Blunt Cerebrovascular Injuries: Early Recognition and Stroke Prevention in the Emergency Department - Stroke EXTRA Supplement (Stroke CME)

Table of Contents

 

Although the overall incidence is low, dissections remain a common cause of stroke in children, young adults, and trauma patients. Symptoms of dissection, such as headache, neck pain, and dizziness, are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient or may not be recognized as being due to a dissection. A missed diagnosis of cervical artery dissection can result in devastating neurologic sequelae, and emergency clinicians must act quickly to recognize this diagnosis and begin treatment as soon as possible. This supplement reviews the application of advanced screening criteria, imaging options, and antithrombotic treatment for patients with blunt cerebrovascular injuries, with a focus on reducing the occurrence of ischemic stroke.

What are the risk factors for blunt cerebrovascular injury?

What findings in the history and physical examination can be indicative of a dissection?

Which diagnostic tests are most appropriate for diagnosis of carotid and vertebral artery dissections?

What should be taken into consideration when determining appropriate interventions to prevent stroke and to treat acute ischemic strokes due to blunt cerebrovascular injury?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. Spontaneous Cervical Artery Dissections
   2. Traumatic Cervical Artery Dissections
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History and Physical Examination
   2. Spontaneous Cervical Artery Dissections
      1. Pain Characteristics
      2. Compressive Symptoms
      3. Transient Ischemic Attack or Stroke
   3. Traumatic Cervical Artery Dissections
9. Diagnostic Studies
   1. Computed Tomographic Angiography
   2. Magnetic Resonance Imaging
   3. Ultrasound
   4. Digital Subtraction Angiography
10. Treatment
    1. Stroke
    2. Medical Therapies for Stroke Prevention
       1. Antiplatelet Medications Versus Anticoagulant Medications
       2. Customization of Treatment
       3. Timing of Treatment
       4. Follow-Up Imaging
       5. Length of Treatment
    3. Endovascular Therapy
11. Special Populations
    1. Intracranial Dissections
    2. Pregnancy and Puerperium
    3. Cervical Artery Dissection in the Pediatric Population
12. Controversies and Cutting Edge
    1. Timing Of Antithrombotic Therapy
    2. Blood Pressure Management
13. Disposition
    1. Prognosis
    2. Consultation
14. Summary
15. Time- and Cost-Effective Strategies
16. Risk Management Pitfalls for Management of Cervical Artery Dissections in the Emergency Department
17. Case Conclusions
18. Clinical Pathway for Diagnosis and Treatment of Cervical Artery Dissection
19. Tables and Figures
    1. Table 1. Guidelines Related to the Treatment of Carotid or Vertebral Artery Dissections
    2. Table 2. Clinical Presentations of Cervical Artery Dissection
    3. Table 3. Screening Criteria for Blunt Cervical Artery Dissection Injuries
    4. Figure 1. Mechanism of Cervical Artery Dissection
    5. Figure 2. Common Sites of Carotid and Vertebral Artery Dissection
    6. Figure 3. Double Lumen in Carotid Artery Dissection on Computed Tomographic Angiography
    7. Figure 4. Magnetic Resonance Imaging Compared to Computed Tomographic Angiography in Cervical Artery Dissection
    8. Figure 5. Carotid Artery Dissection on Ultrasound
    9. Figure 6. Pseudoaneurysm On Digital Subtraction Angiography
20. References

Abstract

Blunt cerebrovascular injuries include cervical carotid dissections and vertebral artery dissections that are due to blunt trauma. Although the overall incidence is low, dissections remain a common cause of stroke in children, young adults, and trauma patients. Symptoms of dissection, such as headache, neck pain, and dizziness, are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient or may not be recognized as being due to a dissection. A missed diagnosis of cervical artery dissection can result in devastating neurologic sequelae, and emergency clinicians must act quickly to recognize this diagnosis and begin treatment as soon as possible. This supplement reviews the application of advanced screening criteria, imaging options, and antithrombotic treatment for patients with blunt cerebrovascular injuries, with a focus on reducing the occurrence of ischemic stroke.

