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脳動脈解離

著者: 星野晴彦 東京都済生会中央病院 脳神経内科 脳卒中センター

監修: 永山正雄 国際医療福祉大学大学院医学研究科 脳神経内科学

著者校正済:2021/10/13
現在監修レビュー中
参考ガイドライン:
  1. 日本脳卒中学会:脳卒中治療ガイドライン2021ガイドライン
  1. American Heart Association/American Stroke Association:2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack.Stroke. 2021;52:e364–e467
  1. American Heart Association/American Stroke Association:Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019;50:e344–e418
患者向け説明資料

概要・推奨   

  1. 動脈硬化の危険因子が比較的少ない若年脳卒中患者では解離を念頭に置いて,頭痛・頸部痛の病歴を聴取する
  1. 大動脈解離の進展による頚部動脈解離を除外する
  1. MRACTAによって解離の特徴的な所見を見逃さないようにする
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
星野晴彦 : 講演料(ブリストル・マイヤーズスクイブ株式会社,第一三共株式会社,ファイザー株式会社)[2021年]
監修:永山正雄 : 未申告[2021年]

改訂のポイント:
  1. 脳卒中治療ガイドライン2021とAHA/ASAの最新のガイドライン、脳卒中データバンク2021に基づき刷新した。 

病態・疫学・診察

疾患情報  
疾患のポイント:
  1. 脳動脈解離とは、若年者脳卒中の主要な原因の1つで、何らかの誘因で脳動脈壁内に出血し壁が裂けた状態である。その結果、出血性の症状(くも膜下出血)、虚血性の症状(一過性脳虚血発作、脳梗塞)、その他の症状(頭痛、解離部の圧迫症状)などを来す。頭痛が神経症候に先行あるいは同時に起こる。
  1. 脳動脈解離の症状としては、解離そのものによる直接症状(頭痛、頚部痛、血管拡張による局所症状)と血管障害による症状(脳梗塞、くも膜下出血)などを来す。特に、突然の激しい頭痛・頚部痛は、動脈解離の約50~80%にみられる特徴的症状である。血管拡張による局所症状としては、頚部内頸動脈解離では血管の拡張による迷走神経、副神経、舌咽・舌下神経障害を、また頭蓋内も含めた内頸動脈解離では血管壁を走る交感神経線維の障害によるホルネル徴候などを来すことがある。
  1. わが国の調査では、SCADS-JAPANによると中央値54歳(13~88歳)、50歳以下が39.4%であった[1]。脳卒中データバンク2021では平均年齢±SDは脳梗塞発症で54.8±15.1歳、くも膜下出血発症で54.8±12.8歳であった[2]
  1. 頚部回旋などの軽い外傷に伴って起こることが多いとされるが、明らかな誘因のない場合も多い。カイロプラクティック(整体)との関連が示唆されている[3]
  1. Fibromuscular dysplasiaや結合織疾患が基礎疾患として存在する場合がある。
  1. 脳卒中データバンク2021では、わが国で990例の動脈解離が登録され、脳梗塞発症が566例(57.2%、男性420、女性146)、脳出血発症が10例(1.0%)、くも膜下出血414例(41.8%、男性227、女性187)であった。併存疾患では高血圧症が多い。解離部位は脳梗塞発症57例では頭蓋内椎骨動脈34例、頚部内頚動脈6例、頭蓋内内頚動脈6例、前大脳動脈5例の順で多く、くも膜下出血発症72例では頭蓋内椎骨動脈27例、後大脳動脈14例、中大脳動脈12例、前大脳動脈12例の順で多かった[2]
  1. 欧米の疫学的研究からは、冬季に発症率が高いことが示されている[4]
  1. ヨーロッパの大規模登録研究であるCervical Artery Dissection and Ischemic Stroke Patients (CADISP) 668例によれば、内頸動脈解離のほうが椎骨動脈解離に比べて、年齢が高く(46.3±9.6対42.0±10.2歳)、男性に多く(62.7%対53.0%)、耳鳴りが多く(10.9%対3.4%)、NIHSSが高スコアである(10±7.1対5±5.9)。椎骨動脈解離では、両側性(15.2%対7.6%)、喫煙者(36.0%対28.7%)、雷鳴頭痛(9.2%対3.6%)と頚部痛(65.8%対33.5%)が多く、くも膜下出血(6.0%対0.6%)と虚血性脳卒中(69.5%対52.2%)も多かった。3カ月後の虚血性脳卒中後の転帰良好例と3カ月以内の虚血性脳卒中再発は椎骨動脈解離のほうが多かった[5]
 
脳動脈解離の分類:
  1. 成因からは、外傷性、医原性、特発性の3種類に分類される。頚部回旋などの軽い外傷に伴って起こることが多いとされるが、明らかな誘因のない場合も多い。
  1. 発症様式からは上述のように、出血性発症、虚血性発症、その他の症状、無症候に分けられる。罹患動脈では内頸動脈系と椎骨動脈系に分けられ、それぞれ頭蓋内、頭蓋外にさらに分類される。わが国の調査では、頭蓋内椎骨動脈解離が多い。
  1. わが国の調査では、頭蓋内椎骨動脈解離が動脈解離全体の63.4%を占め、海外の頭蓋外内頸動脈解離が多いのとは対照的である。
  1. 頭蓋内脳動脈系では前大動脈解離が比較的多い。
  1. 頭蓋外脳動脈解離では虚血性発症(一過性脳虚血発作(TIA)/脳梗塞)を、頭蓋内脳動脈解離では虚血性発症(TIA/脳梗塞)のみでなく、出血性発症(くも膜下出血)を来す。
  1. Borgess分類[6]
  1. Type I:内膜断裂なし
  1. Type IA:壁内血腫による内腔狭窄はあるが順行性血流がある
  1. Type IB:壁内血腫による完全閉塞で順行性血流がない
  1. Type II:内膜断裂あり
  1. Type IIA:小さい内膜の局所断裂があり外側への動脈瘤形成を伴うが、外膜は正常で、動脈瘤内に血流うっ滞が認められる
  1. Type IIB:大きな内膜の断裂があり、偽腔または動脈瘤拡張がみられる
病歴・診察のポイント  
病歴:
  1. TIA/脳梗塞による神経症候およびくも膜下出血による激しい頭痛の発症前に頚部から頭部にかけて、頭痛が先行あるいは同時に出現したかどうかを問診する。

