warfarin and Aortic-Dissection

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction and sudden cardiac death. We present a case of a 36-year-old female runner who was successfully thrombolysed for acute anterior ST elevation myocardial infarction. Coronary angiography revealed spontaneous dissection of the left anterior descending and diagonal arteries. The patient was treated medically with warfarin and dual antiplatelet therapy. Repeat angiography at 8 weeks showed significant angiographic improvement. Exercise stress testing at 10 months was normal and allowed a return to exercise. At 28 months the patient is asymptomatic and fully active. A review of the etiology and available treatment options is presented.

Topics: Adult; Anticoagulants; Aortic Dissection; Coronary Aneurysm; Coronary Angiography; Drug Therapy, Combination; Exercise Test; Female; Humans; Myocardial Infarction; Platelet Aggregation Inhibitors; Risk Factors; Thrombolytic Therapy; Treatment Outcome; Warfarin

We report a 41-year-old woman with embolic stroke of the mid-pons attributed to embolism from vertebral artery dissection. Angiography revealed an occluded artery on one side and an incidental pseudoaneurysm of the midcervical portion of the vertebral artery on the other. After 3 months of warfare in therapy control angiography showed complete occlusion of the pseudoaneurysm. We discuss therapeutic choices and review the literature.

Topics: Adult; Aneurysm, False; Anticoagulants; Aortic Dissection; Cerebral Angiography; Female; Humans; Vertebral Artery; Vertebrobasilar Insufficiency; Warfarin; Wound Healing

Cervical artery dissection is an important cause of stroke in the young. It can present with local symptoms or stroke/transient ischaemic attacks. Following presentation there is a risk of stroke, particularly in the first month following presentation. The mechanism of stroke is believed to be thromboembolic in the majority of cases. Many clinicians anticoagulate patients with cervical dissection for 3-6 months. This is not evidence based and is supported by a paucity of data and no data from randomised control trials.. CADISS is a prospective multicentre randomised-controlled trial in acute (within 7 days of onset) carotid and vertebral artery dissection. Intracerebral artery dissection is excluded.. Patients are randomised to antiplatelet therapy (aspirin, dipyridamole or clopidogrel alone or in dual combination) or anticoagulation therapy [heparin followed by warfarin aiming for an International Normalised Ratio (INR) in the range 2-3] for at least 3 months. Treatment is open-label.. The primary end-point is ipsilateral stroke or death within 3 months from randomisation. Secondary end-points include any TIA or stroke, major bleeding and presence of residual stenosis at 3 months (>50%). All neuroimaging and serious adverse events will be adjudicated blinded to treatment. An initial feasibility phase of 250 subjects will allow us to determine whether *there are sufficient clinical end-points to provide the power to determine a treatment effect and *adequate numbers of patients can be recruited. The feasibility phase will be continued into a fully powered definitive treatment trial. Initial power calculations based on limited natural history data suggest a sample size of approximately 3000. Sample size calculations will be refined once the frequency of outcome events during the feasibility phase is known.

Topics: Anticoagulants; Aortic Dissection; Aspirin; Clinical Protocols; Clopidogrel; Diagnostic Imaging; Dipyridamole; Drug Therapy, Combination; Endpoint Determination; Feasibility Studies; Heparin; Humans; Patient Selection; Platelet Aggregation Inhibitors; Prospective Studies; Quality Assurance, Health Care; Research Design; Sample Size; Single-Blind Method; Stroke; Ticlopidine; United Kingdom; Warfarin