Case Presentations

You arrive for your shift in the ED on a busy Friday night. Your first patient is a 29-year-old man who was the restrained driver in a motor vehicle crash in which he ran off the road at a high speed. He was intubated on the scene for airway protection. On examination, he has a GCS score of 6T, a large scalp laceration, symmetric pupils, and he withdraws all extremities from painful stimulation. His cardiac, pulmonary, and abdominal examinations are without significant findings, and his extremities have scattered abrasions. His initial trauma imaging includes a portable chest x-ray, a noncontrast CT of the head and cervical spine, and a CT of the abdomen/pelvis with contrast. The head CT showed a diffuse axonal injury and a temporal bone fracture. The remainder of the imaging showed no significant traumatic injuries. What else should be done at this point? What are his biggest risks right now? Is the temporal bone fracture concerning?

As you are pondering these questions, your next patient arrives. He is a healthy 42-year-old man who came to the ED due to neck pain. He was involved in a low-speed rear-end motor vehicle crash 2 days prior and felt fine, but today he developed severe pain in the left side of his neck that radiates to his left jaw. On examination, he has diffuse paraspinal tenderness that you presume to be muscle spasm, no apparent jaw abnormalities that would cause his pain, and his neurologic examination is negative. You obtain a CT of the head and cervical spine without contrast, which are both read as negative. You think there is only musculoskeletal involvement, but you keep wondering about the jaw pain. What else could this be? You give him some pain medications and decide to check on him later.

After leaving that patient’s room, you are called to the bedside of another patient just brought in by EMS. She is a 54-year-old woman with acute onset of vertigo and nausea/vomiting that started while she was at dinner with her family, 30 minutes prior to presentation. In the history, you note that she is otherwise healthy and takes no medications. She does experience chronic neck discomfort, for which she sees a chiropractor routinely, but she has never experienced symptoms like this. On examination, she has left-sided ataxia and nystagmus to left lateral gaze. You send her for a stat head CT without contrast and order stat labs. You think that she might be having a stroke, so you consult neurology for emergent evaluation. You have heard about the possibility of neck manipulation and dissection, but you wonder whether she is a candidate for any treatment.

Introduction

Although a cervical artery dissection is rarely seen in the emergency department (ED), it can have devastating consequences if it is not recognized. Cervical artery dissections can occur spontaneously or due to a traumatic event, even with trivial or forgotten trauma. The incidence of spontaneous dissection is approximately 2 to 3 in 100,000 people per year, with carotid artery dissections more common than vertebral artery dissections.¹ The incidence of traumatic cerebrovascular dissections is much higher, at approximately 1% of all adult blunt trauma admissions,^2-4 and traumatic dissection causes up to 20% of strokes in patients aged < 45 years.^5-10

Given the subtlety of symptoms in many patients, the condition is often not diagnosed until irreversible neurological injury has occurred. Symptoms may be delayed, and they may be similar to general symptoms, such as headache, neck pain, and dizziness, that are often seen in patients presenting to the ED. In the obtunded trauma patient, signs or symptoms of dissection may not be readily apparent, and the diagnosis will rely solely on advanced screening criteria. Unfortunately, 67% of these patients develop ischemia as a result of the untreated dissection, many within the first 24 hours.

Early treatment with an antithrombotic agent has been shown to be beneficial in the prevention of stroke due to dissection; however, the specific agent to use is not standardized. One randomized controlled trial attempted to determine superiority of antiplatelet agents versus anticoagulants, but the results were inconclusive.¹¹ Therefore, the appropriate treatment is left to the judgment of the clinician and must be tailored to each patient based on comorbidities, risk for stroke, and contraindications to therapy.

This Emergency Medicine Practice: Trauma EXTRA supplement will review the mechanism of injury of cervical artery dissections, identify common presenting signs or symptoms and factors that place trauma patients at high risk, and discuss current diagnostic criteria and treatment options so that emergency clinicians can make a determination on the best treatment for each patient.

Critical Appraisal of the Literature

A literature search was performed using PubMed and the Cochrane Library with the search terms carotid artery dissection, vertebral artery dissection, cervical artery dissection, blunt cerebral vascular injury, dissecting intracranial aneurysm, intracranial dissection, and stroke dissection. The search was limited to human studies in the English language from 2001 to the present. The search yielded more than 1700 articles that were reviewed for appropriateness. Only clinically relevant, peer-reviewed journal articles were included.

