Manipulating Controversies in Carotid/Vertebral Artery Dissection

Transcription

1 Manipulating Controversies in Carotid/Vertebral Artery Dissection Dr. Rick Kvas MAY 1, 2013 Dr. Rick Kvas Dr. Frank Silver 1

2 Disclosure of Commercial Support This program has received financial support from NEO Stroke Network in the form of an honarium. Potential for conflict(s) of interest: None Past Honoraria: Bristol Myers Squibb, Boehringer Ingelheim Objectives Incidence of ICD/VAD Understanding the Presenting Symptoms and Clinical Course Treatment Controversies OAC vs. Antiplatelets vs. Stenting. Correlation with Chiropractor Manipulation 2

3 CASE #1 Feb 2, female presents at 8 am to ER c/o dizziness, nausea, stumbling, numbness to L hand/l leg/l foot. Symptoms started the previous night a 8 pm with some numbness, went to sleep, awoke at 3am unsteady on her feet, went back to bed waking up at 7am unable to walk, dizzy and nauseous. Too Late TPA? Time of onset 8 pm previous night **4.5 hours** 3

4 PAST Hx Headache earlier in week with neck pain on R side. She had long standing neck pain after lifting her computer from back of van 1/12 prior. She received massage to her upper neck from her husband a registered massage therapist. Saw a chiropractor in Guelph a week ago who advised her she had an injury to her C1,C2,C3 from long standing neck pain and received neck manipulations. Stroke Risk Factors No HTN No DM, non smoker, no FamHX of MI/CVA No known hyperlipidemia No collagen vascular disease 4

5 Social Hx Married with 2 children Financial Advisor working in Guelph Visiting her mother who was post op in Timmins MED HX: Chronic Cystitis, ALLERGIES : Morphine MEDS Lorazepam.5mg po od prn 5

6 Physical Exam VS T 36.3, Pulse 98 reg.,bp=133/93 O2sat=92% room air, RR 20 GCS =15, talking to husband able to ambulate in hallway using handrail somewhat drifting to R side. Chest/CVS/ABD;normal, CNS Exam R facial numbness Decreased light touch and temp below L knee Ataxic Gait drift to R side Rapid Alternating Movements normal Slight R lid lag and R miosis( HORNER s Syndrome) 6

7 Horner s Syndrome LABS HB 144, WBC 9.1, PLT 234 INR 1.0, PTT 29 Na 140,K 4.0,Cl 108,Cr 71 TSH 2.21 ECG NSR no Atrial Fib on Telemetry TChol 4.71, LDL 2.84,HDL 1.05, TG

8 CT/ CT Angiogram Investigations Abrupt narrowing of R vertebral artery as it enters the skull base R vertebral artery dissection CT Scan 8

9 CT SCAN ANGIO CT ANGIO 9

10 MRI Acute infarct R aspect of medulla R vertebral artery dissection. Absence of Flow MRI 10

11 MRI Flow void MRA 11

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13 Dr. Frank Silver TELESTROKE Lateral Medullary Syndrome secondary to R medullary stroke caused by R vertebral artery dissection. (C3 distally to junction with L vertebral artery as it forms the basilar artery. ) ASA 81mg po od Ramipril 2.5mg po od Tiazac 120mg po od F/Up TWH in 8 12 wk at Stroke Clinic Wallenberg Syndrome Adolf Wallenberg( ) German neurologist clinical and autopsy findings Thrombosis of Posterior Inferior Cerebellar Artery Causes Lateral part of the medulla oblongata to infarct. Most common affected artery is the vertebral, then PICA, Sup/Inf. Medullary arteries. 13

14 Wallenberg Ipsilateral loss of pain/temp of FACE (spinal trigeminal nucleus) Contralateral loss of pain/temp of BODY (lateral spinothalamic tract) Dysphagia, Dysarthria, Dysphonia(nucleus ambiguus,cn X ) Ataxia (Cerebellum) Ipsilateral Horner s (Descending sympathetic relay hypothalamospinal fibers) Vertigo(Deiter s Nucleus Vestibular) Anatomy 14

