38 Approaches to Extracranial and Intracranial Dissection

Ahmad Sweid, Kareem El Naamani, Peter S. Amenta, and Pascal M. Jabbour

Abstract

Arterial dissection is attributed as the etiology of stroke in less than 1% of all cases. Intracranial dissections accounts for 10 to 25% of strokes in those aged 25 to 45 years. Untreated carotid artery dissections are associated with a mortality rate of 20 to 40% and a morbidity rate of approximately 40 to 80%. Carotid dissection is categorized as either spontaneous or traumatic. Arterial dissections are the result of longitudinal division of the vessel wall by the entrance of blood into the tunica media. The expanding diameter of the vessel wall results in partial or complete occlusion of the true vessel lumen. Exposure of the subendothelial layer also brings the prothrombotic components of the vessel wall into contact with intraluminal blood, resulting in the formation of thrombus and a source of potential embolization. The Cervical Artery Dissection in Ischemic Stroke Patients (CADISP) Study Group report represents the most comprehensive review regarding the use of antiplatelet agents versus anticoagulation. The report was inconclusive and recommended randomized controlled trials to identify the superiority of one regimen over the other. If there is hemodynamic insufficiency secondary to decreased luminal diameter, pseudoaneurysms, or subarachnoid hemorrhage, then consideration should be given to open or endovascular surgical repair. Development of several endovascular options has resulted in effective and efficient revascularization or vessel reconstruction using stenting, stent-assisted coiling, and flow diversion.

Key words

arterial dissection - intimal tear - ischemic stroke - subarachnoid hemorrhage - and pseudoaneurysm

• 1 Ducrocq X, Lacour JC, Debouverie M, Bracard S, Girard F, Weber M. Cerebral ischemic accidents in young subjects. A prospective study of 296 patients aged 16 to 45 years.. Rev Neurol (Paris) 1999; 155 (8) 575-582 PubMed

• 2 Hart RG, Easton JD. Dissections.. Stroke 1985; 16 (6) 925-927 PubMed

• 3 Kremer C, Mosso M, Georgiadis D et al. Carotid dissection with permanent and transient occlusion or severe stenosis: long-term outcome.. Neurology 2003; 60 (2) 271-275 PubMed

• 4 Davis JW, Holbrook TL, Hoyt DB, Mackersie RC, Field Jr TO, Shackford SR. Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment.. J Trauma 1990; 30 (12) 1514-1517 PubMed

• 5 Krajewski LP, Hertzer NR. Blunt carotid artery trauma: report of two cases and review of the literature.. Ann Surg 1980; 191 (3) 341-346 PubMed

• 6 Mas J-L, Bousser M-G, Hasboun D, Laplane D. Extracranial vertebral artery dissections: a review of 13 cases.. Stroke 1987; 18 (6) 1037-1047 PubMed

• 7 Ast G, Woimant F, Georges B, Laurian C, Haguenau M. Spontaneous dissection of the internal carotid artery in 68 patients.. Eur J Med 1993; 2 (8) 466-472 PubMed

• 8 Sandmann W, Hennerici M, Aulich A, Kniemeyer H, Kremer KW. Progress in carotid artery surgery at the base of the skull.. J Vasc Surg 1984; 1 (6) 734-743 PubMed

• 9 Ohta H, Natarajan SK, Hauck EF et al. Endovascular stent therapy for extracranial and intracranial carotid artery dissection: single-center experience.. J Neurosurg 2011; 115 (1) 91-100 PubMed

• 10 Guillon B, Brunereau L, Biousse V, Djouhri H, Lévy C, Bousser M-G. Long-term follow-up of aneurysms developed during extracranial internal carotid artery dissection.. Neurology 1999; 53 (1) 117-122 PubMed

• 11 Boet R, Wong HT, Yu SC, Poon WS. Vertebrobasilar artery dissections: current practice.. Hong Kong Med J=Xianggang Yi Xue Za Zhi 2002; 8 (1) 33-38 PubMed

• 12 Provenzale JM, Barboriak DP, Taveras JM. Exercise-related dissection of craniocervical arteries: CT, MR, and angiographic findings.. J Comput Assist Tomogr 1995; 19 (2) 268-276 PubMed

• 13 Engelter ST, Brandt T, Debette S, et al. Antiplatelets versus anticoagulation in cervical artery dissection.. Stroke 2007; 38 (9) 2605-2611 PubMed

• 14 Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study.. Neurology 2011; 77 (12) 1174-1181 PubMed

• 15 Chowdhury MM, Sabbagh CN, Jackson D, Coughlin PA, Ghosh J. Antithrombotic treatment for acute extracranial carotid artery dissections: a meta-analysis.. Eur J Vasc Endovasc Surg 2015; 50 (2) 148-156 PubMed

• 16 Surdell DL, Bernstein RA, Hage ZA, Batjer HH, Bendok BR. Symptomatic spontaneous intracranial carotid artery dissection treated with a self-expanding intracranial nitinol stent: a case report.. Surg Neurol 2009; 71 (5) 604-609 PubMed

• 17 Wilkinson IM. The vertebral artery. Extracranial and intracranial structure.. Arch Neurol 1972; 27 (5) 392-396 PubMed

• 18 Yeung TW, Lai V, Lau HY, Poon WL, Tan CB, Wong YC. Long-term outcome of endovascular reconstruction with the pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery.. J Neurosurg 2012; 116 (4) 882-887 PubMed

• 19 Chen SH, McCarthy DJ, Sheinberg D et al. Pipeline embolization device for the treatment of intracranial pseudoaneurysms.. World Neurosurg 2019; 127: e86-e93 PubMed

• 20 Benndorf G, Herbon U, Sollmann WP, Campi A. Treatment of a ruptured dissecting vertebral artery aneurysm with double stent placement: case report.. AJNR Am J Neuroradiol 2001; 22 (10) 1844-1848 PubMed

• 21 Guerrero WR, Ortega-Gutierrez S, Hayakawa M et al. Endovascular treatment of ruptured vertebrobasilar dissecting aneurysms using flow diversion embolization devices: single-institution experience.. World Neurosurg 2018; 109: e164-e169 PubMed

• 22 Pham MH, Rahme RJ, Arnaout O et al. Endovascular stenting of extracranial carotid and vertebral artery dissections: a systematic review of the literature.. Neurosurgery 2011; 68 (4) 856-866, discussion 866 PubMed