The Cochrane Database of Systematic Reviews search yielded only 1 relevant article involving antithrombotic drugs for carotid artery dissection.¹² One randomized controlled trial was found addressing medical, surgical, or endovascular treatment.¹¹ Due to the low incidence of cervical artery dissections, there is a paucity of trials, and most of the data are from cohort and case-control studies in which patients with dissection were compared to patients without dissection with regard to symptoms, risk factors, imaging, treatment, and outcomes.

There are many guidelines related to the treatment of headache or stroke that mention cervical artery dissection, but there are no guidelines regarding the workup and treatment specifically focused on this condition. Organizations with related guidelines include the American Heart Association, American Stroke Association, American College of Radiology, and the Eastern Association for the Surgery of Trauma, among others. (See Table 1.) There are currently no clinical policies on the diagnosis or treatment of spontaneous or traumatic cervical artery dissections from the American College of Emergency Physicians.

Risk Management Pitfalls for Management of Cervical Artery Dissections in the Emergency Department

1. “This patient has a left temporal headache that radiates into his left ear. His examination is benign, except his pupil is smaller on that side. I did a noncontrast head CT and it’s negative. The headache is probably just due to a hard game of basketball yesterday. I’m going to give him some IV ketorolac and send him out.”

Dissections can occur spontaneously or as a result of minor trauma, even from a rough basketball game. Failure to consider cervical artery dissection may result in a missed diagnosis. Headaches in carotid artery dissections can be nonspecific, but are mostly located in the frontal or temporal regions; radiation to the ear is also characteristic. His examination is also concerning for a partial Horner syndrome, which is also suspicious for carotid artery dissection and warrants further vascular imaging.

6. “I really thought that patient with the headache, anterolateral neck pain, and partial Horner syndrome had a carotid dissection, but the CTA was read as negative, so I guess I was wrong. I’ll just treat her pain and send her home.”

CTA is an excellent screening tool, but it is not 100% sensitive and can miss small intimal flaps, intramural hematomas, or slight fusiform dilatation of the vessel. In patients for whom there is a high suspicion of dissection and a negative or equivocal CTA or MRA, further imaging with MRI or digital subtraction angiography is indicated.

9. “The CTA showed a vertebral artery dissection in a patient who came to the ED after a roller coaster ride, so I consulted the neurology service for admission. Her neurologic examination was normal, so I’m going to wait to treat her and see what neurology recommends.”

An antithrombotic agent for stroke prevention can be started in the ED to avoid treatment delays. Studies have not shown superiority of one agent over another, so the choice of aspirin or heparin depends on patient factors. For uncomplicated dissections, antiplatelet agents are sufficient, and heparin is preferred in patients with an acute thrombus or high risk for thromboembolic events, if no contraindications exist.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, random-ized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the ref-erence, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

