Spontaneous dissection of the internal carotid artery: a nineteen-year clinical experience. Recanalization of cervical artery dissection: influencing factors and role in neurological outcome. Cervical carotid dissecting aneurysms. Dissection of cervical arteries: Long-term follow-up study of 130 consecutive cases. [Spontaneous dissection of the exocranial internal carotid artery. Therapeutic aspects]. Intracranial haemodynamics in patients with spontaneous carotid dissection. Transcranial Doppler ultrasound follow-up studies. Long-term follow-up after extracranial internal carotid artery dissection. Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients. Spontaneous dissection of cervico-cerebral arteries. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Antiplatelet therapy: an alternative to heparin for blunt carotid injury. Spontaneous dissection of the internal carotid artery in 68 patients. Spontaneous dissection of the internal carotid artery. Clinical, radiologic and evolutive aspects. Apropos of 46 cases. [Spontaneous carotid and vertebral arteries dissection in a multiethnic population]. Outcome of extracranial cervicocephalic arterial dissections: a follow-up study. Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. Blunt vascular injuries of the head and neck: is heparinization necessary? Cervico-cerebral artery dissection. Nonpenetrating trauma to the carotid artery: seven cases and a literature review. Primary headaches and painful spontaneous cervical artery dissection. Spontaneous dissection of the internal carotid artery. Dissection of the cervical internal carotid artery. The role of Doppler/Duplex studies and conservative management. [Traumatic injury affecting the extracranial portion of internal carotid artery (17 case reports) (author's transl)]. [Carotid dissections]. [Dissection of cervical arteries as a cause of cerebral ischemia or cranial nerve dysfunction]. Ischemic optic neuropathy associated with internal carotid artery dissection. Cervicocephalic arterial dissections. A ten-year experience. [Spontaneous dissection of arteries supplying the brain]. Spontaneous carotid dissection with acute stroke. Blunt carotid injury: reassessing the role of anticoagulation. Adult cervicocerebral artery dissection: a single-center study of 301 Finnish patients. Extracranial internal carotid artery dissections: noniatrogenic traumatic lesions. Spontaneous dissection of the cervical internal carotid artery.
This article reviews our experience with internal carotid artery dissection (ICAD), evaluates the usefulness of Duplex scanning in diagnosis, provides current recommendations for treatment, and better defines long-term prognosis.
                The records from 1976 to 1995 of 24 patients who had 28 ICAD were reviewed. All diagnoses were confirmed by arteriography. Presenting symptoms, diagnostic tests, clinical management, and outcome were examined.
                Nine patients had visual symptoms or headache, 10 had transient focal neurologic symptoms (TIA), and five had stroke. Five of the 19 who had visual symptoms or TIA had a stroke before the diagnosis of ICAD. Seventeen patients who had 19 ICAD underwent a Duplex scan at the time of presentation. Duplex scan identified 18 arterial abnormalities consistent with ICAD (sensitivity, 95%). Three patients died from stroke during the initial hospitalization. Of the 21 who survived, 12 were treated with anticoagulation therapy, six with aspirin, and three with aspirin and anticoagulation therapy. None of the 21 patients had a subsequent stroke. Six patients subsequently had an operation for residual occlusive disease or aneurysm. The mean duration of follow-up was 9.3 years. Two patients developed contralateral ICAD. During follow-up, 19 arteries were studied with Duplex scan, and seven had no residual evidence of ICAD.
                Patients who have ICAD often have prodromal symptoms before stroke. If diagnosed early, treatment with anticoagulation may prevent stroke. Duplex scans are accurate for defining carotid abnormalities consistent with ICAD and for indicating the need for arteriography. Patients should undergo a follow-up Duplex scan to identify contralateral ICAD. Generally, the prognosis for cervical artery dissection (CAD) is uncertain. The recanalization rate of CAD can be up to 85% within 3 months. This study evaluates the variables that might affect recanalization and the role of recanalization as a predictor for neurological outcome.
                This study prospectively included 38 patients with acute stroke following occlusion due to CAD (18 males, 20 females, median age 50.5 years, range 16-82). Vertebral and carotid dissections were equally distributed (19 carotid dissections). The recanalization rate was influenced by the presence of hypertension (p = 0.001). Outcomes were dependent on infarct location. Patients with lateral medullary infarction returned to functional independence (p = 0.026), while patients with deep hemispheric infarction tended to have a disabling stroke (p = 0.068). The presence of good collaterals seemed to influence functional independence (p = 0.03).
