Oltre la terapia medica nelle dissezioni carotidee

Transcription

1 Oltre la terapia medica nelle dissezioni carotidee Rodolfo Pini Chirurgia Vascolare Università di bologna Alma Mater Studiorum

2 Carotid and Vertebral Artery Dissection What we know from the literature Epidemiology Clinical presentation in the real world

3 Carotid and Vertebral Artery Dissection What we know from the literature Epidemiology Clinical presentation in the real world

4 Carotid and Vertebral Artery Dissection Common types: ICDs (80%) VADs (15%) ICD+VAD (5%) ICD: 2.5% of strokes 20% of strokes in patients < 45 yo Aethiopathogenesis not clear

5 Carotid and Vertebral Artery Dissection Common types: ICDs (80%) VADs (15%) ICD+VAD (5%) ICD: 2.5% of strokes 20% of strokes in patients < 45 yo Aethiopathogenesis not clear

6 Clinical Manifestations Intracranial SAH TIA Major/Minor stroke Extracranial Neck/ jaw/ face sharp pain Headache Partial Horner syndrome Ipsilateral cranial palsies ICD and VAD pain localization

7 Diagnosis of ICD US MRI/MRA CT Angiography Catheter Angiography

8 Diagnosis of ICD US MRI/MRA CT Angiography Catheter Angiography

9 Diagnosis of ICD US MRI/MRA CT Angiography Catheter Angiography

10 ICD Treatment Antiplatelets vs Anticoagulants for the Treatment of Cervical Artery Dissection: Bayesian Meta-Analysis Relative Risk Antiplatelets Anticoagulants Sarikaya et al, Plos One 2014

11 ICD Treatment Antiplatelets vs Anticoagulants for the Treatment of Cervical Artery Dissection: Bayesian Meta-Analysis Antiplatelets should be given precedence over anticoagulants as a first line treatment in patients with cervical artery dissection Relative Risk Antiplatelets Anticoagulants Sarikaya et al, Plos One 2014

12 ICD Treatment Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial 126 antiplatelet 124 anticoagulant CADISS investigators, Lancet Neurol 2015

13 ICD Treatment Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial 126 antiplatelet 124 anticoagulant No difference in efficacy of antiplatelet and anticoagulant drugs at preventing stroke and death CADISS investigators, Lancet Neurol 2015

14 Surgical reconstruction ICD Treatment

15 ICD Treatment Stenting Not recommended (low-rate of event in medical therapy) Recurrent event in BMT: hemodynamic Efficacy and durability: not demonstrated Class IIb, level of evidence C

16 ICD Treatment Stenting Not recommended in asymptomatic or stable cases (low-rate of event in medical therapy) Recurrent event in BMT: hemodynamic Efficacy and durability: not demonstrated Class IIb, level of evidence C

17 ICD Treatment Stenting Not recommended in asymptomatic or stable cases (low-rate of event in medical therapy)? Recurrent event in BMT: hemodynamic Efficacy and durability: not demonstrated Class IIb, level of evidence C

18 ICD Treatment Stenting Not recommended in asymptomatic or stable cases (low-rate of event in medical therapy)? Recurrent event in BMT: hemodynamic? Efficacy and durability: not demonstrated Class IIb, level of evidence C

19 ICD Treatment Level of Recommendation Treatment Asymptomatic or with unrepeated symptoms With symptoms recurrence Class IIa Class IIb Medical Therapy CAS CEA ASA/AHA/AANN/AANS/ACR/ASNR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline

20 Carotid and Vertebral Artery Dissection What we know from the literature Epidemiology Clinical presentation in the real world

21 Carotid and Vertebral Artery Dissection Policlinico S. Orsola, Bo aa Tot N 39 ICD VAD TOT SIDE Left Right Bilateral AETHIOLOGY Unknown Traumatic Iatrogenic 2-2 CLINICAL MANIFESTATIONS Stroke TIA Horner Sd. 2-2 Others 5-5 None 4 1 5

22 Carotid and Vertebral Artery Dissection ICD VAD TOT Antiplatelets Anticoagulants Both Thrombolysis 2-2 Stenting 1-1 Surgery 1-1 None 6 1 7

23 Carotid and Vertebral Artery Dissection What we know from the literature Epidemiology Clinical presentation in the real world