15 Anatomy of Horner s Syndrome Anatomy of Cranial Neuropathies 15

16 Incidence of Dissection Spontaneous Carotid Dissection per 100,000 per year Spontaneous Vertebral Artery Dissection per 100,000 per year Overall account for 2% of all ischemic strokes 8 10% cause of stroke in patients <40 Rate is 1:1000 in settings of trauma 16

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18 ED Evaluation Western Trauma Association High Risk Groups Arterial hemorrhage neck/nose/mouth Expanding Cervical Hematoma Cervical Bruit<50 Focal Neurological Deficit Stroke on CT or MRI Neuro deficit INCONSISTENT with Head CT. WTA High Risk Traumatic Mechanism Cervical Hyperextension with Rotation/Hyper flexion Le Fort II or III Basilar Skull Fractures Diffuse Axonal Injury and GCS<6 Cervical/vertebral body fractures/subluxation at any level Near Hanging with anoxic brain injury Seatbelt/clothesline injury with neck pain/or altered mental status 18

19 IMAGING Digital Subtraction Angiography GOLD STANDARD CTA 90% sensitivity for Cervical artery dissection MRA % sensitivity CTA is better to evaluate vertebral arteries vs. MRA CTA replacing Angiography(esp in trauma) Vertinsky, AJNR

20 Prognosis 36 56% of patients with extra cranial CAD detected in hospital setting will have a stroke within 24 hrs 78% 82% develop stroke < 7 days. Decreases over time(rare after 2/12) Outcomes are varied because many factors play a role 20

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22 Studies Evidence Despite systemic reviews, no conclusive evidence of an association. Many are DC Sponsored Many patients present to chiropractors with symptoms of neck pain, headache, etc. that could be early spontaneous ICAD or VAD. Consent Forms at DC offices warn of stroke. 22

23 Evidence Improvement if Treated 2002 Miller et al 139 traumatic Dissections(75 CAD, 64 VAD) 43 CAD treated and 39 VAD treated (hep/asa) Stroke rate CAD 6.8%, VAD 2.6% Untreated stroke rate CAD 64%, VAD 54% P<.001 No comparison trials of OAC/HEP/ASA tpa ASA OAC STENTING Medical Management DR. FRANK SILVER 23

24 Vertebral Artery Dissection Frank L. Silver, MD, FRCP(C) Director, UHN Stroke Program Professor of Medicine (Neurology) University of Toronto 24

25 Outline What is an arterial dissection? How common is vertebral artery dissection (VAD)? How does a VAD cause a stroke? How should patients with acute VAD be managed? What is the prognosis? What is the relationship between neck manipulation and VA dissection? Schievink: N Engl J Med, (6),

26 Symptoms Neck pain Pulsatile tinnitus Vertebrobasilar Ischemia vertigo double vision, binocular loss of vision incoordination, ataxia dysarthria, dysphagia, hiccoughs facial numbness or weakness bilateral leg/arm weakness loss of consciousness memory disturbance Clinical Signs Vertebrobasilar Ischemia Field defects, cortical blindess Horner s syndrome, Parinaud s syndrome Ophthalmoplegia, nystagmus Dysarthria, dysphagia Limb and/or gait ataxia Corticospinal tract signs (especially bilateral) Crossed and dissociative sensory signs Memory disturbances, hypersomnolence 26

27 Imaging- Vertebrobasilar Ischemia CT scan often negative as infarcts in the brain stem, may show hematoma in the vessel wall on axial thin sections CTA look at axial images MRI / MRA axial fat suppressed T1 and T2 sequences are the most sensitive and specific for dissection Duplex doppler / Transcranial doppler of little value selective arterial angiography if diagnosis unclear and to assess collaterals T2 Saggital ATECO MRA FLAIR DWI Arrow = Infarct Arrow = Occluded Carotid Artery 27