                There seemed to be no relationship between outcome and the rate of recanalization following CAD. Recanalization appeared to be a spontaneous mechanism, which could have depended on the intrinsic condition of the vessels. Finally, neurological outcome was dependent on lesion localization and the presence of good collaterals.
                Copyright 2004 S. Karger AG, Basel Thirteen cases of cervical carotid dissecting aneurysm have been seen at the University of Florida during the past 3 years. In our experience, two groups of patients with this disease can be distinguished clearly by either clinical or angiographic criteria. One group of cervical carotid dissecting aneurysms is characterized by spontaneous onset, unilaterality, and the absence of pseudoaneurysm formation. These lesions have a strong tendency to resolve with appropriate medical therapy. The other group is characterized by an association with obvious predisposing factors, such as fibromuscular dysplasia, angiography, or trauma. These lesions are often associated with pseudoaneurysms and rarely resolve spontaneously. These two groups of lesions probably represent a spectrum of the same basic disease process. The natural history of patients who survive a cervical carotid dissection is usually one of stability or improvement. A trial of medical therapy (to prevent embolic symptoms) and repeat arteriography are indicated before the consideration of surgical therapy. We describe the natural history, functional prognosis and long-term recurrences of patients with dissection of cervical arteries (DCA) in a sequential observational study.
                We describe 130 patients with angiographically-proven DCA admitted to the Neurology Institute in Mexico City (Mexico), and analyzed clinical and neuroimaging data, treatment and outcome. Treatment with either anticoagulation or aspirin was decided by the primary physician. Primary outcome measures were recurrence (stroke and death) and clinical outcome at 6 months. Follow-up studies were performed to determine recanalization.
                Mean age was 35.4 years; 4 patients died (3%) and 126 were followed for 3,906 person/years; 17 patients (13%) had a heralding ischemic cerebral event (6 strokes, 11 TIAS) about 8 days before the diagnosis of DCA. After diagnosis, recurrent ischemic stroke occurred in 6 patients (4.8%) within the 2 first weeks (1.5 persons/1,000 follow-up years). No significant differences were found between aspirin and anticoagulation. Recanalization was more frequent in vertebral dissections. Complete recanalization of vertebral dissections was associated with a favorable prognosis [OR 3.2 (95% CI 1.1-8.8; p = 0.02)].
                In Mexico, DCA affects young adults and may present with a heralding stroke or TIA. We found rare, early ischemic recurrences. Vertebral territory dissections had better prognosis than carotid ones, particularly in patients with demonstrated complete recanalization.
                Copyright 2006 S. Karger AG, Basel. Spontaneous dissection of the extracranial internal carotid artery is uncommon and has been first described in 1959. Since then, 250 cases have been published. The authors report on 5 recent cases and on that occasion, they review the literature and discuss the different therapeutic possibilities. This pathology can be envisaged when a middle-aged adult, free of any previous pathology or trauma, presents with latero-cervical pain followed by cerebral ischemic stroke. The angiographic findings are of three types: regular or irregular extensive stenosis, pseudo-aneurysmal dilatation followed by luminal stenosis, funnel-like tapering of the vessel. The spontaneous course of such a dissection most often (80%) leads to an almost complete resolution of clinical and angiographic signs. Treatment, therefore, should essentially be based on anticoagulant and antiaggregant therapy, so as to prevent ischemic attacks or carotid thrombosis. Surgical indications should remain exceptional. In this study 11 patients aged between 34 and 57 years with clinical and angiographic findings typical of carotid dissection were thoroughly examined with transcranial Doppler ultrasound (TCD) repeatedly during a follow-up period of 1-6 months. Stagnating blood flow velocities in the downstream middle cerebral artery (MCA) were recorded initially as well as enhanced velocities due to postischaemic hyperperfusion syndrome. MCA embolism originating from the extracranial carotid artery with or without resolution could be detected by TCD in 5 cases. TCD findings in another 2 cases pointed to haemodynamic upset. In 3 cases, clinical as well as TCD data did not allow strict differentiation between embolic and haemodynamic complications, suggesting more complex pathophysiological mechanisms as the cause of infarction. Carotid recanalization was seen in 9 cases. The follow-up investigations moreover demonstrated that intracranial haemodynamics may change from day to day in patients suffering from internal carotid artery dissection. TCD data may thus improve the understanding of pathogenetics as well as rationales for individual therapeutic intervention in this particular disease. To evaluate long-term outcome after extracranial internal carotid artery dissection (eICAD) in consideration of the applied antithrombotic therapy.