Oral anticoagulation prior to emergency surgery is associated with an increased risk of perioperative bleeding, especially when this therapy cannot be discontinued or reversed in time. The goal of this study was to analyse the impact of different oral anticoagulants on the outcome of patients who underwent emergency surgery for acute type A aortic dissection (ATAAD).. This was a single-centre retrospective study of patients treated with oral anticoagulation at the time of surgery for ATAAD. Outcomes of patients on new oral anticoagulant (NOAC) therapy were compared to respective outcomes of patients on Coumadin. Additionally, a survival analysis was performed comparing these 2 groups with patients who were operated on with no prior anticoagulation.. Between January 2013 and April 2020, a total of 437 patients (63.8 ± 11.8 years, 68.4% male) received emergency surgery for ATAAD; 35 (8%) were taking oral anticoagulation at the time of hospital admission: 20 received phenprocoumon; 14, rivaroxaban; and 1, dabigatran. Compared to Coumadin, NOAC was associated with a greater need for blood-product transfusions and haemodynamic compromise. Operative mortality was 53% in the NOAC group and 30% in the Coumadin group. A 5-year survival analysis showed no significant difference between the NOAC and the Coumadin group (P = 0.059). Compared to 402 patients treated during the study period without anticoagulation, patients taking NOAC had significantly worse survival (P = 0.001), whereas that effect was not observed in patients undergoing surgery who were taking Coumadin (P = 0.99).. Emergency surgery for ATAAD in patients taking NOAC is associated with high morbidity and mortality. NOAC are a major risk factor for uncontrollable bleeding and haemodynamic compromise. New treatment strategies must be defined to improve surgical outcomes in these high-risk patients.

Topics: Administration, Oral; Anticoagulants; Aortic Dissection; Atrial Fibrillation; Female; Hemorrhage; Humans; Male; Retrospective Studies; Warfarin

Disseminated intravascular coagulation (DIC) is a critical and rare complication after thoracic endovascular aortic repair (TEVAR) of type B aortic dissection. The optimal treatment of aortic dissection-related DIC remains controversial.. We herein describe the successful management of a 65-year-old man who presented with gingival bleeding and multiple subcutaneous petechiae and was proven to have DIC after TEVAR of aortic dissection. The patient had initially been discharged with improved laboratory tests after anticoagulation treatment followed by oral rivaroxaban for maintenance. However, he was readmitted with recurrent gingival bleeding 17 days later. The DIC was successfully controlled with a combination of anticoagulation and antifibrinolytics. After the patient was discharged, his treatment was switched to oral tranexamic acid and warfarin for maintenance. During a 15-month follow-up, the patient had no recurrence of hemorrhage symptoms and maintained stable coagulative and fibrinolytic parameters.. Aortic dissection-related DIC requires long-term management under conservative treatment. The combination of warfarin and tranexamic acid may be a feasible method for long-term maintenance therapy.

Topics: Aged; Anticoagulants; Aortic Aneurysm, Thoracic; Aortic Dissection; Blood Vessel Prosthesis Implantation; Disseminated Intravascular Coagulation; Endovascular Procedures; Hemorrhage; Humans; Male; Tranexamic Acid; Treatment Outcome; Warfarin

Evidence-based recommendations about anticoagulation in acute type B aortic dissection (TBAD) are completely missing, but there is a diffuse conviction that it could prevent the healing process of the dissected aorta's false lumen. However, several clinical conditions may lead to the necessity to start anticoagulant therapy among patients with acute type B aortic dissection, ranging from atrial fibrillation to more complicated clinical scenarios and the correct management in this kind of patients is still an open issue.. We are presenting a 51-years-old man with multi-infarct encephalopathy referred to us for an acute TBAD and a first diagnosis of ischemic cardiomyopathy complicated by left ventricular (LV) thrombus formation. Coronary angiography revealed a critical stenosis of left anterior descending artery (LAD) treated with drug-eluting stent deployment. The patient was addressed to triple antithrombotic therapy with acetylsalicylic acid, clopidogrel and warfarin with target INR 2.0-2.5. After 6 months, computed tomography angiography revealed the stability of the dissection flap. Cardiac magnetic resonance imaging, however, confirmed the persistence of a small thrombotic formation in LV apex, thus double antithrombotic therapy with warfarin and clopidogrel was instituted. The patient remained asymptomatic during the follow-up period but was advised to suspend his job and physical activities.. Current guidelines do not discuss anticoagulant therapy in the setting of TBAD and large randomized trials are lacking. Despite it is generally considered unsafe to administer anticoagulants in patients with TBAD, we present a case in which triple antithrombotic therapy was well tolerated and did not lead to progression of the intimal flap after 6 months.