1. * Lee VH, Brown RD Jr, Mandrekar JN, et al. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006;67(10):1809-1812. (Cross-sectional study; 48 patients) DOI: 10.1212/01.wnl.0000244486.30455.71
2. Stein DM, Boswell S, Sliker CW, et al. Blunt cerebrovascular injuries: does treatment always matter? J Trauma. 2009;66(1):132-143. (Retrospective cohort study; 147 patients)
3. * Miller PR, Fabian TC, Croce MA, et al. Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes. Ann Surg. 2002;236(3):386-393. (Prospective cohort study; 216 patients) DOI: 10.1097/01.SLA.0000027174.01008.A0
4. McNutt MK, Kale AC, Kitagawa RS, et al. Management of blunt cerebrovascular injury (BCVI) in the multisystem injury patient with contraindications to immediate anti-thrombotic therapy. Injury. 2018;49(1):67-74. (Retrospective cohort study; 323 patients)
5. Schwartz NE, Vertinsky AT, Hirsch KG, et al. Clinical and radiographic natural history of cervical artery dissections. J Stroke Cerebrovasc Dis. 2009;18(6):416-423. (Retrospective cohort study; 177 patients)
6. Putaala J, Metso AJ, Metso TM, et al. Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: the Helsinki young stroke registry. Stroke. 2009;40(4):1195-1203. (Retrospective cohort study; 1008 patients)
7. Bogousslavsky J, Regli F. Ischemic stroke in adults younger than 30 years of age. Cause and prognosis. Arch Neurol. 1987;44(5):479-482. (Single-center prospective cohort study; 41 patients)
8. Rafay MF, Armstrong D, Deveber G, et al. Craniocervical arterial dissection in children: clinical and radiographic presentation and outcome. J Child Neurol. 2006;21(1):8-16. (Retrospective cohort study; 16 patients)
9. Leys D, Bandu L, Henon H, et al. Clinical outcome in 287 consecutive young adults (15 to 45 years) with ischemic stroke. Neurology. 2002;59(1):26-33. (Prospective cohort study; 287 patients)
10. von Sarnowski B, Schminke U, Grittner U, et al. Cervical artery dissection in young adults in the stroke in young Fabry patients (sifap1) study. Cerebrovasc Dis. 2015;39(2):110-121. (Multicenter prospective nested control study; 4208 total patients, 439 patients with cervical artery dissection)
11. * Markus HS, Hayter E, Levi C, et al. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015;14(4):361-367. (Randomized controlled trial; 250 patients) DOI: 10.1016/S1474-4422(15)70018-9
12. Lyrer PA, Brandt T, Metso TM, et al. Clinical import of Horner syndrome in internal carotid and vertebral artery dissection. Neurology. 2014;82(18):1653-1659. (Multicenter prospective nested control study; 496 patients)
13. Daffner R, Weissman B, Wippold FI, et al. ACR Appropriateness Criteria® on suspected spine trauma. Reston, VA: American College of Radiology; 2012. (Guideline)
14. Harrigan MR, Hadley MN, Dhall SS, et al. Management of vertebral artery injuries following non-penetrating cervical trauma. Neurosurgery. 2013;72 Suppl 2:234-243. (Guideline)
15. Ricotta JJ, Aburahma A, Ascher E, et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54(3):e1-e31. (Guideline)
16. * Biffl WL, Cothren CC, Moore EE, et al. Western Trauma Association critical decisions in trauma: screening for and treatment of blunt cerebrovascular injuries. J Trauma. 2009;67(6):1150-1153. (Review) DOI: 10.1097/TA.0b013e3181c1c1d6
17. * Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 2010;68(2):471-477. (Practice guidelines) DOI: 10.1097/TA.0b013e3181cb43da
18. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA / ACCF / AHA / AANN / AANS / ACR / ASNR / CNS / SAIP / SCAI / SIR / SNIS / SVM / SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011;124(4):489-532. (Practice guidelines)
19. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. (Practice guidelines)
20. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020-3035. (Practice guidelines)
21. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236. (Practice guidelines)
22. Thomas LC, Rivett DA, Attia JR, et al. Risk factors and clinical presentation of cervical arterial dissection: preliminary results of a prospective case-control study. J Orthop Sports Phys Ther. 2015;45(7):503-511. (Prospective case-controlled study; 45 patients)