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文献 

著者: José Biller, Ralph L Sacco, Felipe C Albuquerque, Bart M Demaerschalk, Pierre Fayad, Preston H Long, Lori D Noorollah, Peter D Panagos, Wouter I Schievink, Neil E Schwartz, Ashfaq Shuaib, David E Thaler, David L Tirschwell, American Heart Association Stroke Council
雑誌名: Stroke. 2014 Oct;45(10):3155-74. doi: 10.1161/STR.0000000000000016. Epub 2014 Aug 7.
Abstract/Text PURPOSE: Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional.
METHODS: Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.
RESULTS: Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.
CONCLUSIONS: CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

© 2014 American Heart Association, Inc.
PMID 25104849  Stroke. 2014 Oct;45(10):3155-74. doi: 10.1161/STR.00000・・・
著者: M Paciaroni, D Georgiadis, M Arnold, J Gandjour, B Keseru, G Fahrni, V Caso, R W Baumgartner
雑誌名: J Neurol Neurosurg Psychiatry. 2006 May;77(5):677-9. doi: 10.1136/jnnp.2005.077073.
Abstract/Text We examined the seasonal variability of spontaneous cervical artery dissection (sCAD) by analysing prospectively collected data from 352 patients with 380 sCAD (361 symptomatic sCAD; 305 carotid and 75 vertebral artery dissections) admitted to two university hospitals with a catchment area of 2,200,000 inhabitants between 1985 and 2004. Presenting symptoms and signs of the 380 sCAD were ischaemic stroke in 241 (63%), transient ischaemic attack in 40 (11%), retinal ischemia in seven (2%), and non-ischaemic in 73 (19%) cases; 19 (5%) were asymptomatic sCAD. A seasonal pattern, with higher frequency of sCAD in winter (31.3%; 95% confidence interval (CI): 26.5 to 36.4; p=0.021) compared to spring (25.5%; 95% CI: 21.1 to 30.3), summer (23.5%; 95% CI: 19.3 to 28.3), and autumn (19.7%; 95% CI: 15.7 to 24.1) was observed. Although the cause of seasonality in sCAD is unclear, the winter peaks of infection, hypertension, and aortic dissection suggest common underlying mechanisms.

PMID 16614034  J Neurol Neurosurg Psychiatry. 2006 May;77(5):677-9. do・・・
著者: Michelle von Babo, Gian Marco De Marchis, Hakan Sarikaya, Christian Stapf, Fréderique Buffon, Urs Fischer, Mirjam R Heldner, Jan Gralla, Simon Jung, Barbara Goeggel Simonetti, Heinrich P Mattle, Ralf W Baumgartner, Marie-Germaine Bousser, Marcel Arnold
雑誌名: Stroke. 2013 Jun;44(6):1537-42. doi: 10.1161/STROKEAHA.113.001057. Epub 2013 Apr 30.
Abstract/Text BACKGROUND AND PURPOSE: To compare potential risk factors, clinical symptoms, diagnostic delay, and 3-month outcome between spontaneous internal carotid artery dissection (sICAD) and spontaneous vertebral artery dissection (sVAD).
METHODS: We compared patients with sICAD (n=668) and sVAD (n=302) treated in 3 university hospitals.
RESULTS: Patients with sICAD were older (46.3 ± 9.6 versus 42.0 ± 10.2 years; P<0.001), more often men (62.7% versus 53.0%; P=0.004), and presented more frequently with tinnitus (10.9% versus 3.4%; P<0.001) and more severe ischemic strokes (median National Institutes of Health Stroke Scale, 10 ± 7.1 versus 5 ± 5.9; P<0.001). Patients with sVAD had more often bilateral dissections (15.2% versus 7.6%; P<0.001) and were more often smokers (36.0% versus 28.7%; P=0.007). Thunderclap headache (9.2% versus 3.6%; P=0.001) and neck pain were more common (65.8% versus 33.5%; P<0.001) in sVAD. Subarachnoid hemorrhage (6.0% versus 0.6%; P<0.001) and ischemic stroke (69.5% versus 52.2%; P<0.001) were more frequent in sVAD. After multivariate analysis, sex difference lost its significance (P=0.21), and all other variables remained significant. Time to diagnosis was similar in sICAD and sVAD and improved between 2001 and 2012 compared with the previous 10-year period (8.0 ± 10.5 days versus 10.7 ± 13.2 days; P=0.004). In sVAD, favorable outcome 3 months after ischemic stroke (modified Rankin Scale, 0-2: 88.8% versus 58.4%; P<0.001), recurrent transient ischemic attack (4.8% versus 1.1%; P=0.001), and recurrent ischemic stroke (2.8% versus 0.7%; P=0.02) within 3 months were more frequent.
CONCLUSIONS: sICAD and sVAD patients differ in many aspects. Future studies should perform separate analyses of these 2 entities.

