Is Digital Subtraction Angiography Still the Method of Choice for Diagnosis and Follow-up of Cervical Artery Dissection?

Abstract

Cervical Artery Dissection (CAD) accounts for up to one fifth of ischaemic strokes occurring before 45 years. The internal carotid artery is the most commonly affected vessel. Cerebral ischemia is the most serious consequence of carotid artery dissection. The enlargement of the artery may lead to laterocervical pain and direct compression of the lower cranial nerves and/or sympathetic peri-carotid plexus. A spontaneous dissection is assumed when no or only minor trauma preceded the onset. The pathogenesis of dissections remains unknown in most cases, but traumas and primary diseases of the arterial wall are the main predisposing factors.

We monitored six patients with CAD (four males, two females; 32–67 years old). All patients underwent US and CT-CTA examinations; five patients had DSA; four patients underwent MRI-MRA within the first two weeks after clinical onset. Four patients have received intravenous heparin treatment followed by oral anticoagulant therapy. Patients were then followed up with US alone (3 patients) or combined with CTA (3 patients) at 3 months to 2 years.

Three patients demonstrated a completed stroke in the middle cerebral artery territory (two patients) and in the posterior inferior cerebellar artery territory (one patient). Five patients had headache and/or cervicofacial pain. One had only neck and brachial pain. Four patients showed a Horner's syndrome alone (two patients) or associated with 9th, 10th, 11th and 12th cranial nerve involvement (one patient) or associated with stroke (one patient). One patient had brachial plexus motor impairment. Four patients had ICA dissection; one patient had VA dissection; one patient had multiple neck vessel dissection, that were correctly demonstrated by CTA and DSA in all cases. In five cases US overestimated the stenosis, showing a false occlusion pattern. MRI-MRA well displayedmural haematoma in the subacute stage, ipsilateral reduced intracranial blood flow and brain damage.

CADs are treated by heparin at the acute stage, although the benefit of such a potenially dangerous treatment has never been proven by a randomized trial. The favorable natural history of CAD emphasizes the need for a non-invasive approach to detection, monitoring and follow-up. A combined morphological and functional analysis of the brain and neck arteries is mandatory. Consequently DSA may be now replaced by US, MRI-MRA and CT-CTA. Because the three sets of CTA images correctly depict arterial wall and lumen without flow artifacts, this technique may be considered the new gold standard for the assessment of CAD.