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Tom 13, Nr 5 (2019)
Wybrane problemy kliniczne
Opublikowany online: 2019-09-29

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Eksport do Mediów Społecznościowych

Eksport do Mediów Społecznościowych

Rozwarstwienie tętnic domózgowych — rzadka przyczyna udaru mózgu

Michał Horyd1, Grzegorz Kozera21
Forum Medycyny Rodzinnej 2019;13(5):207-222.

Streszczenie

Postęp metod neuroobrazowania istotnie wpływa na poprawę jakości diagnostyki i leczenia
chorób naczyniowych ośrodkowego układu ner wowego i pozwala na skuteczniejsze
rozpoznawanie tak zwanych „rzadkich” przyczyn udaru mózgu, takich jak rozwarstwienie
tętnic domózgowych. W pracy przedstawiono czynniki ryzyka, przyczyny, objawy, metody
diagnostyczne oraz zasady leczenia rozwarstwienia tętnic domózgowych z uwzględnieniem
istotnej roli badania ultrasonograficznego w diagnostyce wczesnych etapów choroby, ocenie
wydolności krążenia obocznego, i kontroli efektów leczenia. Podkreślono konieczność
indywidualizacji metod leczenia wobec braku jasnych wytycznych dla postępowania terapeutycznego
opartych na wynikach wieloośrodkowych badań.

Słowa kluczowe: rozwarstwieniekrwiak śródściennytętnice domózgoweudar mózguultrasonografia

