AHA and ASA Issue Statement on Cervical Arterial Dissections
The American Heart Association (AHA) and the American Stroke Association (ASA) have issued a scientific statement regarding cervical artery dissections (CDs), which has grown to become one of the most common causes of stroke in young and middle-aged adults, accounting for eight to 25 percent of strokes in patients under 45 years of age.
The statement, published Aug. 7 in Circulation, reviewed the current evidence on the diagnosis and management of CD, as well as its statistical association with cervical manipulative therapy (CMT). According to the statement authors, CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Patients with CD may present a number of symptoms, including unilateral headaches, posterior cervical pain, oculosympathetic palsy, CD cranial nerve palsies, cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, or pulsatile tinnitus. The diagnosis of CD relies on a thorough look at the patient’s history, a physical examination, and targeted ancillary investigation. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography have demonstrated to be useful tactics in determining if a patient has CD.
Though the underlying pathogenesis responsible for CDs is unknown, a list of factors are believed to be associated, including major and minor cervical trauma, fibromuscular dysplasia, ultrastructural connective tissue abnormalities, hereditary hemochromatosis and vessel redundancies. The authors also explain that "ultrastructural aberrations of dermal collagen fibrils and elastic fibers have been reported in about 50 percent of patients with spontaneous CDs in whom there was no prior diagnosis of a connective tissue disorder, suggesting a molecular defect in the biosynthesis of the extracellular matrix. Seasonal variability, particularly increased CD occurring more often in autumn or winter than in the spring or summer, has also been demonstrated and believed to be a result of increased occurrence of infection or weather-related changes in blood pressure." They add that "one study found a significant association between an elevated C-reactive protein and dissection that was not present in patients with cryptogenic or large-artery strokes (adjusted odds ratio [OR] 7.9; P<0.004). Results from the Cervical Artery Dissection and Ischemic Stroke Patients Study [an international observational study focusing on risk factors and short-term outcomes of CD and ischemic stroke in young adults], have suggested that hypercholesterolemia, obesity and increased body mass index are less commonly associated with CD than ischemic stroke."
In addition to these factors, case-control and other articles have suggested an epidemiologic link between CD – particularly vertebral artery dissection – and CMT. While the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and likely low, moving forward, the authors of the statement advise physicians to strongly consider the possibility of CD as a presenting symptom, and note that patients should be informed of the statistical relationship between CD and CMT prior to undergoing manipulation of the cervical spine.
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