                Among 33 consecutive eICAD patients initially treated either with anticoagulation (n = 25) or with antiplatelets (n = 8), a standardized interview was performed after 28 +/- 22.1 months to analyze risks and benefits of both agents. Ischemic and hemorrhagic complications, occurrence of seizure and rates of arterial recanalization were compared and long-term clinical outcome was assessed using the modified Rankin Scale (mRS) and Barthel Index (BI).
                Among anticoagulated patients, 1 died due to brain herniation. In 3 patients stroke (n = 2) or TIA (n = 1) recurred. In the antiplatelet group, none died and no subsequent ischemic events happened. Hemorrhagic complications were noted in neither treatment group. Functional outcome among anticoagulated patients was BI 92 +/- 21.6 and mRS 1.48 +/- 1.50, which did not differ from patients initially treated with antiplatelets (BI 89 +/- 18.9, mRS 1.50 +/- 1.41, p > 0.05). Four anticoagulated patients developed seizures, compared to 2 patients with antiplatelets (p > 0.05). Arterial recanalization occurred in 16 of 22 antico- agulated patients with ultrasound follow-up, compared to 6 of 6 patients with antiplatelets (p > 0.05).
                In the absence of iatrogenic side effects, both anticoagulation and antiplatelets seem to be safe for eICAD. The rates for death and stroke were low and outcome ratings did not differ between both agents. These findings may indicate that a controlled randomized trial comparing anticoagulation and antiplatelets is ethically justified.
                Copyright 2000 S. Karger AG, Basel No randomized study has yet compared efficacy and safety of aspirin and anticoagulants in patients with spontaneous dissection of the cervical carotid artery (sICAD).
                Prospectively collected data from 298 consecutive patients with sICAD (56% men; mean age 46 +/- 10 years) treated with anticoagulants alone (n = 202) or aspirin alone (n = 96) were retrospectively analyzed. Admission diagnosis was ischemic stroke in 165, TIA in 37, retinal ischemia in 8, and local symptoms and signs (headache, neck pain, Horner syndrome, cranial nerve palsy) in 80 patients, while 8 patients were asymptomatic. Clinical follow-up was obtained after 3 months by neurologic examination (97% of patients) or structured telephone interview. Outcome measures were 1) new cerebral ischemic events, defined as ischemic stroke, TIA, or retinal ischemia, 2) symptomatic intracranial hemorrhage, and 3) major extracranial bleeding.
                During follow-up, ischemic events were rare (ischemic stroke, 0.3%; TIA, 3.4%; retinal ischemia, 1%); their frequency did not significantly differ between patients treated with anticoagulants (5.9%) and those treated with aspirin (2.1%). The same was true for hemorrhagic adverse events (anticoagulants, 2%; aspirin, 1%). New ischemic events were significantly more frequent in patients with ischemic events at onset (6.2%) than in patients with local symptoms or asymptomatic patients (1.1%).
                Within the limitations of a nonrandomized study, our data suggest that frequency of new cerebral and retinal ischemic events in patients with spontaneous dissection of the cervical carotid artery is low and probably independent of the type of antithrombotic treatment (aspirin or anticoagulants). Sixteen cases of spontaneous dissection of the cervical internal carotid artery (6 verified) are described. The mean age was 45 years. The clinical picture varied from simply headache and a bruit to hemiplegia and aphasia. Eleven patients had transient ischemic attacks. Headache, facial pain, a subjective bruit, oculo-sympathetic palsy and transient monocular blindness were present in various combinations in two-thirds of cases and their presence suggested the correct diagnosis. Examples of suspected dissection of the intracranial internal carotid, middle cerebral, posterior cerebral and extracranial vertebral arteries are also presented. Spontaneous dissection is more common than the literature indicates. To assess the risk of stroke, TIA, or dissection recurrence after a first event of cervical artery dissection (CAD).
                The authors undertook a historical cohort study of consecutive patients with a first event of CAD who were admitted in 24 departments of neurology within a period of at least 1 year. Patients were retrospectively selected from a stroke data bank or from the local administrative data bank using the 10th revision of the International Statistical Classification of Diseases. A neurologist and a radiologist reviewed all charts to validate diagnosis and collect data. In 2002, patients were interviewed by phone or during a visit by the local investigators.
