Oltre la terapia medica nelle dissezioni carotidee · 2017-11-17 · ICD Treatment Antiplatelets vs...

Rodolfo Pini

Università di bologna

Alma Mater Studiorum

Chirurgia Vascolare

Oltre la terapia medica nelle

dissezioni carotidee

What we know from the literature

Epidemiology

Clinical presentation in the real world

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

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

Carotid and Vertebral Artery Dissection

Clinical Manifestations

Intracranial

SAH

TIA

Major/Minor stroke

Extracranial

Neck/ jaw/ face sharp pain

Headache

Partial Horner syndrome

Ipsilateral cranial palsiesICD and VAD pain localization

Diagnosis of ICD

US

MRI/MRA

CT Angiography

Catheter Angiography

Diagnosis of ICD

US

MRI/MRA

CT Angiography

Catheter Angiography

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

Antiplatelets Anticoagulants

Relative Risk

Sarikaya et al, Plos One 2014

ICD Treatment

Antiplatelets vs Anticoagulants for the Treatment of

Cervical Artery Dissection: Bayesian Meta-Analysis

Antiplatelets Anticoagulants

Relative Risk

Sarikaya et al, Plos One 2014

Antiplatelets should be given precedence over

anticoagulants as a first line treatment

in patients with cervical artery dissection

ICD Treatment

Antiplatelet treatment compared with anticoagulation treatment for cervical

artery dissection (CADISS): a randomised trial

CADISS investigators, Lancet Neurol 2015

126 antiplatelet

124 anticoagulant

ICD Treatment

Antiplatelet treatment compared with anticoagulation treatment for cervical

artery dissection (CADISS): a randomised trial

CADISS investigators, Lancet Neurol 2015

126 antiplatelet

124 anticoagulant

No difference in efficacy of antiplatelet and anticoagulant drugs at

preventing stroke and death

ICD Treatment

Surgical reconstruction

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

Class IIa Medical Therapy

With symptoms recurrence

Class IIbCAS

CEA

ASA/AHA/AANN/AANS/ACR/ASNR/CNS/

SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline

What we know from the literature

Epidemiology

Clinical presentation in the real world

Carotid and Vertebral Artery Dissection

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

Policlinico

S. Orsola, Bo

aa. 2012-15

Tot N 39

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

Carotid and Vertebral Artery Dissection

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

New event

Aphasia

E.R.

11:45 12:00

Neurologic event

8:00

ICD # 1

Symptoms regression

No thrombolysis

Neurologic event

8:00

E.R.

11:45

Aphasia

12:00 12:30

ICD # 1

Imaging

Cerebral CT

Supra-aortic vessels CTA

Neurologic event

8:00

E.R.

11:45

Aphasia

12:00

Regression

12:30 13:00

ICD # 1

Imaging

Neurologic event

8:00

E.R.

11:45

Aphasia

12:00

Regression

12:30 13:00

No ischemic or hemorrhagic lesions

ICD # 1

Neurologic event

8:00

E.R.

11:45

Aphasia

12:00

Regression

12:30 13:00

Focal extracranial left internal carotid dissection

Patency from the intrapetrosus section

ICD # 1

Neurologic event

8:00

E.R.

11:45

Aphasia

12:00

Regression

12:30

Imaging

13:00

Vascular Surgeon Evaluation

Internal left carotid dissection

Patency from the intrapetrosus section

No neurological deficit, stable last hour

13:30

ICD # 1

Medical therapy: anticoagulation

New neurologic symptoms

Right arm ipostenia Aphasia

1 hour duration

DAY 2

10:00

ICD # 1

New cerebral CT2 new ischemic frontal lesions

New event

10:00 12:30

9 mm

10 mm

ICD # 1

10:00 12:30

New event CT

13:00

Vascular Surgeon Evaluation

Distal internal left carotid dissecation

Neurologic symptoms “in crescendo”

Small cerebral lesions

ICD # 1

Revascularization: stenting

Filterwire: no

progression

Command 0.014

Wallstent 7x40

10:00 12:30

New event CT Surg Evaluation

13:00Operation Theather

17:30

ICD # 1

No deficit

CTAcontrol

2 yr follow-up:

Patient asymptomatic

Stent patent

ICD # 1

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

Ist Supra-aortic Vessels CTA

Focal left internal

carotid dissection

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

Anticoagulants

LMWH 10000 U 2/die (3 days)

First Line Treatment

ICD, # 2

2nd Supra-aortic vessels

CTA

3 days later:

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

ICD, # 2

Antiplatelets (Clopidogrel 75 mg/die) +

↓ Anticoagulants (LMWH 4000 U/die)

ICD # 2

3rd Supra-aortic vessels CTA

ICD # 2

3rd Supra-aortic vessels CTA

Stability of

false lumen haematoma

ICD # 2

1 month CTA

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

ICD # 2

3 month CTA

False lumen haematoma stability

ICA stenosis ↓ ↓ ↓

Regular arterial wall

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

Carotid and Vertebral Artery Dissection