Purpose: To study the clinical usefulness of serial color-coded duplex ultrasound (DUS) examinations in cervical artery dissection (CeAD) patients. Methods: Single-center, CeAD registry-based re-review of serial, routine DUS exams in consecutive CeAD patients treated at the Stroke Center Basel, Switzerland (2009–2015). Two experienced raters reassessed all DUS for the occurrence of new arterial findings during follow-up, that is. (i) recanalization of the dissected artery (if occluded at baseline), (ii) delayed occlusion of a patent dissected artery, and (iii) recurrent CeAD. We studied whether these new arterial findings were associated with clinical symptoms. Results: In 94 CeAD patients (n = 40 female [42.6%], median age 46 years [interquartile range (IQR) 36.2–53]), 506 DUS examinations were reviewed covering a median length of follow-up of 54.1 weeks (IQR 30.5–100.5). In total, 105 dissected arteries were detected, of which 27 (25.7%) were occluded. In 28/94 patients (29.8%), 31 new arterial findings were recorded, which were associated with clinical symptoms in 9/31 (30%) patients. Recanalization of occluded CeAD was observed in 22/27 (81.5%) arteries and occurred in 20/22 arteries within 3 months. In 4/22 patients (18.2%), recanalization was associated with clinical symptoms (ischemic events [n = 2], pure local symptoms [n = 2]). Delayed occlusions were observed in 4/78 (5.1%) dissected arteries patent at baseline. All were clinically asymptomatic and occurred within 14 days from baseline. Recurrent CeAD (all symptomatic) occurred in 5 previously non-dissected arteries. Conclusion: In CeAD patients, follow-up DUS identified new arterial findings, of which several were associated with clinical symptoms: we found that about 1 of 5 recanalizations were associated with clinical symptoms, of whom half were ischemic symptoms. Further, delayed occlusions occurred in patients with no or mild stenosis at baseline and were asymptomatic. This study emphasizes the potential importance of repeated DUS in CeAD particularly in the early phase of up to 4 weeks.

Keywords:
Stroke, Artery occlusion, Dissection, Duplex ultrasound
1.
Engelter ST, Traenka C, Lyrer P. Dissection of Cervical and Cerebral Arteries. Curr Neurol Neurosci Rep. 2017 Aug;17(8):59.
2.
Debette S. Pathophysiology and risk factors of cervical artery dissection: what have we learnt from large hospital-based cohorts? Curr Opin Neurol. 2014 Feb;27(1):20–8.
3.
Engelter ST, Traenka C, Von Hessling A, Lyrer PA. Diagnosis and treatment of cervical artery dissection. Neurol Clin. 2015 May;33(2):421–41.
4.
Lichy C, Metso A, Pezzini A, Leys D, Metso T, Lyrer P, et al. Predictors of delayed stroke in patients with cervical artery dissection. Int J Stroke. 2015 Apr;10(3):360–3.
5.
Nedeltchev K, Bickel S, Arnold M, Sarikaya H, Georgiadis D, Sturzenegger M, et al. R2-recanalization of spontaneous carotid artery dissection. Stroke. 2009 Feb;40(2):499–504.
6.
Dreier JP, Lurtzing F, Kappmeier M, Bohner G, Klingebiel R, Leistner S, et al. Delayed occlusion after internal carotid artery dissection under heparin. Cerebrovasc Dis. 2004;18(4):296–303.
7.
Machet A, Fonseca AC, Oppenheim C, Touzé E, Meder JF, Mas JL, et al. Does anticoagulation promote mural hematoma growth or delayed occlusion in spontaneous cervical artery dissections? Cerebrovasc Dis. 2013;35(2):175–81.
8.
Kloss M, Grond-Ginsbach C, Ringleb P, Hausser I, Hacke W, Brandt T. Recurrence of cervical artery dissection: an underestimated risk. Neurology. 2018 Apr;90(16):e1372–8.
9.
Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668–78.
10.
Benninger DH, Georgiadis D, Gandjour J, Baumgartner RW. Accuracy of color duplex ultrasound diagnosis of spontaneous carotid dissection causing ischemia. Stroke. 2006 Feb;37(2):377–81.
