Bucak, Bilal

Objective: Cervical artery dissection (CeAD) was previously thought to be more common in men, but recent epidemiology studies show a disproportionate increase in the incidence of CeAD in women. In addition to sex-based differences in clinical presentation, there are unique biological risk factors for CeAD in women. Identifying risk factors for ischemic stroke in CeAD is crucial in individualizing treatment options. Herein, we utilized an inpatient cohort to investigate whether noncancerous gynecologic conditions or pregnancy are risk factors for ischemic stroke in CeAD. Methods: The National Inpatient Sample was queried from 2016 to 2020 for patients diagnosed with CeAD using the International Classification of Diseases, 10th edition, correction of the mean codes. Diagnoses of pregnancy/puerperium and noncancerous gynecologic conditions were identified. Among CeAD admissions, acute ischemic stroke (AIS) was also identified. Hierarchical, multivariable regression, adjusted for patient demographics and medical comorbidities, was conducted to assess factors associated with AIS. Results: A total of 34,925 women with CeAD were identified. Of these women, 2.1% were pregnant or up to six weeks postpartum, 1.3% had a noncancerous gynecologic condition, and 0.09% had both active pregnancy/puerperium and a noncancerous gynecologic condition. Noncancerous gynecologic conditions (odds ratio = 1.86, P = 0.012) were found to be an independent risk factor for AIS in CeAD but not active pregnancy/puerperium (odds ratio = 0.84, P = 0.34). Conclusion: In this national inpatient sample of female patients with CeAD, the presence of noncancerous gynecologic conditions is associated with an increased risk of AIS. Further studies are needed to validate this observation and help guide the best antithrombotic treatment decisions in this patient population.

Introduction: Iatrogenic cervical artery dissection (CeAD) may result from various procedures such as procedural and diagnostic angiography. Due to the rarity of iatrogenic CeAD, existing literature on management and outcomes is limited. This observational cohort study investigates clinical approaches and long-term outcomes of iatrogenic CeAD after endovascular interventions. Methods: We conducted a retrospective chart review to analyze patients who underwent endovascular treatments at the Mayo Clinic from 1998 to 2021. We focused on patients with iatrogenic CeAD resulting from interventions. Pertinent patient factors were extracted. Descriptive statistics highlighted the relationship between treatments and long-term clinical outcomes. Results: Between 1998 and 2021, 21,191 patients underwent catheter cerebral angiography. Among them, 32 had iatrogenic CeAD (30 identified as white, 23 women, median age 59 [range 40.5–92.9]). Common comorbidities included hypertension (62.5%), smoking (56.3%), and hyperlipidemia (46.9%). Of the 32 patients, 9(28.1%) had dissection with diagnostic angiograms, 6(18.8%) endovascular thrombectomy, 15(46.9%) aneurysm treatment, and 2(6.3%) angioplasty with or without stenting. The location of dissections was dependent upon the intervention: 17(53.1%) had internal carotid artery dissection, 13(40.6%) vertebral artery dissection, and 2(6.3%) common carotid dissection. One patient was symptomatic with neck pain. All dissections were diagnosed by cerebral angiography during the same session as the initial intervention. Only 4(12.5%) were treated with hyperacute stenting. Following diagnosis, 30(93.7%) were placed on antithrombotic therapy, including aspirin alone (34.4%) or dual antiplatelet therapy with aspirin and clopidogrel (37.5%). The median duration of acute treatment was 3 months. The median duration of imaging follow up was 1022 days. Follow-up imaging showed an excellent radiological course, with complete or nearly complete dissection remodeling. Conclusions: Iatrogenic CeAD with endovascular interventions is rare and typically benign. Most cases are managed medically without significant clinical complications or long-term negative outcomes. Single or dual antiplatelet therapies remain preferred treatments, in line with current trends. Key factors influencing clinical decision-making include location, occlusion rate, pseudoaneurysm formation, intracranial extension, distal collateral circulation, and ischemia.

Background Iatrogenic cervical artery dissection (CeAD) results from various procedures including interventional angiographic procedures and diagnostic angiography. Iatrogenic CeAD is rare, resulting in limited literature on management and outcomes. This observational cohort study investigates approaches and outcomes of iatrogenic CeAD after endovascular interventions. Methods We conducted a retrospective review for patients who underwent endovascular intervention with resulting iatrogenic CeAD at Mayo Clinic, Rochester, MN, from 1998 to 2021. Pertinent patient factors were extracted and descriptive statistics generated. Results Between 1998 and 2021, 21,191 patients underwent catheter-based cerebral angiography. Thirty-two had iatrogenic CeADs (23 women; median age 59 [range 40.5–92.9]). Common comorbidities included hypertension (62.5%), smoking (56.3%), and hyperlipidemia (46.9%). Nine (28.1%) had dissection with diagnostic angiograms, 6 (18.8%) endovascular thrombectomy, 15 (46.9%) intracranial aneurysm treatment/coiling, and 2 (6.3%) intracranial angioplasty with/without stenting. All dissections were diagnosed by cerebral angiography during the same session as initial interventions. Four (12.5%) underwent hyperacute stenting. Thirty (93.7%) were placed on antithrombotic therapy with aspirin alone (34.4%) or dual-antiplatelet therapy with aspirin and clopidogrel (37.5%). Median duration of acute treatment was three months. Follow-up imaging showed excellent radiological course. Conclusions Iatrogenic CeAD with endovascular interventions is rare and typically benign. Most are managed medically without complications or long-term negative outcomes. Oral single or dual-antiplatelet therapies are preferred compared to previous studies which emphasize intravenous anticoagulation. The duration of acute therapy varied from three months to lifelong. Key factors influencing clinical decision-making may include occlusion rate, pseudoaneurysm formation, intracranial extension, distal collateral circulation, and resultant ischemia.

Stroke is one of the leading causes of disability worldwide despite recent advances in hyperacute interventions to lessen the initial impact of stroke. Stroke recovery therapies are crucial in reducing the long-term disability burden after stroke. Stroke recovery treatment options have rapidly expanded within the last decade, and we are in the dawn of an exciting era of multimodal therapeutic approaches to improve post-stroke recovery. In this narrative review, we highlighted various promising advances in treatment and technologies targeting stroke rehabilitation, including activity-based therapies, non-invasive and minimally invasive brain stimulation techniques, robotics-assisted therapies, brain–computer interfaces, pharmacological treatments, and cognitive therapies. These new therapies are targeted to enhance neural plasticity as well as provide an adequate dose of rehabilitation and improve adherence and participation. Novel activity-based therapies and telerehabilitation are promising tools to improve accessibility and provide adequate dosing. Multidisciplinary treatment models are crucial for post-stroke neurorehabilitation, and further adjuvant treatments with brain stimulation techniques and pharmacological agents should be considered to maximize the recovery. Among many challenges in the field, the heterogeneity of patients included in the study and the mixed methodologies and results across small-scale studies are the cardinal ones. Biomarker-driven individualized approaches will move the field forward, and so will large-scale clinical trials with a well-targeted patient population.