Topics: Anticoagulants; Aortic Aneurysm, Thoracic; Aortic Dissection; Aspirin; Clinical Decision-Making; Clopidogrel; Coronary Stenosis; Disease Progression; Drug-Eluting Stents; Dual Anti-Platelet Therapy; Fibrinolytic Agents; Humans; Male; Middle Aged; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Risk Assessment; Thrombosis; Treatment Outcome; Warfarin

A 68-year-old man presented with complaints of right-sided neck and chest pain with systolic blood pressure greater than 200 mm Hg but denied any recent blunt trauma or whiplash events. A computed tomography angiography demonstrated an acute dissection involving the origin of the right brachiocephalic artery that extended into the right common carotid and right subclavian arteries. The patient was neurologically intact and computed tomography angiography of the brain demonstrated a stable arachnoid cyst and a brain perfusion scan demonstrated homogenous perfusion. In the absence of strong indications for arch replacement, the patient was treated with warfarin and clopidogrel to prevent further thrombotic potentiation.

Topics: Aged; Anticoagulants; Aorta, Thoracic; Aortic Dissection; Aspirin; Brachiocephalic Trunk; Brain; Clopidogrel; Computed Tomography Angiography; Humans; Male; Platelet Aggregation Inhibitors; Warfarin

Due to the rarity of this condition, clinical treatment and outcomes in isolated superior mesenteric artery dissection (ISMAD) patients remain unknown. The primary aim of this retrospective multicenter study was to elucidate the treatment strategies and in-hospital outcomes for ISMAD patients by using administrative data.. We retrospectively analyzed patients that were primarily diagnosed with ISMAD using the Diagnosis Procedure Combination data collected at 141 hospitals in Japan in 2015. Patients with comorbidities that included "aneurysm" were excluded.. A total of 221 ISMAD without aneurysm patients (male: 90.5%; mean age: 52.5±10.1 years) were enrolled, and 95 (67.4%) of these encountered just one ISMAD case per year. We found only one (0.5%) in-hospital death and length of stay for ISMAD patients was 13.2±9.1 days. One-third of patients received antiplatelet therapy (32.1%) and anticoagulation therapies, such as heparin (38.9%) and warfarin (10.0%). A total of 146 (66.1%) patients received antihypertensive treatment (either orally or via an intravenous route) during hospitalization. Twelve (5.4%) patients underwent surgical procedures during hospitalization as follows: 4 (33.3%) patients underwent bypass surgery, 3 (25.0%) patients underwent exploratory laparotomies, 2 (16.7%) patients underwent bowel resection, 1 (8.3%) patient underwent a thrombectomy, and 2 (16.7%) patients underwent surgical angioplasties.. We found that conservative therapy for ISMAD patients without aneurysm is safe and is also associated with a low rate of surgical intervention in clinical practice.

Topics: Adult; Aneurysm; Anticoagulants; Antihypertensive Agents; Aortic Dissection; Comorbidity; Female; Heparin; Humans; Japan; Male; Mesenteric Artery, Superior; Middle Aged; Platelet Aggregation Inhibitors; Retrospective Studies; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Acute Disease; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aspirin; Blood Vessel Prosthesis Implantation; Coronary Angiography; Coronary Thrombosis; Heparin; Humans; Male; Middle Aged; Plastic Surgery Procedures; Platelet Aggregation Inhibitors; Postoperative Complications; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Antifibrinolytic Agents; Aorta; Aortic Aneurysm; Aortic Dissection; Blood Coagulation Factors; Heparin; Humans; Jehovah's Witnesses; Male; Postoperative Hemorrhage; Tranexamic Acid; Warfarin

Aortic false aneurysm is life-threatening with high morbidity and mortality rates. Surgical treatment varies according to the pathologic process, infection status, and site of origin of the aneurysm. We presented a case of false aneurysm of the ascending aorta, developing after type A acute aortic dissection repair. The operation was performed with the use of deep hypothermia and circulatory arrest to avoid massive uncontrollable hemorrhage.