PMID 23632978  Stroke. 2013 Jun;44(6):1537-42. doi: 10.1161/STROKEAHA.・・・
著者: Brandon C Perry, Firas Al-Ali
雑誌名: Front Neurol. 2013;4:133. doi: 10.3389/fneur.2013.00133. Epub 2013 Sep 17.
Abstract/Text BACKGROUND AND PURPOSE: The pathogenesis of spontaneous cervical artery dissections (sCAD) and its best medical treatment are debated. This may be due to a lack of clear classification of sCAD. We propose the new Borgess classification of sCAD, based on the presence or absence of intimal tear as depicted on imaging studies and effect on blood flow.
MATERIALS AND METHODS: This is a single-center investigator-initiated registry on consecutive patients treated for sCAD. In the Borgess classification, type I dissections have intact intima and type II dissections have an intimal tear.
RESULTS: Forty-four patients and 52 dissected arteries were found. Forty-nine of 52 dissections (93%) were treated with dual anti-platelet therapy. Twenty-one of 52 dissections were type I; 31 were type II. Type I dissections were more likely to present with ischemic symptoms [stroke, transient ischemic attack (TIA)] (p = 0.001). More type I dissections occurred in the vertebral artery, while more type II dissections occurred in the internal carotid artery (p < 0.001). Follow-up averaged 18.1 months (range: 3-108 months) with no recurrent ischemic events (stroke, TIA), deaths, or hemorrhage. Forty-six vessels had 6 month follow-up on medical treatment; 19/46 (41%) healed. Type I dissections were more likely to heal than type II (p < 0.001).
CONCLUSION: The two dissection types in the Borgess classification appear to relate to clinical presentation and rate of healing, making the classification useful in clinical management. Dual anti-platelet therapy for sCAD seems to have a very low risk of subsequent stroke; however, a large prospective study is needed to investigate the best treatment.

PMID 24062720  Front Neurol. 2013;4:133. doi: 10.3389/fneur.2013.00133・・・
著者: Christopher Traenka, Daphne Dougoud, Barbara Goeggel Simonetti, Tiina M Metso, Stéphanie Debette, Alessandro Pezzini, Manja Kloss, Caspar Grond-Ginsbach, Jennifer J Majersik, Bradford B Worrall, Didier Leys, Ralf Baumgartner, Valeria Caso, Yannick Béjot, Annette Compter, Peggy Reiner, Vincent Thijs, Andrew M Southerland, Anna Bersano, Tobias Brandt, Henrik Gensicke, Emmanuel Touzé, Juan J Martin, Hugues Chabriat, Turgut Tatlisumak, Philippe Lyrer, Marcel Arnold, Stefan T Engelter, CADISP-Plus Study Group
雑誌名: Neurology. 2017 Apr 4;88(14):1313-1320. doi: 10.1212/WNL.0000000000003788. Epub 2017 Mar 3.
Abstract/Text OBJECTIVE: In a cohort of patients diagnosed with cervical artery dissection (CeAD), to determine the proportion of patients aged ≥60 years and compare the frequency of characteristics (presenting symptoms, risk factors, and outcome) in patients aged <60 vs ≥60 years.
METHODS: We combined data from 3 large cohorts of consecutive patients diagnosed with CeAD (i.e., Cervical Artery Dissection and Ischemic Stroke Patients-Plus consortium). We dichotomized cases into 2 groups, age ≥60 and <60 years, and compared clinical characteristics, risk factors, vascular features, and 3-month outcome between the groups. First, we performed a combined analysis of pooled individual patient data. Secondary analyses were done within each cohort and across cohorts. Crude and adjusted odds ratios (OR [95% confidence interval]) were calculated.
RESULTS: Among 2,391 patients diagnosed with CeAD, we identified 177 patients (7.4%) aged ≥60 years. In this age group, cervical pain (ORadjusted 0.47 [0.33-0.66]), headache (ORadjusted 0.58 [0.42-0.79]), mechanical trigger events (ORadjusted 0.53 [0.36-0.77]), and migraine (ORadjusted 0.58 [0.39-0.85]) were less frequent than in younger patients. In turn, hypercholesterolemia (ORadjusted 1.52 [1.1-2.10]) and hypertension (ORadjusted 3.08 [2.25-4.22]) were more frequent in older patients. Key differences between age groups were confirmed in secondary analyses. In multivariable, adjusted analyses, favorable outcome (i.e., modified Rankin Scale score 0-2) was less frequent in the older age group (ORadjusted 0.45 [0.25, 0.83]).
CONCLUSION: In our study population of patients diagnosed with CeAD, 1 in 14 was aged ≥60 years. In these patients, pain and mechanical triggers might be missing, rendering the diagnosis more challenging and increasing the risk of missed CeAD diagnosis in older patients.

