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• In Re: Recurrent stroke after cervical artery dissection
  Joshua Z Willey
  Published on: 8 October 2010

• Published on: 8 October 2010

  In Re: Recurrent stroke after cervical artery dissection

  • Joshua Z Willey, Assistant Professor of Neurology

  I read the article by Weimar, et al with interest. The authors describe the largest case series to date of cervico-cephalic dissection in a multi-hospital registry in Germany. I found the findings on the risk of recurrent stroke being lower in the anti-coagulation group, similar in internal carotid versus vertebral artery, and higher in the occlusion versus stenosis group telling. The overall risk of recurrent stroke bein...

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  I read the article by Weimar, et al with interest. The authors describe the largest case series to date of cervico-cephalic dissection in a multi-hospital registry in Germany. I found the findings on the risk of recurrent stroke being lower in the anti-coagulation group, similar in internal carotid versus vertebral artery, and higher in the occlusion versus stenosis group telling. The overall risk of recurrent stroke being high, particularly in the first year, was a useful result for clinical care. As the authors pointed out they did not include patients with asymptomatic dissection, but 12% of the sample did not have a cerebral infarction and presumably had a TIA. Were the patients with no cerebral infarction at a different risk of recurrence?

  I wondered however if case selection may have driven some of the results as I have encountered several cases that were erroneously diagnosed with dissection. I have encountered several patients with atherosclerotic plaque rupture with subsequent "dissection" that may appear as a vessel wall hematoma. The selection of patients was a concern as some may have had atherosclerosis rather than dissection. Atherosclerosis could have a very different risk of recurrence than dissection. The average age of the sample was 48, and the standard deviation was 12 indicating that a substantial proportion of the sample was aged 60 or older. In addition the burden of atherosclerotic disease risk factors was high in the sample (40% had hypertension, 35% smoked) while few had an indentified trigger for dissection (though this is common in dissection case series). The most common diagnostic finding was long segment stenosis, which could well be due to atherosclerosis rather than dissection in many cases given that atherosclerosis is much more common that dissection (1). Was the risk of recurrence different based on that vascular finding? Further information on how vertebral dissection was diagnosed would have been interesting given the difficulties with diagnostic modalities in this artery, or the carotid artery (2, 3). Fat- suppressed MRI may not be optimal, and not visualizing whether there are calcifications in the artery may make vertebral dissection difficult to diagnose. There was also little information on whether the patients were imaged on follow up, and resolution of the abnormalities on imaging would have been more telling.

  There were 5 in hospital deaths, and 13 recurrent strokes, for which it may have been useful to know if the deaths or recurrences were due to ischemic or hemorrhagic stroke. In clinical rounds we often discuss the risk of acute anti-coagulation in patients with vertebral dissection out of concern that they may subsequently develop subarachnoid hemorrhage.

  1 Dittrich R, Nassenstein I, Harms S, Maintz D, Heindel W, Kuhlenb?umer G, Ringelstein EB. Arterial elongation ("redundancy") is not a feature of spontaneous cervical artery dissection. J Neurol. 2010 Sep 10. [Epub ahead of print] 2 Khan S, Cloud GC, Kerry S, Markus HS. Imaging of vertebral artery stenosis: a systematic review. J Neurol Neurosurg Psychiatry 2007;78:1218- 1225 3 Naggara O, Louillet F, Touz? E, Roy D, Leclerc X, Mas JL, Pruvo JP, Meder JF, Oppenheim C. Added Value of High-Resolution MR Imaging in the Diagnosis of Vertebral Artery Dissection. AJNR Am J Neuroradiol. 2010 Jul 1. [Epub ahead of print]

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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