11.
Arning C. Ultrasonographic criteria for diagnosing a dissection of the internal carotid artery. Ultraschall Med. 2005 Feb;26(1):24–8.
12.
Arning C, Rieper J, Kazarians H. Nonarteriosclerotic disease of the cervical arteries. Ultraschall Med. 2008 Dec;29(6):576–93.
13.
Habs M, Pfefferkorn T, Cyran CC, Grimm J, Rominger A, Hacker M, et al. Age determination of vessel wall hematoma in spontaneous cervical artery dissection: a multi-sequence 3T cardiovascular magnetic resonance study. J Cardiovasc Magn Reson. 2011 Nov;13(1):76.
14.
Baracchini C, Tonello S, Meneghetti G, Ballotta E. Neurosonographic monitoring of 105 spontaneous cervical artery dissections: a prospective study. Neurology. 2010 Nov;75(21):1864–70.
15.
Debette S, Grond-Ginsbach C, Bodenant M, Kloss M, Engelter S, Metso T, et al.; Cervical Artery Dissection Ischemic Stroke Patients (CADISP) Group. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology. 2011 Sep;77(12):1174–81.
16.
de Bray JM, Lhoste P, Dubas F, Emile J, Saumet JL. Ultrasonic features of extracranial carotid dissections: 47 cases studied by angiography. J Ultrasound Med. 1994 Sep;13(9):659–64.
17.
Benninger DH, Baumgartner RW. Ultrasound diagnosis of cervical artery dissection. Front Neurol Neurosci. 2006;21:70–84.
18.
Sturzenegger M, Mattle HP, Rivoir A, Baumgartner RW. Ultrasound findings in carotid artery dissection: analysis of 43 patients. Neurology. 1995 Apr;45(4):691–8.
19.
Sengelhoff C, Nebelsieck J, Nassenstein I, Maintz D, Nabavi DG, Kuhlenbaeumer G, et al. Neurosonographical follow-up in patients with spontaneous cervical artery dissection. Neurol Res. 2008 Sep;30(7):687–9.
20.
Steinke W, Rautenberg W, Schwartz A, Hennerici M. Noninvasive monitoring of internal carotid artery dissection. Stroke. 1994 May;25(5):998–1005.
21.
Engelter ST, Grond-Ginsbach C, Metso TM, Metso AJ, Kloss M, Debette S, et al.; Cervical Artery Dissection and Ischemic Stroke Patients Study Group. Cervical artery dissection: trauma and other potential mechanical trigger events. Neurology. 2013 May;80(21):1950–7.
22.
Dziewas R, Konrad C, Dräger B, Evers S, Besselmann M, Lüdemann P, et al. Cervical artery dissection—clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003 Oct;250(10):1179–84.
23.
Arnold M, Baumgartner RW, Stapf C, Nedeltchev K, Buffon F, Benninger D, et al. Ultrasound diagnosis of spontaneous carotid dissection with isolated Horner syndrome. Stroke. 2008 Jan;39(1):82–6.
24.
Baumgartner RW, Arnold M, Baumgartner I, Mosso M, Gönner F, Studer A, et al. Carotid dissection with and without ischemic events: local symptoms and cerebral artery findings. Neurology. 2001 Sep;57(5):827–32.
25.
Lyrer PA, Brandt T, Metso TM, Metso AJ, Kloss M, Debette S, et al.; Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) Study Group. Clinical import of Horner syndrome in internal carotid and vertebral artery dissection. Neurology. 2014 May;82(18):1653–9.
26.
Kellert L, Kloss M, Pezzini A, Debette S, Leys D, Caso V, et al. Prognostic significance of pulsatile tinnitus in cervical artery dissection. Eur J Neurol. 2016 Jul;23(7):1183–7.
27.
Lumsden S, Rosta G, Bismuth J, Lumsden AB, Garami Z. Spontaneous Recanalization After Carotid Artery Dissection: The Case for an Ultrasound-Only Monitoring Strategy. Methodist Debakey Cardiovasc J. 2017 Oct-Dec;13(4):243–7.
© 2020 S. Karger AG, Basel
2020
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.