© 2017 American Academy of Neurology.
PMID 28258079  Neurology. 2017 Apr 4;88(14):1313-1320. doi: 10.1212/WN・・・
著者: Stéphanie Debette, Tiina Metso, Alessandro Pezzini, Shérine Abboud, Antti Metso, Didier Leys, Anna Bersano, Fabien Louillet, Valeria Caso, Chantal Lamy, Elisabeth Medeiros, Yves Samson, Caspar Grond-Ginsbach, Stefan T Engelter, Vincent Thijs, Simone Beretta, Yannick Béjot, Maria Sessa, Maria Lorenza Muiesan, Philippe Amouyel, Maurizio Castellano, Dominique Arveiler, Turgut Tatlisumak, Jean Dallongeville, Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) Group
雑誌名: Circulation. 2011 Apr 12;123(14):1537-44. doi: 10.1161/CIRCULATIONAHA.110.000125. Epub 2011 Mar 28.
Abstract/Text BACKGROUND: Little is known about the risk factors for cervical artery dissection (CEAD), a major cause of ischemic stroke (IS) in young adults. Hypertension, diabetes mellitus, smoking, hypercholesterolemia, and obesity are important risk factors for IS. However, their specific role in CEAD is poorly investigated. Our aim was to compare the prevalence of vascular risk factors in CEAD patients versus referents and patients who suffered an IS of a cause other than CEAD (non-CEAD IS) in the multicenter Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) study.
METHODS AND RESULTS: The study sample comprised 690 CEAD patients (mean age, 44.2 ± 9.9 years; 43.9% women), 556 patients with a non-CEAD IS (44.7 ± 10.5 years; 39.9% women), and 1170 referents (45.9 ± 8.1 years; 44.1% women). We compared the prevalence of hypertension, diabetes mellitus, hypercholesterolemia, smoking, and obesity (body mass index ≥ 30 kg/m²) or overweightness (body mass index ≥ 25 kg/m² and <30 kg/m²) between the 3 groups using a multinomial logistic regression adjusted for country of inclusion, age, and gender. Compared with referents, CEAD patients had a lower prevalence of hypercholesterolemia (odds ratio 0.55; 95% confidence interval, 0.42 to 0.71; P<0.0001), obesity (odds ratio 0.37; 95% confidence interval, 0.26 to 0.52; P<0.0001), and overweightness (odds ratio 0.70; 95% confidence interval, 0.57 to 0.88; P=0.002) but were more frequently hypertensive (odds ratio 1.67; 95% confidence interval, 1.32 to 2.1; P<0.0001). All vascular risk factors were less frequent in CEAD patients compared with young patients with a non-CEAD IS. The latter were more frequently hypertensive, diabetic, and current smokers compared with referents.
CONCLUSION: These results, from the largest series to date, suggest that hypertension, although less prevalent than in patients with a non-CEAD IS, could be a risk factor of CEAD, whereas hypercholesterolemia, obesity, and overweightness are inversely associated with CEAD.

PMID 21444882  Circulation. 2011 Apr 12;123(14):1537-44. doi: 10.1161/・・・
著者: Lukas Mayer, Christian Boehme, Thomas Toell, Benjamin Dejakum, Johann Willeit, Christoph Schmidauer, Klaus Berek, Christian Siedentopf, Elke Ruth Gizewski, Gudrun Ratzinger, Stefan Kiechl, Michael Knoflach
雑誌名: J Stroke. 2019 Jan;21(1):112-115. doi: 10.5853/jos.2018.03055. Epub 2019 Jan 31.
Abstract/Text
PMID 30732447  J Stroke. 2019 Jan;21(1):112-115. doi: 10.5853/jos.2018・・・
著者: Philippe A Lyrer, Tobias Brandt, Tiina M Metso, Antti J Metso, Manja Kloss, Stephanie Debette, Didier Leys, Valeria Caso, Alessandro Pezzini, Leo H Bonati, Vincent Thijs, Anna Bersano, Emmanuel Touzé, Henrik Gensicke, Juan J Martin, Christoph Lichy, Turgut Tatlisumak, Stefan T Engelter, Caspar Grond-Ginsbach, Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) Study Group
雑誌名: Neurology. 2014 May 6;82(18):1653-9. doi: 10.1212/WNL.0000000000000381. Epub 2014 Apr 11.
Abstract/Text OBJECTIVE: To study the prognostic importance of Horner syndrome (HS) in patients with internal carotid artery dissection (ICAD) or vertebral artery dissection (VAD).
METHODS: In this observational study, characteristics and outcome of patients with ICAD or VAD from the CADISP (Cervical Artery Dissection and Ischemic Stroke Patients) database were analyzed. The presence of HS was systematically assessed using a standardized questionnaire. Patients with HS (HS+) were compared with HS- patients. Crude odds ratios (ORs) with 95% confidence intervals and ORs adjusted for age, sex, center, arterial occlusion, bilateral dissection, stroke severity, and type of antithrombotic treatment were calculated.
RESULTS: We analyzed 765 patients (n = 496 with ICAD, n = 269 with VAD, n = 303 prospective, n = 462 retrospective). HS was present in 191 (38.5%) of the patients with ICAD and 36 (13.4%) of the patients with VAD (p < 0.001). HS+ ICAD patients presented less often with stroke or TIA (p < 0.001), less often had bilateral (p = 0.019) or occlusive (p = 0.001) dissections, and had fewer severe strokes (p = 0.041) than HS- ICAD patients. HS+ ICAD patients had a better functional 3-month outcome than those without HS (ORcrude = 4.0 [2.4-6.7]), and also after adjustment for outcome-relevant covariates (ORadjusted = 2.0 [1.1-4.0]). HS+ ICAD patients were less likely to have new strokes than HS- ICAD patients (p = 0.039). HS+ VAD patients more often had vessel occlusion (p = 0.014) than HS- patients but did not differ in any of the other aforementioned variables.
CONCLUSION: In patients with ICAD, HS is an easily assessable marker that might indicate a more benign clinical course. HS had no prognostic meaning in patients with VAD.

