Stroke prevention by endovascular treatment of carotid and vertebral artery dissections.
BACKGROUND
Endovascular intervention for cervical carotid artery dissection (CAD) and vertebral artery dissection (VAD) may be indicated in specific circumstances.


OBJECTIVE
To review our institutional experience with endovascular treatment of cervical dissections over the past 20 years to examine indications for treatment, interventional methods, and outcomes.


METHODS
Retrospective review of a prospectively maintained database to identify patients with extracranial dissection who underwent endovascular intervention between January 1996 and January 2016. Demographic data and details of procedures, outcomes, and complications were extracted.


RESULTS
Of 116 patients [93 CAD, 23 VAD; mean age 44.9 years (range 5-76 years)], 104 underwent stent placement; 11, coil occlusion of the parent artery; and 1, stenting with contralateral vessel occlusion. The cohorts were well matched for age, sex, dissection etiology, and admission and follow-up modified Rankin Scale (mRS) scores. Patients with CAD had significantly more stent placements (p<0.001), failure of medical therapy (p=0.004), and interventions for enlarging pseudoaneurysms (p=0.01) or thromboembolic events (p=0.004). Patients with VAD had significantly more interventions for traumatic occlusion with recanalization (p<0.001). Dissections were spontaneous (n=67), traumatic (n=36), or iatrogenic (n=13). Traumatic dissections in patients with CAD were associated with poor admission mRS scores (p=0.01). Six of 67 (9.0%) patients with spontaneous dissection reported recent chiropractic manipulation. Mean follow-up was 3.5 years (range 1-146 months). Permanent morbidity/mortality was 3.4%, including two deaths. Over a follow-up period of 364 patient-years, 1 stroke occurred (0.27% per year). At last follow-up, 41 previously disabled patients [CAD, 31/93 (33.3%); VAD, 10/23 (43.5%)] were no longer disabled; no patient reported worsened disability.


CONCLUSIONS
Patients with CAD and VAD differ significantly in presentation, indications for treatment, and treatment methods. Endovascular treatment of CAD and VAD has low procedural morbidity and is associated with a low incidence of future stroke.
Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Karam
K
Moon
Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Felipe C
FC
Albuquerque
Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Tyler
T
Cole
Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Bradley A
BA
Gross
Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Cameron G
CG
McDougall
D000293:Adolescent; D000328:Adult; D000368:Aged; D020215:Carotid Artery, Internal, Dissection / Q000000981:diagnostic imaging / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D015607:Stents; D020521:Stroke / Q000000981:diagnostic imaging / Q000517:prevention & control* / Q000601:surgery*; D016896:Treatment Outcome; D020217:Vertebral Artery Dissection / Q000000981:diagnostic imaging / Q000601:surgery*; D055815:Young Adult
Aneurysm; Angioplasty; Dissection; Stent; Stroke