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Referencje

  1. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001; 344(12): 898–906.
    CrossRefPubMed
  2. Debetle S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009; 8(7): 668–678.
  3. Lefebvre P, Cornez N, Quintart C, et al. [Spontaneous dissection of the internal carotid artery: apropos of a case]. Rev Med Brux. 1996; 17(5): 342–345.
    PubMed
  4. Provenzale JM. Dissection of the internal carotid and vertebral arteries: imaging features. AJR Am J Roentgenol. 1995; 165(5): 1099–1104.
    CrossRefPubMed
  5. Lee VH, Brown RD, Mandrekar JN, et al. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006; 67(10): 1809–1812.
    CrossRefPubMed
  6. Schievink W, Roiter V. Epidemiology of cervical artery dissection. Front Neurol Neurosci. 2005; 20: 12–15.
    CrossRefPubMed
  7. Zach V, Zhovtis S, Kirchoff-Torres KF, et al. Common carotid artery dissection: a case report and review of the literature. J Stroke Cerebrovasc Dis. 2012; 21(1): 52–60.
    CrossRefPubMed
  8. Khimenko LP, Esham HR, Ahmed W. Spontaneous internal carotid artery dissection. South Med J. 2000; 93(10): 1011–1016.
    PubMed
  9. Bogousslavsky J, Regli F. Ischemic stroke in adults younger than 30 years of age. Cause and prognosis. Arch Neurol. 1987; 44(5): 479–482.
    CrossRefPubMed
  10. Kidwell CS, Burgess RE. Dissection syndromes. eMedicine, 25 May 2010.
  11. Chaves C, Estol C, Esnaola MM, et al. Spontaneous intracranial internal carotid artery dissection: report of 10 patients. Arch Neurol. 2002; 59(6): 977–981.
    CrossRefPubMed
  12. Wessels T, Mosso M, Krings T, et al. Extracranial and intracranial vertebral artery dissection: long-term clinical and duplex sonographic follow-up. J Clin Ultrasound. 2008; 36(8): 472–479.
    CrossRefPubMed
  13. Völker W, Dittrich R, Grewe S, et al. The outer arterial wall layers are primarily affected in spontaneous cervical artery dissection. Neurology. 2011; 76(17): 1463–1471.
    CrossRefPubMed
  14. Sasaki O, Ogawa H, Koike T, et al. A clinicopathological study of dissecting aneurysms of the intracranial vertebral artery. J Neurosurg. 1991; 75(6): 874–882.
    CrossRefPubMed
  15. Beena NV, Kishore MS, Mahale A, et al. Pseudoaneurysm of internal carotid artery. Indian J Pediatr. 2007; 74(3): 307–309.
    CrossRefPubMed
  16. Mokri B, Pieogras DB, Sundt TM. Extracranial internal carotid artery aneurysms. Mayo Clin Proc. 1982; 57(310): 321.
  17. Baracchini C, Tonello S, Vitaliani R, et al. Vasomotion in multiple spontaneous cervical artery dissections. Stroke. 2008; 39(4): 1148–1151.
    CrossRefPubMed
  18. Baumgartner RW, Lienhardt B, Mosso M, et al. Spontaneous and endothelial-independent vasodilation are impaired in patients with spontaneous carotid dissection: a case-control study. Stroke. 2007; 38(2): 405–406.
    CrossRefPubMed
  19. de Bray JM, Baumgartner RW. History of spontaneous dissection of the cervical carotid artery. Arch Neurol. 2005; 62(7): 1168–1170.
    CrossRefPubMed
  20. Guthrie W, Maclean H. Dissecting aneurysms of arteries other than the aorta. J Pathol. 1972; 108(3): 219–235.
    CrossRefPubMed
  21. Nedeltchev K, Bickel S, Arnold M, et al. R2-recanalization of spontaneous carotid artery dissection. Stroke. 2009; 40(2): 499–504.
    CrossRefPubMed
  22. Pozzati E, Giuliani G, Poppi M, et al. Blunt traumatic carotid dissection with delayed symptoms. Stroke. 1989; 20(3): 412–416.
    CrossRefPubMed
  23. Schlemm L, Nolte CH, Engelter ST, et al. Cervical artery dissection after sports - An analytical evaluation of 190 published cases. Eur Stroke J. 2017; 2(4): 335–345.
    CrossRefPubMed
  24. Grau AJ, Brandt T, Buggle F, et al. Association of cervical artery dissection with recent infection. Arch Neurol. 1999; 56(7): 851–856.
    CrossRefPubMed
  25. Paciaroni M, Georgiadis D, Arnold M, et al. Seasonal variability in spontaneous cervical artery dissection. J Neurol Neurosurg Psychiatry. 2006; 77(5): 677–679.
    CrossRefPubMed
  26. Hassan AE, Zacharatos H, Mohammad YM, et al. Comparison of single versus multiple spontaneous extra- and/or intracranial arterial dissection. J Stroke Cerebrovasc Dis. 2013; 22(1): 42–48.
    CrossRefPubMed
  27. Béjot Y, Aboa-Eboulé C, Debette S, et al. CADISP Group. Characteristics and outcomes of patients with multiple cervical artery dissection. Stroke. 2014; 45(1): 37–41.