PMID 24727317  Neurology. 2014 May 6;82(18):1653-9. doi: 10.1212/WNL.0・・・
著者: Ayumi Kato, Yuki Shinohara, Eijiro Yamashita, Shinya Fujii, Fuminori Miyoshi, Keita Kuya, Toshihide Ogawa
雑誌名: Neuroradiology. 2015 Sep;57(9):909-15. doi: 10.1007/s00234-015-1549-x. Epub 2015 Jun 13.
Abstract/Text INTRODUCTION: Acute intramural hematoma resulting from cerebral artery dissection is usually visualized as a region of intermediate signal intensity on T1-weighted images (WI). This often causes problems with distinguishing acute atheromatous lesions from surrounding parenchyma and dissection. The present study aimed to determine whether or not R2* maps generated by the iterative decomposition of water and fat with echo asymmetry and least-squares estimation quantitation sequence (IDEAL IQ) can distinguish cerebral artery dissection more effectively than three-dimensional variable refocusing flip angle TSE T1WI (T1-CUBE) and T2*WI.
METHODS: We reviewed data from nine patients with arterial dissection who were assessed by MR images including R2* maps, T2*WI, T1-CUBE, and 3D time-of-flight (TOF)-MRA. We visually assessed intramural hematomas in each patient as positive (clearly visible susceptibility effect reflecting intramural hematoma as hyperintensity on R2* map and hypointensity on T2*WI), negative (absent intramural hematoma), equivocal (difficult to distinguish between intramural hematoma and other paramagnetic substances such as veins, vessel wall calcification, or hemorrhage) and not evaluable (difficult to determine intramural hematoma due to susceptibility artifacts arising from skull base).
RESULTS: Eight of nine patients were assessed during the acute phase. Lesions in all eight patients were positive for intramural hematoma corresponding to dissection sites on R2* maps, while two lesions were positive on T2*WI and three lesions showed high-intensity on T1-CUBE reflected intramural hematoma during the acute phase.
CONCLUSION: R2* maps generated using IDEAL IQ can detect acute intramural hematoma associated with cerebral artery dissection more effectively than T2*WI and earlier than T1-CUBE.

PMID 26070299  Neuroradiology. 2015 Sep;57(9):909-15. doi: 10.1007/s00・・・
著者: Rebecca F Gottesman, Priti Sharma, Karen A Robinson, Martinson Arnan, Megan Tsui, Ali Saber-Tehrani, David E Newman-Toker
雑誌名: Neurologist. 2012 Sep;18(5):255-60. doi: 10.1097/NRL.0b013e3182675511.
Abstract/Text BACKGROUND: Vertebral artery dissection (VAD) is an important cause of stroke in the young. VAD can present with a range of imaging findings. We sought to summarize the diagnostic value of various imaging findings in patients with symptomatic VAD.
METHODS: We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality and imaging data were abstracted. Pooled proportions were calculated.
RESULTS: Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. Most studies utilized conventional angiography or magnetic resonance angiography (MRA) to diagnose VAD; computed tomographic angiography (CTA) and Doppler ultrasonography were described less frequently. Imaging findings reported were vertebral artery stenosis (51%), string and pearls (48%), arterial dilation (37%), arterial occlusion (36%), and pseudoaneurysm, double lumen, and intimal flap (22% each). In cases where conventional angiography was the reference standard, CTA was more sensitive (100%) than either MRA (77%) or Doppler ultrasonography (71%) (P=0.001).
CONCLUSIONS: Imaging findings vary widely in patients with VAD, with no single radiographic sign present in the majority of VAD patients. Nonspecific radiographic signs predominate. CTA probably has greater sensitivity for dissection than MRA or ultrasound relative to conventional angiography. Higher quality studies on imaging techniques and radiographic criteria in subjects with VAD are needed. Future studies should compare imaging techniques in well-defined, undifferentiated populations of clinical VAD suspects.

PMID 22931729  Neurologist. 2012 Sep;18(5):255-60. doi: 10.1097/NRL.0b・・・
著者: Antonio Arauz, Juan Manuel Márquez, Carol Artigas, Jorge Balderrama, Hector Orrego
雑誌名: Stroke. 2010 Apr;41(4):717-21. doi: 10.1161/STROKEAHA.109.568790. Epub 2010 Feb 11.
Abstract/Text BACKGROUND AND PURPOSE: We investigated the predictors and time course for recanalization after vertebral artery dissection.
METHODS: We prospectively studied 61 consecutive patients with confirmed diagnoses of vertebral artery dissection without intracerebral hemorrhage. Neuroimaging and clinical follow-up were performed at presentation and at 3, 6, and 12 months.
RESULTS: We included 61 patients with confirmed vertebral artery dissection; 19 were evaluated and followed up with conventional angiography, 24 with MR angiography, and 18 with CT angiography. Fifty-one patients had a stenotic dissection, 7 had an occlusive dissection, one had a double-lumen image, and 2 had a pseudoaneurysm. The estimated rate of complete recanalization after vertebral artery dissection was 45.9% at 3 months, 62.3% at 6 months, and 63.9% at 12 months. We found no association between outcome and complete or partial recanalization nor did we find any factors associated with recanalization.
CONCLUSIONS: These results suggest that recanalization of vertebral artery dissection occurs mainly within the first 6 months after the onset of symptoms regardless of the location or pattern of the dissection.