23. Engelter ST, Grond-Ginsbach C, Metso TM, et al. Cervical artery dissection: trauma and other potential mechanical trigger events. Neurology. 2013;80(21):1950-1957. (Multicenter prospective nested control study; 1897 patients)
24. Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(10):3155-3174. (Scientific statement)
25. Dziewas R, Konrad C, Drager B, et al. Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003;250(10):1179-1184. (Retrospective cohort study; 126 patients)
26. Grau AJ, Brandt T, Buggle F, et al. Association of cervical artery dissection with recent infection. Arch Neurol. 1999;56(7):851-856. (Prospective cohort study; 43 patients)
27. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001;344(12):898-906. (Review)
28. Arnold M, Cumurciuc R, Stapf C, et al. Pain as the only symptom of cervical artery dissection. J Neurol Neurosurg Psychiatry. 2006;77(9):1021-1024. (Retrospective cohort study; 20 patients)
29. Hasan I, Wapnick S, Tenner MS, et al. Vertebral artery dissection in children: a comprehensive review. Pediatr Neurosurg. 2002;37(4):168-177. (Review)
30. * Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology. 2011;77(12):1174-1181. (Prospective nested case-controlled study; 982 patients) DOI: 10.1212/WNL.0b013e31822f03fc
31. Bejot Y, Aboa-Eboule C, Debette S, et al. Characteristics and outcomes of patients with multiple cervical artery dissection. Stroke. 2014;45(1):37-41. (Prospective nested case control study; 149 patients)
32. * Biffl WL, Ray CE, Jr., Moore EE, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg. 2002;235(5):699-706. (Single-center prospective cohort study; 171 patients) DOI: 10.1097/00000658-200205000-00012
33. Burlew CC, Biffl WL, Moore EE, et al. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012;72(2):330-335. (Prospective cohort study; 418 patients)
34. Berne JD, Cook A, Rowe SA, et al. A multivariate logistic regression analysis of risk factors for blunt cerebrovascular injury. J Vasc Surg. 2010;51(1):57-64. (Prospective cohort study; 102 patients)
35. Franz RW, Willette PA, Wood MJ, et al. A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries. J Am Coll Surg. 2012;214(3):313-327. (Systematic review/meta-analysis; 418 patients)
36. Baumgartner RW, Arnold M, Baumgartner I, et al. Carotid dissection with and without ischemic events: local symptoms and cerebral artery findings. Neurology. 2001;57(5):827-832. (Prospective cohort study; 181 patients)
37. Baumgartner RW, Bogousslavsky J. Clinical manifestations of carotid dissection. Front Neurol Neurosci. 2005;20:70-76. (Review)
38. Biousse V, D’Anglejan-Chatillon J, Touboul PJ, et al. Time course of symptoms in extracranial carotid artery dissections. A series of 80 patients. Stroke. 1995;26(2):235-239. (Single-center case-controlled mixed retrospective and prospective cohort study; 80 patients)
39. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009;8(7):668-678. (Review)
40. Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology. 1995;45(8):1517-1522. (Retrospective cohort study; 161 patients)
41. von Babo M, De Marchis GM, Sarikaya H, et al. Differences and similarities between spontaneous dissections of the internal carotid artery and the vertebral artery. Stroke. 2013;44(6):1537-1542. (Multicenter prospective cohort study; 970 patients)
42. Hardmeier M, Haller S, Steck A, et al. Vertebral artery dissection presenting with fifth cervical root (C5) radiculopathy. J Neurol. 2007;254(5):672-673. (Case report)
43. Tabatabai G, Schöber W, Ernemann U, et al. Vertebral artery dissection presenting with ispilateral acute C5 and C6 sensorimotor radiculopathy: A case report. Cases J. 2008;1:139-139. (Case report)
44. Sturzenegger M. Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients. J Neurol. 1995;242(4):231-238. (Prospective cohort study; 41 patients)
45. Fabian TC, Patton JH, Croce MA, et al. Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996;223(5):513-525. (Prospective cohort study; 67 patients)
46. Ramadan F, Rutledge R, Oller D, et al. Carotid artery trauma: a review of contemporary trauma center experiences. J Vasc Surg. 1995;21(1):46-55. (Review)