    CrossRefPubMed
  28. de Bray JM, Marc G, Pautot V, et al. Fibromuscular dysplasia may herald symptomatic recurrence of cervical artery dissection. Cerebrovasc Dis. 2007; 23(5-6): 448–452.
    CrossRefPubMed
  29. Dittrich R, Nassenstein I, Ringelstein EB, et al. A distinctive case of fibromuscular dysplasia. Neurol Res. 2007; 29(6): 551–552.
    CrossRefPubMed
  30. Dittrich R, Nassenstein I, Bachmann R, et al. Polyarterial clustered recurrence of cervical artery dissection seems to be the rule. Neurology. 2007; 69(2): 180–186.
    CrossRefPubMed
  31. Blunt SB, Galton C. Cervical carotid or vertebral artery dissection. BMJ. 1997; 314(7076): 243.
    CrossRefPubMed
  32. Rubinstein SM, Peerdeman SM, van Tulder MW, et al. A systematic review of the risk factors for cervical artery dissection. Stroke. 2005; 36(7): 1575–1580.
    CrossRefPubMed
  33. Cronenwett JL, Johnston W. Rutherford’s vascular surgery. 2-Volume Set, Expert Consult, 7th Ed. Elsevier, Philadelphia .
  34. Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology. 1995; 45(8): 1517–1522.
    CrossRefPubMed
  35. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ. 2000; 163(1): 38–40.
    PubMed
  36. 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.
    CrossRefPubMed
  37. Biousse V, Touboul PJ, D’Anglejan-Chatillon J, et al. Ophthalmologic manifestions of internal carotid artery dissection. American Journal of Ophthalmology. 1998; 126(4): 565–577.
    CrossRef
  38. Guidetti D, Pisanello A, Giovanardi F, et al. Spontaneous carotid dissection presenting lower cranial nerve palsies. Journal of the Neurological Sciences. 2001; 184(2): 203–207.
    CrossRef
  39. Walker S, McCarron MO, Flynn PA, et al. Left internal carotid artery dissection presenting with headache, Collet-Sicard syndrome and sustained hypertension. Eur J Neurol. 2003; 10(6): 731–732.
    PubMed
  40. Misztal M, Kwiatkowska W, Ohly P, et al. Rozwarstwienie tętnicy szyjnej wewnętrznej- symptomatologia, diagnostyka i leczenie. Kardiologia Polska . 2011; 69(9): 958–962.
  41. Hart RG, Easton JD. Dissections. Stroke. 1985; 16(6): 925–927.
    CrossRefPubMed
  42. Baumgartner R, Bogousslavsky J. Clinical manifestations of carotid dissection. Front Neurol Neurosci. 2005; 20: 70–76.
    CrossRefPubMed
  43. Benninger DH, Georgiadis D, Kremer C, et al. Mechanism of ischemic infarct in spontaneous carotid dissection. Stroke. 2004; 35(2): 482–485.
    CrossRefPubMed
  44. Lucas C, Moulin T, Deplanque D, et al. Stroke patterns of internal carotid artery dissection in 40 patients. Stroke. 1998; 29(12): 2646–2648.
    CrossRefPubMed
  45. Oliveira V, Batista P, Soares F, et al. HITS in internal carotid dissections. Cerebrovasc Dis. 2001; 11(4): 330–334.
    CrossRefPubMed
  46. Srinivasan J, Newell DW, Sturzenegger M, et al. Transcranial Doppler in the evaluation of internal carotid artery dissection. Stroke. 1996; 27(7): 1226–1230.
    CrossRefPubMed
  47. Gabriel M, Góźdź T, Zielonka D, et al. Rozwarstwienie tętnicy kręgowej jako rzadka przyczyna niedokrwienia ośrodkowego układu nerwowego. Przegląd lekarski. 2008; 65: 3.
  48. Bartels E, Flügel KA. Evaluation of extracranial vertebral artery dissection with duplex color-flow imaging. Stroke. 1996; 27(2): 290–295.
    CrossRefPubMed
  49. 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.
    CrossRefPubMed
  50. Lovrencic-Huzjan A. New trends in neurosonology and cerebral hemodynamics — an update. In: Bartels E, Bartels s, Poppert H. ed. Perspectives in medicine. 2012: 244–249.
  51. Dittrich R, Ritter M, Ringelstein E. Ultrasound in spontaneous cervical artery dissection. Perspectives in Medicine. 2012; 1(1-12): 250–254.
    CrossRef
  52. Rodallec MH, Marteau V, Gerber S, et al. Craniocervical arterial dissection: spectrum of imaging findings and differential diagnosis. Radiographics. 2008; 28(6): 1711–1728.
    CrossRefPubMed
  53. Nebelsieck J, Sengelhoff C, Nassenstein I, et al. Sensitivity of neurovascular ultrasound for the detection of spontaneous cervical artery dissection. J Clin Neurosci. 2009; 16(1): 79–82.
    CrossRefPubMed
  54. Sturzenegger M, Mattle HP, Rivoir A, et al. Ultrasound findings in carotid artery dissection: analysis of 43 patients. Neurology. 1995; 45(4): 691–698.
    CrossRefPubMed