Topics: Acute Disease; Aneurysm, False; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aortography; Blood Vessel Prosthesis Implantation; Circulatory Arrest, Deep Hypothermia Induced; Debridement; Drug Overdose; Fatal Outcome; Humans; Intracranial Hemorrhages; Male; Middle Aged; Reoperation; Stroke; Suture Techniques; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

A 78-year-old man presented with abdominal pain, high International Normalised Ratio and rapidly falling haemoglobin. He had a background of Marfan syndrome and was on warfarin following mechanical aortic valve replacement. Abdominal CT imaging showed haemoperitoneum with a leaking aneurysm of the left gastric artery measuring 10 mm in diameter. The decision whether to reverse his anticoagulation provided a difficult clinical scenario given the risk of thrombosis associated with the mechanical aortic valve. The patient went on to have a successful percutaneous embolisation of the aneurysm using a metallic coil and Onyx. Left gastric artery aneurysms are rare and have a reported mortality of up to 70%. This is the first case of gastric artery aneurysm described in a patient with Marfan syndrome.

Topics: Abdominal Pain; Aged; Anticoagulants; Aortic Aneurysm, Abdominal; Aortic Dissection; Blood Vessel Prosthesis Implantation; Celiac Artery; Embolization, Therapeutic; Heart Valve Prosthesis; Humans; Male; Marfan Syndrome; Risk; Warfarin

Isolated brachiocephalic artery dissection is an extremely rare condition. Its presentation as an acute stroke can pose a significant diagnostic challenge in patients because of its rarity. We present a case of isolated spontaneous brachiocephalic artery dissection presenting as acute cerebrovascular accident. This case also illustrates the treatment dilemma brachiocephalic artery dissection can present, whether to choose antithrombotic/anticoagulation therapy and/or surgery, and also the dilemma in blood pressure management.

Topics: Adult; Anticoagulants; Antihypertensive Agents; Aortic Dissection; Aspirin; Ataxia; Brachiocephalic Trunk; Heparin; Humans; Male; Medical History Taking; Obesity; Platelet Aggregation Inhibitors; Stroke; Warfarin

Dissection of the subclavian artery usually occurs as a result of trauma, endovascular interventions or connective tissue disorders. Only rarely has it been described occurring spontaneously. The treatment can be endovascular, open surgery, conservative or a combination of the above. There are no guidelines. The best approach is the one tailored to the lesion itself. This case presents a 73-year-old man with a tiresome and heavy feeling in the right arm. He was diagnosed having a spontaneous dissection of the right subclavian artery, accompanied by a complete occlusion more distally. Because of the relatively minor symptoms he was treated conservatively using anticoagulants. After 6 months of treatment there was complete revascularisation with good pulsations at the right wrist.

Topics: Aged; Aortic Dissection; Computed Tomography Angiography; Conservative Treatment; Humans; Male; Risk Assessment; Severity of Illness Index; Subclavian Artery; Treatment Outcome; Warfarin

An 84-year-old male on oral steroids, coumadin and multiple antiplatelets for stented superficial femoral artery presented to our hospital with chest oppression. His CT scan showed cardiac tamponade with periaortic hematoma. At first, sealed rupture of aortic dissection with thrombosed false lumen was suspected. However, delayed enhancement view revealed extravasation of contrast agent, which appeared to drain into the pericardium or pericardial space. Emergency thoracotomy revealed normal aorta with several small spurting vessels of pulmonary side of the pericardium. To the best of our knowledge, this is the first reported case in the literature of a parietal pleural hematoma without known cause such as malignancy or hematologic disorders.

