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May 10 Highlight and Commentary

Insights into pathogenesis and treatment of cervical artery dissection

Georgiadis et al. analyzed 33 cases and concluded that IV thrombolysis in acute stroke due to spontaneous carotid artery dissection was safe: there were no new local signs, subarachnoid hemorrhage, pseudoaneurysm formation, or vessel rupture.

see page 1612

Generalized arteriopathy in spontaneous cervical artery dissection (sCAD)

Multiple nearly simultaneous sCAD in about 10% of cases suggests a generalized arteriopathy in sCAD patients. The study of superficial temporal artery biopsies by Völker et al. demonstrated pathologic changes on electron microscopy in sCAD but not in control specimens.

see page 1508

Insights into pathogenesis and treatment of cervical artery dissection

Commentary by Tobias Brandt, MD, and Caspar Grond-Ginsbach, PhD

CAD is a leading cause of stroke in younger patients. Aggressive treatment to prevent severe consequences is often indicated. Georgiadis et al. show in this first substantial multicenter study that systemic thrombolysis is both feasible and safe in acute stroke caused by CAD. Although uncontrolled, and having limited vascular data, clinical follow-up data suggest good outcome after thrombolysis without enhanced rate of subarachnoid hemorrhage or vessel wall hematoma enlargement. Prospective thrombolytic intervention studies are now needed.

The pathogenesis of sCAD has long been a matter for speculation. Dissection frequently develops spontaneously in otherwise healthy individuals without risk factors. Connective tissue abnormalities in dermal biopsies of CAD patients pointed to a structural defect of the arterial wall as a predisposition.¹ The study by Völker et al. is a new approach suggesting "that the majority of sCADs may not be caused by an intimal tear, but by a hemorrhage in the arterial wall itself, e.g., originating from the vasa vasorum." Moreover, they find "extensive vacuolization" of smooth muscle cells in superficial temporal arteries. One limitation of this study is that no cervical arteries were examined; here, connective tissue is more readily analyzed. Moreover, biopsies were performed in patients on anticoagulants whereas some of the contols were not.

The signs of segmental mediolytic arteriopathy described by the authors, however, bring further evidence for a systemic arteriopathy as found in the very few postmortem or endarterectomy studies² and in own ultrastructural studies of the cervical arteries themselves (figure).³

Figure. A) Typical myocyte with excessive vacuolations from tunica media of anterior cerebral artery (ACI) from a patient with CAD and B) myocyte tunica media of ACI from a control subject. (EM: x 15 000)

see pages 1508 and 1612

References

1. Brandt T, Orberk E, Weber R, et al. Pathogenesis of cervical artery dissections: Association with connective tissue abnormalities. Neurology 2001;57:24–30.[Abstract/Free Full Text]
2. Peters M, Bohl J, Thomke F, et al. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology. 1995;45:2284–2286.[Abstract/Free Full Text]
3. Brandt T, Grond-Ginsbach C, Flechtenmacher C, et al. Ultrastrukturelle Untersuchungen an Arterien von Dissektionspatienten. Akt Neurol 2000;27:S145(249).

This Article Full Text (PDF) Correspondence: Submit a response Alert me when this article is cited Alert me when Correspondence are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Related Collections Related Articles