  55. Arning C. Ultrasonographic criteria for diagnosing a dissection of the internal carotid artery. Ultraschall Med. 2005; 26(1): 24–28.
    CrossRefPubMed
  56. Gobin-Metteil MP, Oppenheim C, Domigo V, et al. Critères diagnostiques en échographie-Doppler des dissections artérielles cervicales à la phase aiguë. Journal de Radiologie. 2006; 87(4): 367–373.
    CrossRef
  57. Steinke W, Rautenberg W, Schwartz A, et al. Noninvasive monitoring of internal carotid artery dissection. Stroke. 1994; 25(5): 998–1005.
    CrossRefPubMed
  58. Benninger DH, Baumgartner RW. Ultrasound diagnosis of cervical artery dissection. Front Neurol Neurosci. 2006; 21: 70–84.
    CrossRefPubMed
  59. Treiman GS, Treiman RL, Foran RF, et al. Spontaneous dissection of the internal carotid artery: a nineteen-year clinical experience. J Vasc Surg. 1996; 24(4): 597–605; discussion 605.
    CrossRefPubMed
  60. Benninger DH, Georgiadis D, Gandjour J, et al. Accuracy of color duplex ultrasound diagnosis of spontaneous carotid dissection causing ischemia. Stroke. 2006; 37(2): 377–381.
    CrossRefPubMed
  61. Alecu C, Fortrat JO, Ducrocq X, et al. Duplex scanning diagnosis of internal carotid artery dissections. A case control study. Cerebrovasc Dis. 2007; 23(5-6): 441–447.
    CrossRefPubMed
  62. Benninger D, Caso V, Baumgartner R. Ultrasound assessment of cervical artery dissection. Front Neurol Neurosci. 2005; 20: 87–101.
    CrossRefPubMed
  63. de Bray JM, Lhoste P, Dubas F, et al. Ultrasonic features of extracranial carotid dissections: 47 cases studied by angiography. J Ultrasound Med. 1994; 13(9): 659–664.
    CrossRefPubMed
  64. Pannone A, Bertoletti GB, Nesi F, et al. Carotid artery dissection. Correlation of different diagnostic techniques. Minerva Cardioangiol. 2000; 48(1-2): 19–27.
    PubMed
  65. 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.
    CrossRefPubMed
  66. Baracchini C. Cervical artery dissection. In: Baracchini C. ed. Manual of neurosonology. Cambridge University Press, Cambridge 2016: 99–110.
  67. Ozdoba C, Sturzenegger M, Schroth G. Internal carotid artery dissection: MR imaging features and clinical-radiologic correlation. Radiology. 1996; 199(1): 191–198.
    CrossRefPubMed
  68. Guillon B, Lévy C, Bousser MG. Internal carotid artery dissection: an update. J Neurol Sci. 1998; 153(2): 146–158.
    CrossRefPubMed
  69. Kirsch E, Kaim A, Engelter S, et al. MR angiography in internal carotid artery dissection: improvement of diagnosis by selective demonstration of the intramural haematoma. Neuroradiology. 1998; 40(11): 704–709.
    CrossRefPubMed
  70. Debette S, Compter A, Labeyrie MA, et al. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol. 2015; 14(6): 640–654.
    CrossRefPubMed
  71. Biffl W. Diagnosis of blunt cerebrovascular injuries. Current Opinion in Critical Care. 2003; 9(6): 530–534.
    CrossRef
  72. Leclerc X, Godefroy O, Salhi A, et al. Helical CT for the diagnosis of extracranial internal carotid artery dissection. Stroke. 1996; 27(3): 461–466.
    CrossRefPubMed
  73. Uchino K, Estrera A, Calleja S, et al. Aortic dissection presenting as an acute ischemic stroke for thrombolysis. J Neuroimaging. 2005; 15(3): 281–283.
    CrossRefPubMed
  74. Niaz A, Steiner T, Caso V, Wahlgren N; for the ESO-KSU session participants. Recommendations from the ESO-Karolinska Stroke Update Conference, Stockholm 13-15 November 2016 European Stroke Journal 0(0) 1-8. European Stroke Organisation 2017 DOI: 10.1177/2396987317699144.
  75. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. American Heart Association Stroke Council and Council on Epidemiology and Prevention. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2016; 47(2): 581–641.
    CrossRefPubMed
  76. Grupa Ekspertów Sekcji Chorób Naczyniowych Polskiego Towarzystwa Neurologicznego. Postępowanie w udarze mózgu Wytyczne Grupy Ekspertów Sekcji Chorób Naczyniowych Polskiego Towarzystwa Neurologicznego. NeurolNeurochir Pol 2012; 46 (supl. 1). 2012.
  77. Członkowska A, Kobayashi A. Postępowanie w udarze mózgu – wytyczne Grupy Ekspertów Sekcji Chorób Naczyniowych Polskiego Towarzystwa Neurologicznego. Aktualizacja 2013: leczenie trombolityczne. Neurologia i Neurochirurgia Polska. 2013; 47(4): 303–309.
    CrossRef
  78. Jauch EC, Saver JL, Adams HP, et al. American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, Council on Clinical Cardiology. 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.