24 ICD # 1 59yo female Dyslipidemia History of headache GCS 15/15 NIHSS 0

25 ICD # 1 8:00 Neurologic event: Right arm Parestesia and Ipostenia

26 ICD # 1 8:00 11:45 E.R: Symptoms regression

27 ICD # 1 Neurologic event 8:00 E.R. 11:45 12:00 New event Aphasia

28 ICD # 1 Neurologic event 8:00 E.R. 11:45 Aphasia 12:00 12:30 Symptoms regression No thrombolysis

29 ICD # 1 Neurologic event E.R. Aphasia Regression 8:00 11:45 12:00 12:30 13:00 Imaging Cerebral CT Supra-aortic vessels CTA

30 ICD # 1 Neurologic event E.R. Aphasia Regression 8:00 11:45 12:00 12:30 13:00 Imaging No ischemic or hemorrhagic lesions

31 ICD # 1 Neurologic event E.R. Aphasia Regression 8:00 11:45 12:00 12:30 13:00 Focal extracranial left internal carotid dissection Patency from the intrapetrosus section

32 ICD # 1 Neurologic event E.R. Aphasia Regression Imaging 8:00 11:45 12:00 12:30 13:00 13:30 Vascular Surgeon Evaluation Internal left carotid dissection Patency from the intrapetrosus section No neurological deficit, stable last hour Medical therapy: anticoagulation

33 ICD # 1 DAY 2 10:00 New neurologic symptoms Right arm ipostenia Aphasia 1 hour duration

34 ICD # 1 New event 10:00 12:30 New cerebral CT 2 new ischemic frontal lesions 10 mm 9 mm

35 ICD # 1 New event CT 10:00 12:30 13:00 Vascular Surgeon Evaluation Distal internal left carotid dissecation Neurologic symptoms in crescendo Small cerebral lesions Revascularization: stenting

36 ICD # 1 New event CT Surg Evaluation 10:00 12:30 13:00 Operation Theather 17:30 Filterwire: no progression Command Wallstent 7x40

37 ICD # 1 No deficit CTA control 2 yr follow-up: Patient asymptomatic Stent patent

38 ICD # 2 50 yro male, Drug resistant hypertension Migraine aura Absence seizures (2 yrs) BP 200/100 mmhg, HR 83/min, O2 sat 92% GCS 15/15

39 ICD # 2 Sudden appearance of thunderclap left temporal headache, during anaerobic exercise (NRS=7) Mental confusion (20 min) Left horizontal diplopia NIHSS 0

40 ICD, # 2 6 days later: Perioral paresthesia Aphasia X-XII nerve palsies (tongue deviation and left soft palate weakness) Cerebral CT: no ischemic or haemorragic acute/cronic lesions EEG (-)

41 ICD # 2 I st Supra-aortic Vessels CTA Focal left internal carotid dissection

42 ICD, # 2

43 ICD, # 2 ICA stenosis below the carotid canal Intimal flap at the entrance of the petrous portion of the temporal bone False lumen haematoma

44 ICD, # 2 MRA TCD TCD with bubble study (-) Focal left ICA dissection: terminal part of the cervical segment (C1) + first part of the petrous segment (C2)

45 ICD, # 2 First Line Treatment Anticoagulants LMWH U 2/die (3 days)

46 ICD, # 2 3 days later: 2 nd Supra-aortic vessels CTA Enlargement of false lumen haematoma

47 ICD, # 2 Internal left carotid dissection Internal carotid artery patency preserved False lumen haematoma No new neurological deficit, stable last hour No indication to revascularization

48 ICD, # 2 Internal left carotid dissection Internal carotid artery patency preserved False lumen haematoma No new neurological deficit, stable last hour Antiplatelets (Clopidogrel 75 mg/die) + Anticoagulants (LMWH 4000 U/die)

49 ICD # 2 3 rd Supra-aortic vessels CTA

50 ICD # 2 3 rd Supra-aortic vessels CTA Stability of false lumen haematoma

51 1 month CTA ICD # 2

52 ICD # 2 1 month CTA False lumen haematoma stability ICA stenosis Regular arterial wall

53 ICD # 2 3 month CTA False lumen haematoma stability ICA stenosis Regular arterial wall

54 ICD # 2 3 month CTA False lumen haematoma stability ICA stenosis Regular arterial wall

55 Carotid and Vertebral Artery Dissection Infrequent but not rare occurence High variety of symptoms and evolution Unclear origin Treatment to be decided based on clinical presentation and anatomical characteristics of the lesion