PMID 20150549  Stroke. 2010 Apr;41(4):717-21. doi: 10.1161/STROKEAHA.1・・・
著者: Hideaki Ono, Hirofumi Nakatomi, Kazuo Tsutsumi, Tomohiro Inoue, Akira Teraoka, Yuhei Yoshimoto, Takafumi Ide, Chifumi Kitanaka, Keisuke Ueki, Hideaki Imai, Nobuhito Saito
雑誌名: Stroke. 2013 Jan;44(1):126-31. doi: 10.1161/STROKEAHA.112.670745. Epub 2012 Nov 29.
Abstract/Text BACKGROUND AND PURPOSE: The frequency and pattern of symptomatic recurrence of spontaneous intracranial arterial dissection (IAD) are unknown.
METHODS: A follow-up study of 143 patients (85 men, 58 women; mean age, 50.7 [7-83] years) with spontaneous IADs at The University of Tokyo and affiliated hospitals from 1980 to 2000 was conducted. Tissue samples of IAD vessels obtained from 13 patients at various intervals from onset were also examined histologically.
RESULTS: With a mean follow-up of 8.2 years, symptomatic recurrence occurred in 47 patients (33%). Of 37 cases initially presenting with hemorrhage, 35 developed hemorrhagic recurrence with a mean interval of 4.8 days, and 2 developed nonhemorrhagic recurrences after 21 and 85 months, respectively. Of 10 patients initially presenting with nonhemorrhagic symptoms, 1 developed hemorrhagic recurrence 4 days later, and 9 developed nonhemorrhagic recurrences with a mean interval of 8.6 months. Histopathologically, the affected vessels in the acute stage of hemorrhage (days 0-6) demonstrated insufficient granulation formation within the pseudolumen, followed by marked intimal thickening around the pseudolumen and recanalizing vessel formation in the late stage (>day 30). In the late stage of brain ischemia, subintimal and subadventitial hemorrhage accompanied with intimal thickening was observed.
CONCLUSIONS: These data indicate that IAD is a disease carrying a relatively high risk of symptomatic recurrence, apparently occurring in 3 phases and patterns: early hemorrhagic recurrence, late nonhemorrhagic recurrence, and chronic fusiform aneurysm transformation. Knowledge of this triphasic recurrence and corresponding histopathological characteristics help determine the treatment and follow-up strategy for IAD patients.

PMID 23204054  Stroke. 2013 Jan;44(1):126-31. doi: 10.1161/STROKEAHA.1・・・
著者: T Mizutani, T Aruga, T Kirino, Y Miki, I Saito, T Tsuchida
雑誌名: Neurosurgery. 1995 May;36(5):905-11; discussion 912-3.
Abstract/Text The clinical characteristics of vertebrobasilar dissecting aneurysms occurring with subarachnoid hemorrhage (SAH) were reviewed in 42 patients, with particular focus on the time, incidence, and outcome in association with subsequent rupture. Twenty-nine patients underwent 31 surgical procedures, and the remaining 13 patients were managed without surgery. Surgical details included 19 proximal vertebral artery obliterations (including 1 case of endovascular surgery using balloon occlusion), 9 trappings, 1 wrapping, 1 bleb clipping, and 1 bleb clipping combined with wrapping. Surprisingly, subsequent rupture occurred in 30 (71.4%) of the 42 patients. Excluding one patient with postoperative rupture, 29 patients suffered a subsequent rupture in the unsecured stage. Of these 29 patients, 19 were operated on after the subsequent rupture and 10 were not operated on because of deteriorated clinical condition (9 patients) or anatomic considerations (1 patient). Of the 30 patients that suffered a subsequent rupture, 14 died. Twelve of the deaths were directly related to the second episode of rupture. Of the 12 patients who did not suffer a subsequent rupture, 10 underwent operations and there were no operative deaths. Only one patient died as the result of the initial critical SAH. The mortality (46.7%) of the patients with subsequent rupture was significantly higher (P < 0.05) than that (8.3%) of the patients without subsequent rupture. Seventeen (56.7%) of the 30 subsequent ruptures occurred within 24 hours after the first SAH, and 24 (80%) occurred within the first week. Six (66.7%) of the 9 patients operated on within 24 hours after the first SAH and 11 (68.8%) of the 16 patients operated on within a week suffered preoperative subsequent ruptures.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 7791980  Neurosurgery. 1995 May;36(5):905-11; discussion 912-3.
著者: S T Engelter, J Dallongeville, M Kloss, T M Metso, D Leys, T Brandt, Y Samson, V Caso, A Pezzini, M Sessa, S Beretta, S Debette, C Grond-Ginsbach, A J Metso, V Thijs, C Lamy, E Medeiros, J J Martin, A Bersano, T Tatlisumak, E Touzé, P A Lyrer, Cervical Artery Dissection and Ischaemic Stroke Patients-Study Group
雑誌名: Eur J Neurol. 2012 Sep;19(9):1199-206. doi: 10.1111/j.1468-1331.2012.03704.x. Epub 2012 Mar 26.
Abstract/Text OBJECTIVE: To examine whether thrombolysis for stroke attributable to cervical artery dissection (CeAD(Stroke) ) affects outcome and major haemorrhage rates.
METHODS: We used a multicentre CeAD(Stroke) database to compare CeAD(Stroke) patients treated with and without thrombolysis. Main outcome measures were favourable 3-month outcome (modified Rankin Scale 0-2) and 'major haemorrhage' [any intracranial haemorrhage (ICH) and major extracranial haemorrhage]. Adjusted odds ratios [OR (95% confidence intervals)] were calculated on the whole database and on propensity-matched groups.
RESULTS: Among 616 CeAD(Stroke) patients, 68 (11.0%) received thrombolysis; which was used in 55 (81%) intravenously. Thrombolyzed patients had more severe strokes (median NIHSS score 16 vs. 3; P < 0.001) and more often occlusion of the dissected artery (66.2% vs. 39.4%; P < 0.001). After adjustment for stroke severity and vessel occlusion, the likelihood for favourable outcome did not differ between the treatment groups [OR(adjusted) 0.95 (95% CI 0.45-2.00)]. The propensity matching score model showed that the odds to recover favourably were virtually identical for 64 thrombolyzed and 64 non-thrombolyzed-matched CeAD(Stroke) patients [OR 1.00 (0.49-2.00)]. Haemorrhages occurred in 4 (5.9%) thrombolyzed patients, all being asymptomatic ICHs. In the non-thrombolysis group, 3 (0.6%) patients had major haemorrhages [asymptomatic ICH (n = 2) and major extracranial haemorrhage (n = 1)].
CONCLUSION: As thrombolysis was neither independently associated with unfavourable outcome nor with an excess of symptomatic bleedings, our findings suggest thrombolysis should not be withheld in CeAD(Stroke) patients. However, the lack of any trend towards a benefit of thrombolysis may indicate the legitimacy to search for more efficient treatment options including mechanical revascularization strategies.

