Oltre la terapia medica nelle dissezioni carotidee

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

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

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

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

Diagnosis of ICD US MRI/MRA CT Angiography Catheter Angiography

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

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

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

Surgical reconstruction ICD Treatment

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

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

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

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

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

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

Carotid and Vertebral Artery Dissection Policlinico S. Orsola, Bo aa. 2012-15 Tot N 39 ICD VAD TOT SIDE Left 17 6 23 Right 9 4 13 Bilateral 2 1 3 AETHIOLOGY Unknown 22 8 30 Traumatic 4 3 7 Iatrogenic 2-2 CLINICAL MANIFESTATIONS Stroke 14 8 22 TIA 4 1 5 Horner Sd. 2-2 Others 5-5 None 4 1 5

Carotid and Vertebral Artery Dissection ICD VAD TOT Antiplatelets 2 4 6 Anticoagulants 13 4 17 Both 3 2 5 Thrombolysis 2-2 Stenting 1-1 Surgery 1-1 None 6 1 7

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

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

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

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

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

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

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

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

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

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

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

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

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

ICD # 1 New event CT Surg Evaluation 10:00 12:30 13:00 Operation Theather 17:30 Filterwire: no progression Command 0.014 Wallstent 7x40

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

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

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

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 (-)

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

ICD, # 2

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

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)

ICD, # 2 First Line Treatment Anticoagulants LMWH 10000 U 2/die (3 days)

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

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

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)

ICD # 2 3 rd Supra-aortic vessels CTA

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

1 month CTA ICD # 2

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

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

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