47. Shahan CP, Croce MA, Fabian TC, et al. Impact continuous evaluation of technology and therapy: 30 years of research reduces stroke and mortality from blunt cerebrovascular injury. J Am Coll Surg. 2017;224(4):595-599. (Retrospective cohort study; 564 patients)
48. Shahan CP, Stavely TC, Croce MA, et al. Long-term functional outcomes after blunt cerebrovascular injury: a 20-year experience. Am Surg. 2018;84(4):551-556. (Retrospective cohort study; 509 patients)
49. Crawford JD, Allan KM, Patel KU, et al. The natural history of indeterminate blunt cerebrovascular injury. JAMA Surg. 2015;150(9):841-847. (Retrospective cohort study; 100 patients)
50. Callcut RA, Hanseman DJ, Solan PD, et al. Early treatment of blunt cerebrovascular injury with concomitant hemorrhagic neurologic injury is safe and effective. J Trauma Acute Care Surg. 2012;72(2):338-345. (Retrospective cohort study; 77 patients)
51. * Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-522. (Single-center prospective cohort study; 249 patients) DOI: 10.1016/s0002-9610(99)00245-7
52. Vilela MD, Kim LJ, Bellabarba C, et al. Blunt cerebrovascular injuries in association with craniocervical distraction injuries: a retrospective review of consecutive cases. Spine J. 2015;15(3):499-505. (Retrospective cohort study; 15 patients)
53. Vranis NM, Mundinger GS, Bellamy JL, et al. Extracapsular mandibular condyle fractures are associated with severe blunt internal carotid artery injury: analysis of 605 patients. Plast Reconstr Surg. 2015;136(4):811-821. (Retrospective cohort study; 605 patients)
54. Kerwin AJ, Bynoe RP, Murray J, et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma. 2001;51(2):308-314. (Prospective cohort study; 48 patients)
55. Malhotra AK, Camacho M, Ivatury RR, et al. Computed tomographic angiography for the diagnosis of blunt carotid/vertebral artery injury: a note of caution. Ann Surg. 2007;246(4):632-642. (Prospective cohort study; 92 patients)
56. Bonatti M, Vezzali N, Ferro F, et al. Blunt cerebrovascular injury: diagnosis at whole-body MDCT for multi-trauma. Insights Imaging. 2013;4(3):347-355. (Retrospective cohort study; 32 patients)
57. Eastman AL, Muraliraj V, Sperry JL, et al. CTA-based screening reduces time to diagnosis and stroke rate in blunt cervical vascular injury. J Trauma. 2009;67(3):551-556. (Prospective pretest-posttest study; 105 patients)
58. Munera F, Soto JA, Palacio D, et al. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology. 2000;216(2):356-362. (Prospective pretest-posttest study; 60 patients)
59. Inaba K, Munera F, McKenney M, et al. Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. J Trauma. 2006;61(1):144-149. (Prospective cohort study; 106 patients)
60. Mutze S, Rademacher G, Matthes G, et al. Blunt cerebrovascular injury in patients with blunt multiple trauma: diagnostic accuracy of duplex Doppler US and early CT angiography. Radiology. 2005;237(3):884-892. (Retrospective cohort study; 24 patients)
61. Chen CJ, Tseng YC, Lee TH, et al. Multisection CT angiography compared with catheter angiography in diagnosing vertebral artery dissection. AJNR Am J Neuroradiol. 2004;25(5):769-774. (Retrospective cohort study; 30 patients)
62. * Eastman AL, Chason DP, Perez CL, et al. Computed tomographic angiography for the diagnosis of blunt cervical vascular injury: is it ready for primetime? J Trauma. 2006;60(5):925-929. (Prospective pretest-posttest study; 146 patients) DOI: 10.1097/01.ta.0000197479.28714.62
63. Baracchini C, Tonello S, Meneghetti G, et al. Neurosonographic monitoring of 105 spontaneous cervical artery dissections: a prospective study. Neurology. 2010;75(21):1864-1870. (Retrospective cohort study; 105 patients)
64. Rundek T, Katsnelson M. Is frequent ultrasound monitoring of spontaneous cervical artery dissection clinically useful? Neurology. 2010;75(21):1858-1859. (Editorial)
65. Flis CM, Jager HR, Sidhu PS. Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol. 2007;17(3):820-834. (Review)
66. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333(24):1581-1587. (Double-blind randomized controlled trial; 624 patients)
67. Arnold M, Nedeltchev K, Sturzenegger M, et al. Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature. Arch Neurol. 2002;59(4):549-553. (Retrospective cohort study; 9 patients)