                Four hundred fifty-nine patients (mean age 44.0 +/- 9.7 years) were included in the study. Among the 457 survivors, 25 (5.5%) could not be contacted in 2002 because they had moved. After a mean follow-up of 31 months, four (0.9%) patients presented a recurrent ischemic stroke attributable to either not yet completely recovered initial CAD (n = 2) or a recurrent CAD (n = 2). Eight (1.8%) patients had a TIA without CAD recurrence. Two TIA occurred at the acute stage of CAD. Of the six remaining TIA, only one was associated with chronic arterial stenosis. In addition, two patients had recurrent CAD without stroke, giving a total of four (0.9%) CAD recurrences.
                Patients with a first event of CAD have a very low risk of ischemic events or dissection recurrences. Ischemic events seem rarely to be in relation with chronic arterial lesions. Blunt carotid injuries (BCIs) are uncommon. Most single-center studies are small and highlight the use of anticoagulation for treatment. In a retrospective review, we identified 22 patients who presented with BCI and assessed neurologic and survival outcomes on the basis of injury grade and treatment with anticoagulation or antiplatelet therapy.
                Patient demographics were identified using the trauma registry at a single Level I trauma center. Chart reviews assessed neurologic function, modalities used for diagnosis, and treatment. Neurologic outcomes were graded good (minimal to no deficit), fair (moderate deficit needing some assistance), poor (requiring institutionalization), and dead.
                Twenty-two adult trauma patients were diagnosed with BCI, for an incidence of 0.45% in the 8-year study period. All BCI patients underwent head computed tomography and four-vessel cerebral arteriography. Eight patients were not anticoagulated, five because of intracranial injuries, two who had surgical CCA repairs, and one with an aortic injury. Full anticoagulation with heparin was attempted in seven patients, with four major bleeding complications requiring cessation of heparin and blood transfusions. Seven patients received antiplatelet therapy. No difference in neurologic outcome was observed between those receiving anticoagulation and those receiving antiplatelet therapy. Bleeding complications from full anticoagulation were higher than with antiplatelet agents (p = 0.05).
                Contrary to previous reports, we did not observe improved outcomes with full anticoagulation compared with antiplatelet therapy. Anticoagulation was associated with increased extracranial bleeding complications. The risks and possible benefits, as well as timing, of anticoagulation or antiplatelet therapy for BCI should be carefully weighed by the major care providers of the patient with multiple injuries. Our purpose was to know more about the symptoms and clinical and radiological outcome of spontaneous dissections of the internal carotid artery in a retrospective study of 68 patients aged 20 to 71 (mean 46).
                The diagnosis of dissection was based on angiographic findings. Nine percent of patients had minor symptoms such as a subjective bruit or painful Horner's syndrome, without an ischaemic event. Cerebral ischaemia was present in 90% of cases and occurred within a month of the initial event in all cases but one and was the first symptom in 53% of cases.
                Magnetic resonance imaging performed in 21 cases showed haemorrhage in the vessel wall. Resolution of the angiographic appearances occurred in 65% of cases after 3 months. In cases of stroke, more than half of the patients had poor functional outcome, factors conveying poor prognosis were massive stroke, embolic mechanism and lack of local recanalization.