    CrossRefPubMed
  79. Powers WJ, Derdeyn CP, Biller J, et al. American Heart Association Stroke Council. 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.
    CrossRefPubMed
  80. Jensen J, Salottolo K, Frei D, et al. Comprehensive analysis of intra-arterial treatment for acute ischemic stroke due to cervical artery dissection. J Neurointerv Surg. 2017; 9(7): 654–658.
    CrossRefPubMed
  81. Arnold M, Bousser MG, Fahrni G, et al. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke. 2006; 37(10): 2499–2503.
    CrossRefPubMed
  82. Engeller S, Brandt T, Debette S. Antiplatelets versus anti- coagulation in cervical artery dissection. Stroke. 2007; 38: 2605–2611.
  83. Kernan WN, Ovbiagele B, Black HR, et al. American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. 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.
    CrossRefPubMed
  84. Wnuk M, Słowik A. Wczesna profilaktyka wtórna udaru mózgu. In: Udar mózgu na dyżurze. Teramedia Wydawnictwa Medyczne , Poznań 2016: 155–181.
  85. Lyrer P, Engelter S, Lyrer P, et al. Antithrombotic drugs for carotid artery dissection. Cochrane Database Syst Rev. 2000; 35(4): CD000255–614.
    CrossRefPubMed
  86. Markus HS, Hayter E, Levi C, et al. CADISS trial investigators. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015; 14(4): 361–367.
    CrossRefPubMed
  87. Arauz A, Ruiz A, Pacheco G, et al. Aspirin versus anticoagulation in intra- and extracranial vertebral artery dissection. European Journal of Neurology. 2012; 20(1): 167–172.
    CrossRef
  88. 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.
    CrossRefPubMed
  89. Nedeltchev K, Bickel S, Arnold M, et al. R2-recanalization of spontaneous carotid artery dissection. Stroke. 2009; 40(2): 499–504.
    CrossRefPubMed
  90. Caprio FZ, Bernstein RA, Alberts MJ, et al. Efficacy and safety of novel oral anticoagulants in patients with cervical artery dissections. Cerebrovasc Dis. 2014; 38(4): 247–253.
    CrossRefPubMed
  91. Kremer C, Mosso M, Georgiadis D, et al. Carotid dissection with permanent and transient occlusion or severe stenosis: Long-term outcome. Neurology. 2003; 60(2): 271–275.
    CrossRefPubMed
  92. Ono H, Nakatomi H, Tsutsumi K, et al. Symptomatic recurrence of intracranial arterial dissections: follow-up study of 143 consecutive cases and pathological investigation. Stroke. 2013; 44(1): 126–131.
    CrossRefPubMed
  93. Sacco R, Adams R, Albers G, et al. Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack. Stroke. 2006; 37(2): 577–617.
    CrossRef
  94. Biondi A, Katz JM, Vallabh J, et al. Progressive symptomatic carotid dissection treated with multiple stents. Stroke. 2005; 36(9): e80–e82.
    CrossRefPubMed
  95. Lin PH, Bush RL, Lumsden AB. Endovascular treatment for symptomatic carotid artery dissection. J Vasc Surg. 2005; 41(3): 555.
    CrossRefPubMed
  96. Malek AM, Higashida RT, Phatouros CC, et al. Endovascular management of extracranial carotid artery dissection achieved using stent angioplasty. AJNR Am J Neuroradiol. 2000; 21(7): 1280–1292.
    PubMed
  97. Edgell RC, Abou-Chebl A, Yadav JS. Endovascular management of spontaneous carotid artery dissection. J Vasc Surg. 2005; 42(5): 854–860.
    CrossRefPubMed
  98. Touze E, Gauvril JY. Histoire naturelle des dissections des arteries cervicales. J Neuroradiol. 2002; 29: 251–256.
  99. Zweifler R, Silverboard G. Arterial dissections. Stroke: pathophysiology, diagnosis and management. Churchill Livingstone, Philadelphia 2004: 561.
  100. Pezzini A, Caso V, Zanferrari C, et al. Arterial hypertension as risk factor for spontaneous cervical artery dissection. A case-control study. J Neurol Neurosurg Psychiatry. 2006; 77(1): 95–97.
    CrossRefPubMed
  101. Milhaud D, de Freitas GR, van Melle G, et al. Occlusion due to carotid artery dissection: a more severe disease than previously suggested. Arch Neurol. 2002; 59(4): 557–561.
    CrossRefPubMed
  102. Schievink WI, Mokri B, Piepgras DG, et al. Recurrent spontaneous arterial dissections: risk in familial versus nonfamilial disease. Stroke. 1996; 27(4): 622–624.
    CrossRefPubMed
  103. Menon RK, Norris JW. Cervical arterial dissection: current concepts . Ann N Y Acad Sci. 2008; 1142: 200–217.
    CrossRefPubMed

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