68. Georgiadis D, Baumgartner RW. Thrombolysis in cervical artery dissection. Front Neurol Neurosci. 2005;20:140-146. (Retrospective cohort study; 50 patients)
69. Qureshi AI, Chaudhry SA, Hassan AE, et al. Thrombolytic treatment of patients with acute ischemic stroke related to underlying arterial dissection in the United States. Arch Neurol. 2011;68(12):1536-1542. (Retrospective cohort study; 488 patients)
70. Tsivgoulis G, Zand R, Katsanos AH, et al. Safety and outcomes of intravenous thrombolysis in dissection-related ischemic stroke: an international multicenter study and comprehensive meta-analysis of reported case series. J Neurol. 2015;262(9):2135-2143. (Prospective international multicenter cohort study; 39 patients)
71. Zinkstok SM, Vergouwen MD, Engelter ST, et al. Safety and functional outcome of thrombolysis in dissection-related ischemic stroke: a meta-analysis of individual patient data. Stroke. 2011;42(9):2515-2520. (Review)
72. * Engelter ST, Dallongeville J, Kloss M, et al. Thrombolysis in cervical artery dissection--data from the Cervical Artery Dissection and Ischaemic Stroke Patients (CADISP) database. Eur J Neurol. 2012;19(9):1199-1206. (Multicenter prospective nested cohort study; 68 patients) DOI: 10.1111/j.1468-1331.2012.03704.x
73. Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139(5):540-545. (Single-center prospective nonequivalent controlled pretest-posttest study; 114 patients)
74. Georgiadis D, Arnold M, von Buedingen HC, et al. Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients. Neurology. 2009;72(21):1810-1815. (Prospective cohort study; 298 patients)
75. Kennedy F, Lanfranconi S, Hicks C, et al. Antiplatelets vs anticoagulation for dissection: CADISS nonrandomized arm and meta-analysis. Neurology. 2012;79(7):686-689. (Multicenter prospective nonrandomized study; 88 patients)
76. Menon R, Kerry S, Norris JW, et al. Treatment of cervical artery dissection: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2008;79(10):1122-1127. (Review)
77. Harrigan MR, Weinberg JA, Peaks YS, et al. Management of blunt extracranial traumatic cerebrovascular injury: a multidisciplinary survey of current practice. World J Emerg Surg. 2011;6:11. (Cross-sectional study; survey of 785 subjects)
78. Ramchand P, Mullen MT, Bress A, et al. Recanalization after extracranial dissection: effect of antiplatelet compared with anticoagulant therapy. J Stroke Cerebrovasc Dis. 2018;27(2):438-444. (Retrospective cohort study; 75 patients)
79. Lichy C, Metso A, Pezzini A, et al. Predictors of delayed stroke in patients with cervical artery dissection. Int J Stroke. 2015;10(3):360-363. (Multicenter prospective nested case-controlled study; 965 patients)
80. Kerr K, Wilkerson C, Shepard S, et al. Use of anti-platelet agents after traumatic intracranial hemorrhage. Clin Neurol Neurosurg. 2016;140:85-90. (Retrospective cohort study; 222 patients)
81. Shahan CP, Magnotti LJ, McBeth PB, et al. Early antithrombotic therapy is safe and effective in patients with blunt cerebrovascular injury and solid organ injury or traumatic brain injury. J Trauma Acute Care Surg. 2016;81(1):173-177. (Retrospective cohort study; 119 patients)
82. Wagenaar AE, Burlew CC, Biffl WL, et al. Early repeat imaging is not warranted for high-grade blunt cerebrovascular injuries. J Trauma Acute Care Surg. 2014;77(4):540-545. (Prospective cohort study; 582 patients)
83. Laser A, Bruns BR, Kufera JA, et al. Long-term follow-up of blunt cerebrovascular injuries. J Trauma Acute Care Surg. 2016;81(6):1063-1069. (Retrospective cohort study; 379 patients)
84. Nedeltchev K, Bickel S, Arnold M, et al. R2-recanalization of spontaneous carotid artery dissection. Stroke. 2009;40(2):499-504. (Prospective cohort study; 249 patients)
85. Fields JD, Lutsep HL, Rymer MR, et al. Endovascular mechanical thrombectomy for the treatment of acute ischemic stroke due to arterial dissection. Interv Neuroradiol. 2012;18(1):74-79. (Multicenter prospective cohort study; 10 patients)
86. Donas KP, Mayer D, Guber I, et al. Endovascular repair of extracranial carotid artery dissection: current status and level of evidence. J Vasc Interv Radiol. 2008;19(12):1693-1698. (Review)