                Spontaneous dissection of the internal carotid artery is not a rare cause of cerebral ischaemia and can present with minor symptoms without an ischaemic event. Doppler ultrasonography and magnetic resonance imagery are helpful in diagnosis and follow-up. nan Spontaneous dissection of the carotid and vertebral arteries (SDCVA) is considered a rare cause of stroke, particularly in countries with multiethnic population. The objective was to evaluate the clinical and neuroimaging features of patients with SDCVA from a multiethnic population. Sixty-six patients diagnosed with SDCVA were studied at two tertiary hospitals at São Paulo. An initial questionnaire was completed and patients were followed prospectively. Among the patients studied, 82% were caucasian, 53% were male and the average age was 41.7 years old. The most frequent cardiovascular risk factors found were systemic hypertension and tobacco use. Other aspects evaluated were history of previous migraine, initial treatment and prognosis. In conclusion, although the population studied was multiethnic, there was a marked predominance of caucasians. The analysis of clinical and neuroimaging data from patients with SDCVA allows a better understanding of the disease, leading to an earlier diagnosis and more appropriate treatment. Cervicocephalic arterial dissections (CCAD) are an increasingly recognized cause of ischemic stroke in young adults. Various treatments have been suggested but no controlled trial has ever been performed. Medical treatment has included anticoagulant or platelet antiaggregant therapy. Surgical correction has been proposed for selected patients who have failed medical therapy. Percutaneous balloon angioplasty and stenting have been increasingly used in some patients, although long-term results are unknown. The objective of the study was to review our recent experience with the management and outcome of extracranial CCAD. We identified 27 patients with extracranial CCAD who were evaluated, treated and/or followed by our Stroke Service from September 1995 to August 2001. Clinical presentation, diagnostic evaluation, management, and outcome were reviewed. There were 15 men (56%) and 12 women (44%) with mean ages of 38 and 43 years respectively. Diagnosis was made by cerebral angiography in 15 (56%) patients and by MRI/MRA only in 12 (44%) patients. Twenty-two patients had spontaneous and five had traumatic extracranial CCAD. Most common associated disorders were arterial hypertension (37%) and migraine (26%). One patient presented only with a painful post-ganglionic Horner syndrome, another patient with neck pain and post-ganglionic Horner syndrome, another patient solely with protracted unilateral headaches, three with transient ischemic attacks (TIA), and 21 with ischemic strokes. The internal carotid artery (ICA) was the most frequently involved vessel (63%), followed by the vertebral artery (30%, and multivessel involvement in two patients (7%). Eighteen patients received anticoagulant therapy and nine platelet anti-aggregants. Follow-up extended from 2 to 115 months, with a mean of 58 months. At the end of follow-up, 23 (85%) patients had either no disability or only minor sequelae (modified Rankin score: 0 to 1), and four (15%) patients had moderate limitations (modified Rankin score: 2 to 3). Two patients had a recurrent ischemic stroke, one unrelated to recurrent CCAD, and the other following percutaneous balloon angioplasty/stenting for treatment of a persistent vertebral artery pseudoaneurysm. Most CCAD involved the extracranial ICA. The clinical presentation is variable, most patients having an ischemic stroke or TIAs. The short- and long-term outcome are usually favorable with either anticoagulant or platelet antiaggregant therapy. A medical initial approach to the management of extracranial CCAD is recommended for most patients. The highly variable clinical course of cervical artery dissections still poses a major challenge to the treating physician. This study was conducted (1) to describe the differences in clinical and angiographic presentation of patients with carotid and vertebral artery dissections (CAD, VAD), (2) to define the circumstances that are related to bilateral arterial dissections, and (3) to determine factors that predict a poor outcome. Retrospectively and by standardised interview, we studied 126 patients with cervical artery dissections. Preceding traumata, vascular risk factors, presenting local and ischemic symptoms, and patient-outcome were evaluated. Patients with CAD presented more often with a partial Horner's syndrome and had a higher prevalence of fibromuscular dysplasia than patients with VAD. Patients with VAD complained more often of neck pain, more frequently reported a preceding chiropractic manipulation and had a higher incidence of bilateral dissections than patients with CAD. Bilateral VAD was significantly related to a preceding chiropractic manipulation. Multivariate analysis showed that the variables stroke and arterial occlusion were the only independent factors associated with a poor outcome. This study emphasises the potential dangers of chiropractic manipulation of the cervical spine. Probably owing to the systematic use of forceful neck-rotation to both sides, this treatment was significantly associated with bilateral VAD. Patients with dissection-related cervical artery occlusion had a significantly increased risk of suffering a disabling stroke. Blunt vascular injuries to the head and neck (BHVI) represent some of the most devastating and morbid injuries seen by a trauma surgeon. This series reviewed the experience of a single institution to determine if diagnostic and therapeutic guidelines can be established for these uncommon injuries. In particular, the utility of anticoagulation in the treatment of these injuries is examined.
                The institutional trauma registry of a single state-designated Level I trauma center was examined for patients with BHVI. Patients were identified and their charts reviewed individually with regard to multiple data points including the type of injury, its presentation, the treatment of the injury, and the functional outcome of the patient.
