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Lean, Lanky, Smoky, Head-achy: At Risk of Cervical Artery Dissection?
Abstract & Commentary
By Dara G. Jamieson, MD, Associate Professor of Clinical Neurology, Weill Cornell Medical College. Dr. Jamieson reports she is a retained consultant for Boehringer Ingelheim, Merck, and Ortho-McNeil, and is on the speaker's bureau for Boehringer Ingelheim and Merck.
Synopsis: Risk factors for spontaneous dissection of carotid and vertebral arteries include smoking, migraine, and a tall, thin body. Women are at increased risk of dissecting multiple arteries.
Sources: Metso TM, Metso AJ, Salonen O, et al. Adult cervicocerebral artery dissection: a single-center study of 301 Finnish patients. Eur J Neurol 2009;Feb 9. [Epub ahead of print]; Arnold M, Pannier B, Chabriat H, et al. Vascular risk factors and morphometric data in cervical artery dissection: A case-control study. J Neurol Neurosurg Psychiatry 2009;80:232-234; Arnold M, De Marchis GM, Stapf C, et al. Triple and quadruple spontaneous cervical artery dissection: Presenting characteristics and long-term outcome. J Neurol Neurosurg Psychiatry 2009;80:171-174; Metso AJ, Tatlisumak T. Cervical artery dissections: Multiple dissections and morphometric data. J Neurol Neurosurg Psychiatry 2009;80:130.
As non-invasive techniques for imaging neck vessels improve, spontaneous cervicocephalic artery dissection (sCAD) is more commonly diagnosed in adults, with or without ischemic stroke. Two recently published retrospective studies assessed the risk factors, comorbidity, and prognostic factors in patients with dissection of the cervicocranial carotid and vertebral arteries.
Metso and colleagues conducted a hospital-based analysis of 301 consecutive Finnish adults with sCAD. Two thirds of the patients were men (68%). Women were younger than men. Migraine (36% of all patients), especially with aura (63% of all migraineurs), and smoking were more common in patients with sCAD than in the general Finnish population. More than 80% of patients had a favorable outcome at three months. Occlusion of the dissected artery, internal carotid artery dissection, and recent infection were associated with a poorer outcome. Seven (2.3%) patients died during the follow-up (mean 4.0 years, 1,186 patient years). Known dissection recurrence was found in only 2% of patients.
In a case-control study by Arnold and colleagues, the major vascular risk factors-body weight, body height, and body mass index (BMI)-of 239 French patients with sCAD, obtained from a prospective hospital-based registry, were compared with 516 matched healthy controls. The mean body height was higher in sCAD patients than in controls (171.3 [SD 8.6] cm vs 167.7 [8.9] cm; p<0.0001) and sCAD patients had a significantly lower mean body weight (67.5 [12.2] kg vs 69.3 [14.6] kg; p<0.001) and mean BMI (22.9 [3.3] kg/m2 vs 24.5 [4.2] kg/m2; p<0.0001) than controls. The overall frequency of hypertension, diabetes, smoking, and dyslipidemia did not differ significantly between sCAD patients and controls. Migraine prevalence was not assessed. Only two patients in the study were found to have a connective tissue disorder.
While sCAD of more than two cervical arteries is rare, multiple cervical vessels can dissect simultaneously. Arnold and colleagues found that of 740 consecutive patients with sCAD, 11 (1.5%) had three, and one had four (0.1%) sCAD, none of whom had evidence of an underlying arteriopathy. Eight of 12 patients were women, consistent with prior data that women are more likely to have multiple dissections. Mirroring the results in the Finnish study, current smoking was noted in five of the 12 French patients and migraine was noted in half. Multiple sCADs caused clinical symptoms and signs mainly in one vascular territory, with most patients having a favorable outcome. Minor trauma or prior infection was associated with multiple dissections.
Dissection of the arteries in the neck is a recognized cause of ischemic stroke in younger patients without traditional vascular risk factors. While some causes of arterial dissection are associated with recognized trauma, most cases appear unrelated to any overt episode of abnormal neck positioning or movement. Two large studies of patients with sCAD reveal risk factors of smoking, migraine and an ectomorphic body type. Smoking and migraine were also risk factors for the simultaneous dissection of multiple arteries. The association between migraine with aura and arterial dissection is particularly intriguing, adding to the possible explanations for the link between migraine with aura and ischemic stroke. While the association with smoking may relate to chronic endothelial damage, correlation with migraine is perplexing. A transient vasculopathy has been suggested as a possible mechanism for multiple sCADs; however, these studies of patients with sCAD did not find an association with an underlying arteriopathy or with traditional vascular risk factors. Metso and Tatlisumak point out in their accompanying editorial that we know relatively little about the pathophysiology or the optimal treatment for sCAD. Ongoing research, such as the Cervical Artery Dissection and Ischemic Stroke Patients consortium and the British trial randomizing patients to antiplatelet or anticoagulant therapy, the Cervical Artery Dissection in Stroke Study, may provide useful information on prevention and treatment.