28 Carotid Dissection DWI hemicord infarction 28

29 Imaging FLAIR hemicord infarction Imaging Bilateral Vertebral Dissection T1 Sag DWI 29

30 MR - Dissection Protocol Fat Suppressed Axial T1 Saggital T2 30

31 Location of Dissection that Caused Upper Spinal Cord and Brainstem Infarction Right Medulla (Brain Stem) Dissection and occluded VA Anterior Spinal Artery Right Vertebral Artery (VA) Cervical Spinal Cord Site of Arterial Dissections Schievink: N Engl J Med, Volume 330(6),

32 Location of Vertebral Artery Dissection MRA/DSA in 152 patients (182 svad) Morphology Vert artery occlusion 70 (38%) Vert artery stenosis 102 (56%) Aneurysmal dilatation 10 (6%) Location (195 svad) Intracranial 21 (11%) Extracranial 155 (79%) Extracranial with Intracranial extension 19 (10%) Segment V1-40 (20%) V2 68 (35%) V3 66 (34%) V4-21 (11%) Arnold et al. (2006). Verterbral artery dissection: Presenting findings and predictors of outcome. Stroke, 37: Anatomy of the Vertebral Artery 32

33 Vascular Anatomy of the Neck and Head Incidence of Vertebral Artery Dissections Vertebral artery dissection is not common (annual incidence of 0.97 cases per 100,000) 1 eight cases of vertebral artery dissection that caused infarction of the upper spinal cord. [Ovid Medline Aug 2008] 1 Lee VH, Brown RD, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a populationbased study. Neurology 2006; 67:

34 Arterial Dissection Penetrating Branch Artery healthy artery with perpendicular penetrating branch True Lumen Adventitia Intima Vessel Wall 34

35 Arterial Dissection Penetrating Branch Artery True Lumen tear of the intima hemorrhage into arterial wall expansion of intra-wall hematoma penetrating branch artery still patent Intimal Tear Arterial Dissection Penetrating Branch Artery False Lumen Emboli True Lumen expansion of the intramural hemorrhage collapse of the true lumen penetrating branch artery still patent risk of clots forming on irregular surface of dissected wall that can break loose and travel to the brain (emboli) 35

36 Arterial Dissection Penetrating Branch Artery True Lumen continued expansion of intramural hematoma collapse of the true lumen obliteration of the penetrating branch artery False Lumen Spontaneous vs Traumatic Dissection most occur spontaneously 15% are bilateral at onset intracranial dissection can occur trauma => neck manipulation neck injury (e.g. MVA) sustained extension rotation» painting the ceiling» head positioning during surgery» backing out the car vigorous dancing, gymnastics, yoga 36

37 Time to Ischemic Stroke (carotid dissection) Biousse: Stroke, 26(2).February Vertebral Artery Injury Predisposing Factors: vessel wall pathology fibromuscular dysplasia medial cystic necrosis atherosclerosis laxity of atlanto-axial joint anomalous arterial supply spondylosis 37

38 Extracranial Arterial Dissection: Outcome many vertebral dissections are asymptomatic or are associated with pain (neck or head) only often the course is benign leaving a mild residual neurological deficit (e.g. Horner s, lateral medullary infarct) some patients have severe brain stem strokes (often with a preceding minor event) mortality? < 10% recurrence rate very low (< 1% / year) Findings and Predictors of outcome Largest documented review of vertebral artery dissection Retrospective analysis of prospective database 537 patients with spontaneous cervical artery dissection o368 (68%) sicad o144 (27%) svad o 25 (5%) both sivad and svad Excluded traumatic etiology (MVA, sports injuries, etc.) Arnold et al. (2006). Verterbral artery dissection: Presenting findings and predictors of outcome. Stroke, 37:

39 Outcomes Modified Rankin Scale at 30 days (107 patients) 0 = No symptoms 26 (24%) 1 = Symptoms no impairment 62 (58%) 2 = Slight disability 10 (9%) 3 = Moderate disability, able to walk 2 (2%) 4 = Moderately severe disability 3 (3%) 5 = Severe disability 2 (2%) 6 = Dead 2 (2%) Arnold et al. (2006). Verterbral artery dissection: Presenting findings and predictors of outcome. Stroke, 37: Cumulative Rate of Recurrent Arterial Dissection All Patients (Upper Panel) According to Age (Lower Panel) From: Schievink: N Engl J Med, Volume 330(6),

40 Management of Arterial Dissection Is dependent on the specific situation and presumed mechanism No symptoms Neck pain only Ischemic Stroke embolic (from dissection to distal cerebral arteries) local penetrating branch occlusion occlusion dissected artery with distal hemodynamic compromise Subarachnoid hemorrhage Pseudoaneurym formation and compression of adjacent structures Management of Extracranial Dissection establish the diagnosis with MR / MRA and / or CTA anticoagulants often recommended in the past and still should be considered to prevent secondary embolism (but unproven) antiplatelet agents (ASA) often recommended, given the lack of evidence for anticoagulation endovascular treatment (stenting) for distal hemodynamic compromise repeat angiography to assess recanalization or exclude pseudoaneurysm 40

41 Cochrane Analysis: antiplatelets vs anticoagulations Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD DOI: / CD pub2. 41

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43 Stroke Related to Neck Manipulation 43

44 First Case Report Pratt-Thomas and Berger: JAMA 1947 report of two adult who died following neck manipulation pathology demonstrated contusion of the vertebral artery with secondary thrombosis Cervical Manipulation: Incidence of Stroke unknown many case reports, no population-based epidemiological study surveys of neurologists conducted by the AAN the problem is determining the denominator (i.e. the number of neck manipulation performed!) incidence is probably very low (?< 1/1,000,000) 44

45 Cervical Manipulation: Pathophysiology - Cadeveric Studies DeKleyn and Neuwenhuyse, 1927 rotation of the C-spine decreased flow through the vertebral arteries compression at the level of the atlanto-axial joint Toole and Tucker, 1960 examined 20 fresh autopsies studies several movements of the neck rotation most likely to compromise vertebral flow Cervical Manipulation: Pathophysiology - Cadeveric Studies (2) Brown and Tatlow, 1963 postmortem vertebral angiograms produced complete occlusion in 5/41 patients using extension plus 90 degrees of rotation traction of the head produced 18 further occlusions occlusion above C-2 (Atlanto-Axial Junction) 45

46 Cervical Manipulation: Pathology no pathological series (patients rarely die) case reports suggest: cervical manipulation results in contusion of the vessel wall granulation tissue appears at the site of injury intramural hemorrhage leading to arterial dissection Vertebral Artery Injury Predisposing Factors: vessel wall pathology fibromuscular dysplasia medial cystic necrosis atherosclerosis laxity of atlanto-axial joint anomalous arterial supply spondylosis 46

47 Systematic Reviews 1. Di Fabio R P. Manipulation of the cervical spine: risks and benefits. Physical Therapy 1999, 79(1), pp articles were included (N = 177 cases of injury) 10% first manipulation, 41% had prior manipulation brain stem stroke most common complication (18% fatal) literature does not recommend that the benefits of MCS outweighs the risks 2. Hurwitz E L, et al. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine 1996, 21(15), pp randomised controlled trials (RCTs) (892 patients), 2 cohort studies, 14 case series, 37 case reports subacute neck pain 3 RCTs 0.42 (95%CI: , 0.85) favouring manipulation 47

48 Conclusions: Stroke Induced by Cervical Manipulation stroke related to neck manipulation is rare in most cases their are no predisposing factors? repeated contusion to vessel wall may predispose rotation of the head with the neck fully extended the maneuver most likely to occlude the vertebral at the level of the A-A junction ischemic stroke in this situation is usually secondary to vertebral artery dissection patients with suspected stroke require immediate referral to the emergency 48