                Twenty-nine BHVI in 23 patients were reviewed from 1989 to 1997. No mortalities were noted. Among the injuries noted were 14 internal carotid artery dissections and 8 carotid artery tears. Thirteen patients had accompanying closed head injuries. Ten patients were diagnosed after an abnormal neurologic examination, and eight others were diagnosed after having carotid canal fractures. Heparin was started within 48 hours of injury in 4 patients (17%) and was used in a total of 12 patients (52%). No patient worsened neurologically after diagnosis independent of the use of heparin. Thirteen patients (57%) had no or minimal deficits upon discharge.
                BHVI represent a serious cause of morbidity in the patient with multiple injuries. Patients with closed head injuries and carotid canal fractures appear most at risk. A multicenter, randomized trial involving antiplatelet therapy, full systemic anticoagulation, or observation with a long-term functional assessment is indicated to determine the optimal management of these injuries. nan Nonpenetrating carotid trauma is uncommon and frequently missed on initial examination. The cases of seven patients seen over a period of 21 years are presented and 100 cases from the most recent literature are reviewed. Causes and mechanisms of injury, clinical presentation, investigations, management, and outcome are discussed. Causes of injury were three motor vehicle collisions, two falls, one sports injury, and one blow to the face. Clinical presentation was early in four and delayed in three. The earliest symptoms and signs were a change in mental status, headache, unprovoked fall, focal weakness, neglect, and dysphasia. Doppler studies may be useful in screening, but a definitive diagnosis is made with the help of angiography. Two patients were treated surgically; one died, one with delayed symptoms from a pseudoaneurysm recovered completely. Five patients were given anticoagulants; all survived with permanent deficits related to their pretreatment neurologic status. The outcome in 100 recent cases from the literature has improved compared with previous reports. The overall mortality was 12%. The outcome in our seven cases supports recent trends toward a strategy of early anticoagulation and selective surgical treatment. The relation between primary headaches (PH) and pain related to spontaneous cervical artery dissection (SCAD) is still unclear, as well as the progress of PH after dissection. To investigate this relation, the characteristics of pain related to SCAD and changes in PH patterns after SCAD, we evaluated 54 consecutive patients. Thirty-five (65%) had previous PH. Painful SCAD occurred in 39 (72%). Frontal and parietal localizations were significantly associated with internal carotid artery dissection (p=0.013 and p=0.010, respectively), whereas occipital and nuchal pain, with vertebral artery dissection (p=0.047 and p<0.001, respectively). Previous PH did not influence the presence of pain at SCAD onset. Twenty-six (74%) patients with PH reported improvement in PH pattern after a mean follow-up of 32 months. These results suggest that mechanisms underlying PH do not modulate dissection-related pain. Disruption of perivascular afferents may be involved in improvement of PH patterns after SCAD. Spontaneous dissection of the internal carotid artery is not well known in Scandinavia. Several hundred cases have been reported world-wide, but none from Finland. We presume the annual incidence in Finland to be at least 20-30 cases, nearly all of which remain undiagnosed. Our experience of 12 cases indicates that the typical patient is a middle-aged man who after strenuous physical exertion suffers a transient ischemic attack or progressing stroke. Manifestations may include ipsilateral incomplete Horner's syndrome and facial or cervical pain. The diagnosis is based on angiography and verified from repeat angiograms. The most typical finding is an extracranial stenosis or occlusion of the internal carotid artery. Irregular expansion, double lumen and aneurysmal dilation are also fairly common. The stenotic area usually recanalizes in a few months. Nonsurgical management is recommended. Prompt diagnosis and adequate heparinization with simultaneous start of oral anticoagulation seem to give the best final result. Cervical internal carotid dissection is not rare. Doppler ultrasound screening of young patients presenting with stroke, identified 10 patients with reduced common and internal carotid blood flow without any evidence of atheroma. Eight, on angiography proved to have a dissection of the cervical internal carotid artery. All were managed conservatively. Seven received anticoagulant therapy, stopping any further neurological symptoms. The authors analyse the detailed clinical course in an homogenous review of 17 cases reports of traumatic injury affecting the extracranial portion of internal carotid artery. Only cases in