© 2012 The Author(s). European Journal of Neurology © 2012 EFNS.
PMID 22448957  Eur J Neurol. 2012 Sep;19(9):1199-206. doi: 10.1111/j.1・・・
著者: Stefan T Engelter, Christopher Traenka, Henrik Gensicke, Sabine A Schaedelin, Andreas R Luft, Barbara Goeggel Simonetti, Urs Fischer, Patrik Michel, Gaia Sirimarco, Georg Kägi, Jochen Vehoff, Krassen Nedeltchev, Timo Kahles, Lars Kellert, Sverre Rosenbaum, Regina von Rennenberg, Roman Sztajzel, Stephen L Leib, Simon Jung, Jan Gralla, Nicole Bruni, David Seiffge, Katharina Feil, Alexandros A Polymeris, Levke Steiner, Janne Hamann, Leo H Bonati, Alex Brehm, Gian Marco De Marchis, Nils Peters, Christoph Stippich, Christian H Nolte, Hanne Christensen, Susanne Wegener, Marios-Nikos Psychogios, Marcel Arnold, Philippe Lyrer, TREAT-CAD investigators
雑誌名: Lancet Neurol. 2021 May;20(5):341-350. doi: 10.1016/S1474-4422(21)00044-2. Epub 2021 Mar 23.
Abstract/Text BACKGROUND: Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines-based on available evidence from mostly observational studies-suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection.
METHODS: We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0-3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460.
FINDINGS: Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI -4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group.
INTERPRETATION: Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection.
FUNDING: Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.

Copyright © 2021 Elsevier Ltd. All rights reserved.
PMID 33765420  Lancet Neurol. 2021 May;20(5):341-350. doi: 10.1016/S14・・・
著者: Dimitrios Georgiadis, Ralf W Baumgartner
雑誌名: Front Neurol Neurosci. 2005;20:140-6. doi: 10.1159/000088158.
Abstract/Text Safety and efficacy of intravenous (IVT) and intra-arterial thrombolysis (LIT) in patients with acute stroke due to spontaneous cervical artery dissection were not assessed in any controlled randomized trial. Data on IVT are derived from 4 studies with a total of 50 patients aged 48 +/- 10 years with internal carotid artery dissection. No new or worsened local signs on the side of dissection, such as Horner syndrome and cranial nerve palsy, and no rupture of the cervical carotid artery or subarachnoid hemorrhage (SAH) were observed. One patient dramatically deteriorated during IVT, probably due to arterial embolism arising from a thrombus dislocated from the dissection site. Mortality was 8%, while 40% of patients had a good outcome defined by a modified Rankin scale (mRS) score of 0-2 points. Up to date, a total of 15 patients with carotid or vertebral artery dissection treated with LIT were described. No intracranial hemorrhage, rupture of the dissected vessel, SAH, or recurrent arterial embolism were reported in any patient. Mortality was 13%, while good outcome (mRS score 0-2 points) was observed in 60% of patients, which is comparable to the results in the active group of the PROACT II study. Currently available data thus suggest that IVT should not be withheld in patients with acute stroke due to cervical artery dissection. LIT treatment can only be based on individual decision-making.

PMID 17290119  Front Neurol Neurosci. 2005;20:140-6. doi: 10.1159/0000・・・
著者: Tiina M Metso, Antti J Metso, Johanna Helenius, Elena Haapaniemi, Oili Salonen, Matti Porras, Juha Hernesniemi, Markku Kaste, Turgut Tatlisumak
雑誌名: Stroke. 2007 Jun;38(6):1837-42. doi: 10.1161/STROKEAHA.106.479501. Epub 2007 May 10.
Abstract/Text BACKGROUND AND PURPOSE: To characterize different forms of intracranial artery dissections (IADs), and to test the assumption that IADs are frequently associated with subarachnoid hemorrhage (SAH) and poor outcome, and that anticoagulant therapy is contraindicated in these patients.
METHODS: We studied 81 consecutive non-SAH IAD patients and 22 IAD patients with SAH, diagnosed between 1994 and 2004 and 1998 and 2004, respectively, and treated the former patients immediately with heparin, followed with at least 3 months of warfarin. Outcomes were recorded at 3 months.
RESULTS: Approximately one-third of all cervicocephalic artery dissections were identifiably either completely located intracranially or extended into the intracranial space. At 3 months, 64 of the 81 non-SAH patients (79%) had a favorable outcome (modified Rankin Scale, 0 to 2); 1 patient died of brain infarction in the acute stage. Only 1 aneurysm developed during follow-up in the non-SAH group, and no intracranial bleeding was observed during anticoagulant treatment. Those presenting with SAH formed approximately 25% of all IADs, and 21 cases out of 22 (95%) were associated with ruptured fusiform dissecting aneurysm. This latter group displayed significantly worse outcomes: 7 died, and only 7 had modified Rankin Scale 0 to 2 at 3 months.
CONCLUSIONS: Our results provide important information for clinical practice. IADs appear to polarize into 2 groups: (1) nonaneurysmatic IADs presenting without SAH that are associated with favorable outcomes and safe anticoagulant therapy; and (2) aneurysmatic IADs, characterized by SAH and poorer prognosis. Literature on IADs may have been biased toward group 2.

