:30
ICD # 1
No deficit
CTAcontrol
2 yr follow-up:
Patient asymptomatic
Stent patent
ICD # 1
ICD # 2
50 yro male,
Drug resistant hypertension
Migraine aura
Absence seizures (2 yrs)
BP 200/100 mmHg, HR 83/min, O2 sat 92%
GCS 15/15
ICD # 2
Sudden appearance of thunderclap left temporal
headache, during anaerobic exercise (NRS=7)
Mental confusion (20 min)
Left horizontal diplopia
NIHSS 0
ICD, # 2
6 days later:
Perioral paresthesia
Aphasia
X-XII nerve palsies (tongue deviation and
left soft palate weakness)
Cerebral CT: no ischemic or haemorragic
acute/cronic lesions
EEG (-)
ICD # 2
Ist Supra-aortic Vessels CTA
Focal left internal
carotid dissection
ICD, # 2
ICA stenosis below the carotid canal
Intimal flap at the entrance of the petrous portion of the
temporal bone
False lumen haematoma
ICD, # 2
MRA
TCD
TCD with bubble study (-)
Focal left ICA dissection: terminal part of
the cervical segment (C1) + first part of the
petrous segment (C2)
ICD, # 2
Anticoagulants
LMWH 10000 U 2/die (3 days)
First Line Treatment
ICD, # 2
2nd Supra-aortic vessels
CTA
3 days later:
Enlargement of
false lumen haematoma
ICD, # 2
Internal left carotid dissection
Internal carotid artery patency preserved
False lumen haematoma
No new neurological deficit, stable last hour
No indication to
revascularization
ICD, # 2
Internal left carotid dissection
Internal carotid artery patency preserved
False lumen haematoma
No new neurological deficit, stable last hour
ICD, # 2
Antiplatelets (Clopidogrel 75 mg/die) +
↓ Anticoagulants (LMWH 4000 U/die)
ICD # 2
3rd Supra-aortic vessels CTA
ICD # 2
3rd Supra-aortic vessels CTA
Stability of
false lumen haematoma
ICD # 2
1 month CTA
ICD # 2
1 month CTA
False lumen haematoma stability
ICA stenosis ↓
Regular arterial wall
ICD # 2
3 month CTA
False lumen haematoma stability
ICA stenosis ↓ ↓ ↓
Regular arterial wall
ICD # 2
3 month CTA
False lumen haematoma stability
ICA stenosis ↓ ↓ ↓
Regular arterial wall
Infrequent but not rare occurence
High variety of symptoms and evolution
Unclear origin
Treatment to be decided based on clinical
presentation and anatomical characteristics of the
lesion
Carotid and Vertebral Artery Dissection