which there were neither cervical perforating wound nor atheromatous predisposing lesion were considered. As in cases reported in the literature, the young age of these patients, with prevalence in the second decade and in men, was attributable to the etiology. Circumstances in which diagnosis was established induce to discern two unequal groups, according as there was either a coma or immediate focal signs, or a delayed symptomatology : it occured most frequently after a free interval shorter than 48 hours, and reaching in the extrema (one instance) 40 days. Brachiofacial hemiparesis was the most frequent clinical picture. Doppler investigation was able to detect, with a rather satisfying reliability, anomalies in the carotid flow before angiography ; angiogram showed lesions nearly always facing first or second cervical vertebra and bilateral lesions in four instances. Injuries consisted in dissecting aneurysm with stenosis aspect much more often than in thrombosis. In a third of cases distal ischemic lesions below dissecting aneurysm were noted. Prognosis in these cases is very poor since eight patients in our series died without any possibility of expectation according to clinical or angiographical data. Medical therapeutics were disappointing, and this induced to consider an extension in preventive realization of extra-intracranial by pass, each time diagnosis is established and patient is lucid. Etiopathogenical aspect is the originaler part of this study, since we could precisely approach incriminated mechanisms in a methodic analysis of impacts and their results. In our review cranial or facial shock was constantly noted, always frontal and often mild. In II cases association to a frontal and upper thoracic traumatism was found ; safety belt may have been responsible in part, in the mechanism of fixation of upper thoracic orifice, in most cases where this thoracic impact seemed to be missing. Thwarted stretching of carotid artery seems to be the necessary condition for occurring of an intimal tear. Other mechanisms like direct cervical shock may certainly be found, but we did not observe any instance in this review. In younger patients, the clinical symptoms of sudden unilateral headache and facial pain, often combined with Horner syndrome and the cerebrovascular symptoms of TIAs or stroke, should indicate the diagnosis of spontaneous carotid dissection. Angiographic findings can verify this diagnosis, showing various signs of eccentric, narrowing stenosis, false lumen, pseudoaneurysms, or complete occlusion. An addition to noninvasive Doppler ultrasonography, B-mode and Duplex investigations, although more or less nonspecific, give some indications of the diagnosis; modern imaging techniques, especially MRI, can image the intramural hematoma directly. As the hematoma is the source of the intracranial emboli, the therapy of choice in this rarely diagnosed disease should be anticoagulation. Nine patients with dissections of the cervical arteries are presented. Dissections cause approximately three per cent of non-haemorrhagic stroke and are usually observed in young and middle-aged patients. Dissections very often give rise to head or neck pain. Carotid artery dissection may lead to lower cranial nerve dysfunction and an incomplete Horner's syndrome in case of subadventitial dissection, and to cerebral ischaemia in case of subintimal spread. Vertebral artery dissection may cause brain stem ischaemia (subintimal dissection) or in rare cases a subarachnoid haemorrhage (subadventitial spread). The history frequently reveals a (trivial) traumatic event. Diagnosis is usually established by angiography or MRI. The prognosis is good and recurrences are rare. Treatment with anticoagulants or acetylsalicylic acid seems recommendable, though scientifically unproven. Ischemic optic neuropathy (ION) is an infarction of the anterior or, less frequently, posterior part of the optic nerve, usually due to a disease of small arteries supplying the optic nerve. Carotid stenosis or occlusions are rare causes, and among them, carotid dissections have been so far reported in only 5 cases.
                We describe 4 patients with ION (2 anterior and 2 posterior) due to internal carotid artery dissection of a consecutive series of 110 patients with internal carotid artery dissection (3.6%).
                None of the patients had signs of central retinal artery occlusion or ischemic ocular syndrome. Ischemic optic neuropathy occurred after a mean of 5.3 days (range, 3-8 days) following the first symptom, which was headache in 1 patient, transient monocular blindness in 2, and hemispheric transient ischemic attack in 1. One patient had associated Homer syndrome, and 2 had severe ipsilateral headache and orbital pain. None of the patients developed a cerebral infarction. These features differ from those observed in "classic" nonarteritic anterior ION and might therefore point to carotid dissection.
