title: Imaging characteristics of symptomatic vertebral artery dissection: a systematic review.
abstract: BACKGROUND
  Vertebral artery dissection (VAD) is an important cause of stroke in the young. VAD can present with a range of imaging findings. We sought to summarize the diagnostic value of various imaging findings in patients with symptomatic VAD.
  
  
  METHODS
  We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality and imaging data were abstracted. Pooled proportions were calculated.
  
  
  RESULTS
  Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. Most studies utilized conventional angiography or magnetic resonance angiography (MRA) to diagnose VAD; computed tomographic angiography (CTA) and Doppler ultrasonography were described less frequently. Imaging findings reported were vertebral artery stenosis (51%), string and pearls (48%), arterial dilation (37%), arterial occlusion (36%), and pseudoaneurysm, double lumen, and intimal flap (22% each). In cases where conventional angiography was the reference standard, CTA was more sensitive (100%) than either MRA (77%) or Doppler ultrasonography (71%) (P=0.001).
  
  
  CONCLUSIONS
  Imaging findings vary widely in patients with VAD, with no single radiographic sign present in the majority of VAD patients. Nonspecific radiographic signs predominate. CTA probably has greater sensitivity for dissection than MRA or ultrasound relative to conventional angiography. Higher quality studies on imaging techniques and radiographic criteria in subjects with VAD are needed. Future studies should compare imaging techniques in well-defined, undifferentiated populations of clinical VAD suspects.
authors.affiliation: Department of Neurology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Rebecca F
authors.initials: RF
authors.lastname: Gottesman
authors.forename: Priti
authors.initials: P
authors.lastname: Sharma
authors.forename: Karen A
authors.initials: KA
authors.lastname: Robinson
authors.forename: Martinson
authors.initials: M
authors.lastname: Arnan
authors.forename: Megan
authors.initials: M
authors.lastname: Tsui
authors.forename: Ali
authors.initials: A
authors.lastname: Saber-Tehrani
authors.forename: David E
authors.initials: DE
authors.lastname: Newman-Toker
mesh_terms: D017541:Aneurysm, False / Q000175:diagnosis / Q000209:etiology; D002533:Cerebral Angiography; D006801:Humans; D018810:Magnetic Resonance Angiography; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D017585:Ultrasonography, Doppler, Transcranial; D014711:Vertebral Artery / Q000000981:diagnostic imaging / Q000473:pathology; D020217:Vertebral Artery Dissection / Q000150:complications / Q000175:diagnosis*; D014715:Vertebrobasilar Insufficiency / Q000175:diagnosis / Q000209:etiology