PMID 17495218  Stroke. 2007 Jun;38(6):1837-42. doi: 10.1161/STROKEAHA.・・・
著者: Philippe Lyrer, Stefan Engelter
雑誌名: Cochrane Database Syst Rev. 2010 Oct 6;(10):CD000255. doi: 10.1002/14651858.CD000255.pub2. Epub 2010 Oct 6.
Abstract/Text BACKGROUND: Extracranial internal carotid artery dissection (eICAD) is a leading cause of stroke in younger patients.
OBJECTIVES: 1. To determine whether, in patients with eICAD, treatment with anticoagulants, antiplatelet agents or control was associated with a better functional outcome. 2. To compare, among patients treated with either anticoagulants or antiplatelet agents, the risk of ischaemic strokes and major bleeding episodes.
SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched 3 October 2009). In addition, we performed comprehensive searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to November 2009) and EMBASE (January 1980 to November 2009), checked all relevant papers for additional eligible studies and contacted authors and researchers in the field.
SELECTION CRITERIA: Randomised controlled trials, controlled clinical trials and non-randomised studies (if they reported on outcome stratified by antithrombotic treatment and included at least four patients) of anticoagulants or antiplatelet agents for the treatment of extracranial internal carotid artery dissection. Two review authors independently extracted data.
DATA COLLECTION AND ANALYSIS: Primary outcomes were death (all causes) and death or disability. Secondary outcomes were ischaemic stroke, symptomatic intracranial haemorrhage, and major extracranial haemorrhage during the reported follow-up period. The first choice treatment was taken for analyses.
MAIN RESULTS: We did not find any completed randomised trials. Comparing antiplatelets with anticoagulants across 36 observational studies (1285 patients), there were no significant differences in the odds of death (Peto odds ratio (Peto OR) 2.02, 95% CI 0.62 to 6.60), or the occurrence of ischaemic stroke (OR 0.63, 95% CI 0.21 to 1.86) (34 studies, 1262 patients). For the outcome of death or disability, there was a non-significant trend in favour of anticoagulants (OR 1.77, 95% CI 0.98 to 3.22; P = 0.06) (26 studies, 463 patients). Symptomatic intracranial haemorrhages (5/627; 0.8%) and major extracranial haemorrhages (7/425; 1.6%) occurred only in the anticoagulation group; however, for both these outcomes, the estimates were imprecise and indicated no significant difference between the two treatment modalities.
AUTHORS' CONCLUSIONS: There were no randomised trials comparing either anticoagulants or antiplatelet drugs with control, thus there is no evidence to support their routine use for the treatment of extracranial internal carotid artery dissection. There were also no randomised trials that directly compared anticoagulants with antiplatelet drugs and the reported non-randomised studies did not show any evidence of a significant difference between the two.

PMID 20927720  Cochrane Database Syst Rev. 2010 Oct 6;(10):CD000255. d・・・
著者: CADISS trial investigators, Hugh S Markus, Elizabeth Hayter, Christopher Levi, Adina Feldman, Graham Venables, John Norris
雑誌名: Lancet Neurol. 2015 Apr;14(4):361-7. doi: 10.1016/S1474-4422(15)70018-9. Epub 2015 Feb 12.
Abstract/Text BACKGROUND: Extracranial carotid and vertebral artery dissection is an important cause of stroke, especially in young people. In some observational studies it has been associated with a high risk of recurrent stroke. Both antiplatelet drugs and anticoagulant drugs are used to reduce risk of stroke but whether one treatment strategy is more effective than the other is unknown. We compared their efficacy in the Cervical Artery Dissection in Stroke Study (CADISS), with the additional aim of establishing the true risk of recurrent stroke.
METHODS: We did this randomised trial at hospitals with specialised stroke or neurology services (39 in the UK and seven in Australia). We included patients with extracranial carotid and vertebral dissection with onset of symptoms within the past 7 days. Patients were randomly assigned (1:1) by an automated telephone randomisation service to receive antiplatelet drugs or anticoagulant drugs (specific treatment decided by the local clinician) for 3 months. Patients and clinicians were not masked to allocation, but investigators assessing endpoints were. The primary endpoint was ipsilateral stroke or death in the intention-to-treat population. The trial was registered with EUDract (2006-002827-18) and ISRN (CTN44555237).
FINDINGS: We enrolled 250 participants (118 carotid, 132 vertebral). Mean time to randomisation was 3·65 days (SD 1·91). The major presenting symptoms were stroke or transient ischaemic attack (n=224) and local symptoms (headache, neck pain, or Horner's syndrome; n=26). 126 participants were assigned to antiplatelet treatment versus 124 to anticoagulant treatment. Overall, four (2%) of 250 patients had stroke recurrence (all ipsilateral). Stroke or death occurred in three (2%) of 126 patients versus one (1%) of 124 (odds ratio [OR] 0·335, 95% CI 0·006-4·233; p=0·63). There were no deaths, but one major bleeding (subarachnoid haemorrhage) in the anticoagulant group. Central review of imaging failed to confirm dissection in 52 patients. Preplanned per-protocol analysis excluding these patients showed stroke or death in three (3%) of 101 patients in the antiplatelet group versus one (1%) of 96 patients in the anticoagulant group (OR 0·346, 95% CI 0·006-4·390; p=0·66).
INTERPRETATION: We found no difference in efficacy of antiplatelet and anticoagulant drugs at preventing stroke and death in patients with symptomatic carotid and vertebral artery dissection but stroke was rare in both groups, and much rarer than reported in some observational studies. Diagnosis of dissection was not confirmed after review in many cases, suggesting that radiographic criteria are not always correctly applied in routine clinical practice.
FUNDING: Stroke Association.

Copyright © 2015 Markus et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.
PMID 25684164  Lancet Neurol. 2015 Apr;14(4):361-7. doi: 10.1016/S1474・・・

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