                Ischemic optic neuropathy may occur as an early sign of carotid dissection: young age, previous transient monocular blindness, an association with pain, Horner syndrome, or hemispheric transient ischemic attacks are suggestive of this cause and should prompt confirmatory investigations. Between April 1976 and April 1986, cervicocephalic arterial dissections were diagnosed in 19 of 4531 patients undergoing cerebral arteriography for acute cerebrovascular symptoms. Most dissections were extracranial. Spontaneous cases were as frequent as those following known trauma. Cerebral infarction was the most common presentation. Thirteen patients received only medical therapy, and six had surgery. Most patients survived the initial insult. Many questions remain to be answered regarding the optimal management of this condition, but treatment should be individualized based on clinical status, computed tomography, and angiographic findings. nan Thirty (2.5%) of 1200 consecutive patients with a first stroke had a spontaneous dissection with occlusion of the cervical internal carotid artery (ICA). A suggestive picture with ipsilateral headache and oculosympathetic paresis was uncommon (17%), so that diagnosis was uncertain before angiography. Seven patients died within one week. During follow-up (mean, 3.2 years) with sequential Doppler ultrasonographic testing, 12 survivors had a good recovery and early reopening of the occluded ICA, and 11 had a poor recovery usually without reopening of the ICA. Recurrence of a dissection occurred in only one patient. Large infarcts causing death or a severe disability were associated with an ICA thrombus and distal emboli; the organization of this intraluminal thrombosis may explain the absence of reopening in these cases while resorption of the intramural hematoma developed. Early heparin sodium therapy may help prevent intraluminal clotting without carrying an important risk of extending the dissection, but its clinical benefit remains unproven. Contrary to current opinions, ICA dissection with occlusion causing cerebral infarction may often carry a severe prognosis. Twenty patients with blunt mechanism injuries to the internal carotid artery were treated over a 10-year period. The purpose of this review is to assess the necessity and timing of anticoagulation as a primary therapeutic modality in patients with this injury. Sixteen patients (80%) survived, the majority with normal neurologic function. Twelve patients with either unilateral or bilateral carotid mural injury were anticoagulated. Ten survived with normal neurologic function. Five patients in the heparin anticoagulant group had a significant delay in the initiation of anticoagulation. All recovered without deficits. Two patients were treated with aspirin alone and recovered without deficits. Two patients received no treatment; one survived without deficits, and the nonsurvivor succumbed to a severe head injury. Therefore, a total of nine patients were either not treated with heparin or had a significant delay in the initiation of heparin. Eight of nine (88%) in this group recovered without deficit. A delay in the initiation of heparin therapy, no therapy, or the institution of antiplatelet therapy may all be appropriate in the initial management of mural injuries of the internal carotid artery. There are only few small studies assessing potential risk factors, comorbidity, and prognostic factors in adult spontaneous cervicocerebral artery dissection (CAD).
                We conducted a retrospective, hospital-based analysis on the prognostic factors and association of CAD with vascular risk factors in 301 consecutive Finnish patients, diagnosed from 1994 to 2007.
                Two thirds of the patients were men (68%). Women were younger than men. Migraine (36% of all patients), especially with visual aura (63% of all migraineurs), and smoking were more common in patients with CAD compared with the general Finnish population. At 3 months, 247 (83%) patients reached a favorable outcome. Occlusion of the dissected artery, internal carotid artery dissection (ICAD), and recent infection in infarction patients were associated with a poorer outcome. ICAD patients had less often brain infarction, but the strokes they had were more severe. Seven (2.3%) patients died during the follow-up (mean 4.0 years, 1186 patient years). Six (2%) patients had verified CAD recurrence.
                This study provides evidence for the association of CAD with male sex, and possible association with smoking and migraine. Occlusion of the dissected artery, ICAD, and infection appear to be associated with poorer outcome. Noniatrogenic traumatic extracranial internal carotid artery dissections were encountered in six patients (five men and one woman) 31 to 62 years old. All but one had overt cerebral ischemia manifest by paresis (three), sensory deficits (three), aphasia (three), or amaurosis fugax (two), One patient had an asymptomatic carotid artery bruit. Cerebral arteriography established the diagnosis in all cases. Internal carotid artery impingement between the mandible and transverse processes of the second and third cervical vertebrae, or undue stretching over these vertebral structures, were the most likely primary mechanisms of injury. Secondary complications, a result of distal thromboembolism, were evident in two patients. Direct cerebral revascularization, staged internal carotid artery constriction and ligation, as well as intensive nonoperative therapy were valid therapeutic options. There were no deaths. Treatment relieved transient ischemic symptoms or arrested progression of established neurologic deficits in each case. In select patients, early surgical intervention may lessen attending neurologic sequelae. Five patients with spontaneous dissection of the cervical internal carotid artery (CICA) are reported. The different patterns of clinical and radiological presentation are described and the frequently benign outcome is underlined. The need for diagnostic angiography is emphasized.