87. Engelter ST, Rutgers MP, Hatz F, et al. Intravenous thrombolysis in stroke attributable to cervical artery dissection. Stroke. 2009;40(12):3772-3776. (Case-controlled cohort study; 55 patients)
88. Chandra A, Suliman A, Angle N. Spontaneous dissection of the carotid and vertebral arteries: the 10-year UCSD experience. Ann Vasc Surg. 2007;21(2):178-185. (Retrospective cohort study; 20 patients)
89. Metso TM, Metso AJ, Helenius J, et al. Prognosis and safety of anticoagulation in intracranial artery dissections in adults. Stroke. 2007;38(6):1837-1842. (Prospective case-controlled cohort study; 103 patients)
90. Yamada M, Kitahara T, Kurata A, et al. Intracranial vertebral artery dissection with subarachnoid hemorrhage: clinical characteristics and outcomes in conservatively treated patients. J Neurosurg. 2004;101(1):25-30. (Prospective cohort study; 24 patients)
91. Rabinov JD, Hellinger FR, Morris PP, et al. Endovascular management of vertebrobasilar dissecting aneurysms. AJNR Am J Neuroradiol. 2003;24(7):1421-1428. (Retrospective cohort study; 35 patients)
92. Strozyk D, Mehta BP, Meyers PM, et al. Coil embolization of intracranial dissecting vertebral artery aneurysms with subclavian steal. J Neuroimaging. 2011;21(1):62-64. (Case report)
93. Arnold M, Camus-Jacqmin M, Stapf C, et al. Postpartum cervicocephalic artery dissection. Stroke. 2008;39(8):2377-2379. (Comparative study; 102 patients)
94. Roach ES, Golomb MR, Adams R, et al. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39(9):2644-2691. (Guideline)
95. Goldenberg NA, Bernard TJ, Fullerton HJ, et al. Antithrombotic treatments, outcomes, and prognostic factors in acute childhood-onset arterial ischaemic stroke: a multicentre, observational, cohort study. Lancet Neurol. 2009;8(12):1120-1127. (Multicenter prospective cohort study; 661 patients)
96. Beslow LA, Jordan LC. Pediatric stroke: the importance of cerebral arteriopathy and vascular malformations. Childs Nerv Syst. 2010;26(10):1263-1273. (Review)
97. Arnold M, Steinlin M, Baumann A, et al. Thrombolysis in childhood stroke: report of 2 cases and review of the literature. Stroke. 2009;40(3):801-807. (Review)
98. Manco-Johnson MJ, Grabowski EF, Hellgreen M, et al. Recommendations for tPA thrombolysis in children. On behalf of the Scientific Subcommittee on Perinatal and Pediatric Thrombosis of the Scientific and Standardization Committee of the International Society of Thrombosis and Haemostasis. Thromb Haemost. 2002;88(1):157-158. (Guideline)
99. deVeber G, Roach ES, Riela AR, et al. Stroke in children: recognition, treatment, and future directions. Semin Pediatr Neurol. 2000;7(4):309-317. (Review)
100. Azarakhsh N, Grimes S, Notrica DM, et al. Blunt cerebrovascular injury in children: underreported or underrecognized?: A multicenter ATOMAC study. J Trauma Acute Care Surg. 2013;75(6):1006-1011. (Multi-institutional retrospective cohort study; 538 patients)
101. Kopelman TR, Berardoni NE, O’Neill PJ, et al. Risk factors for blunt cerebrovascular injury in children: do they mimic those seen in adults? J Trauma. 2011;71(3):559-564. (Retrospective cohort study; 127 patients)
102. Ravindra VM, Riva-Cambrin J, Sivakumar W, et al. Risk factors for traumatic blunt cerebrovascular injury diagnosed by computed tomography angiography in the pediatric population: a retrospective cohort study. J Neurosurg Pediatr. 2015;15(6):599-606. (Retrospective cohort study; 234 patients)
103. Ravindra VM, Bollo RJ, Sivakumar W, et al. Predicting blunt cerebrovascular injury in pediatric trauma: validation of the “Utah Score”. J Neurotrauma. 2017;34(2):391-399. (Retrospective cohort study; 411 patients)
104. Cook MR, Witt CE, Bonow RH, et al. A cohort study of blunt cerebrovascular injury screening in children. J Trauma Acute Care Surg. 2018;84(1):50-57. (Retrospective cohort study; 96 pediatric patients, 128 blunt cerebrovascular injuries)
105. Touze E, Gauvrit JY, Moulin T, et al. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology. 2003;61(10):1347-1351. (Retrospective multicenter cohort study; 459 patients)
106. Schievink WI, Roiter V. Epidemiology of cervical artery dissection. Front Neurol Neurosci. 2005;20:12-15. (Review)