Topics: Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Cardiac Tamponade; Coronary Restenosis; Drug Therapy, Combination; Hematoma; Humans; Male; Platelet Aggregation Inhibitors; Steroids; Tomography, X-Ray Computed; Warfarin

Topics: Acute Coronary Syndrome; Anticoagulants; Aortic Dissection; Coronary Aneurysm; Coronary Angiography; Electrocardiography; Female; Humans; International Normalized Ratio; Middle Aged; Predictive Value of Tests; Treatment Outcome; Warfarin

Topics: Adult; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Aortic Dissection; Coronary Angiography; Coronary Thrombosis; Female; Humans; Ventricular Dysfunction, Left; Warfarin

Topics: Anticoagulants; Aortic Dissection; Aspirin; Coronary Aneurysm; Coronary Angiography; Drug Therapy, Combination; Fibrinolytic Agents; Humans; Male; Middle Aged; Myocardial Infarction; Recurrence; Warfarin

The aim of this study was to evaluate the correlation of clinical characteristics with serial imaging findings of symptomatic spontaneous celiac artery dissection treated by conservative management.. Eight consecutive, hemodynamically stable patients with symptomatic spontaneous celiac artery dissection without associated aortic dissection that received non-operative treatments were included in this study. Their clinical characteristics, treatment methods, serial imaging findings and outcomes were analyzed retrospectively.. Acute left flank pain related to splenic infarction was the most common clinical manifestation. Initial contrast-enhanced dynamic computed tomography scan showed celiac artery dissection with partial thrombosis in all eight patients and involvement of branch vessels in 7. Full anticoagulation was carried out immediately after the diagnosis in seven patients. All patients, except one with endovascular stent placement, were asymptomatic after successful conservative management and follow-up computed tomography scan showed preservation of distal perfusion with ongoing regression of false lumen in five patients. After a mean follow-up of 16 months, there was no mortality or morbidity related to the dissection.. Serial imaging findings showed that conservative management of celiac artery dissection can be performed successfully in selective patients with stable hemodynamics.

Topics: Adult; Anticoagulants; Aortic Dissection; Celiac Artery; Celiac Disease; Contrast Media; Flank Pain; Follow-Up Studies; Heparin; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Radiographic Image Enhancement; Retrospective Studies; Thrombosis; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Aged; Alcohol Withdrawal Delirium; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aortic Valve Insufficiency; Atrial Fibrillation; Delayed Diagnosis; Diagnostic Errors; Dyspnea; Edema; Epilepsy, Tonic-Clonic; Fatal Outcome; Heart Failure; Heart Valve Prosthesis; Humans; Hypertension; Male; Postoperative Complications; Psychomotor Agitation; Tomography, X-Ray Computed; Warfarin

In this case report, we present a 45-year-old man who experienced abdominal pain while bench-pressing heavy weights. A computed tomography angiogram showed a dissection of the celiac artery extending into the hepatic and splenic arteries, with thrombus in the false lumen into the common hepatic artery. With resolution of his symptoms, he was discharged after several days of warfarin and metoprolol therapy. To our knowledge, this is the first reported case of a dissection of the celiac artery and its branches caused by weight lifting.

Topics: Anticoagulants; Antihypertensive Agents; Aortic Dissection; Athletic Injuries; Celiac Artery; Humans; Male; Metoprolol; Middle Aged; Thrombosis; Warfarin; Weight Lifting

Spontaneous coronary artery dissection (SCAD) still is a rare cause of acute coronary syndrome. SCAD has been observed in three groups of patients: those with coronary atherosclerosis, peripartal women and idiopathic group. SCAD may be associated with some conditions. We report an unusual association: SCAD and pulmonary thromboembolism.

Topics: Anticoagulants; Aortic Dissection; Coronary Aneurysm; Coronary Angiography; Diagnosis, Differential; Echocardiography; Fibrinolytic Agents; Heparin; Humans; Male; Middle Aged; Pulmonary Embolism; Rupture, Spontaneous; Streptokinase; Warfarin

Spontaneous dissection of visceral arteries is rare in the absence of concurrent dissection of the aorta, iatrogenic injury from instrumentation, or trauma. We describe a spontaneous dissection of the celiac artery that was identified by computed tomographic scan in an otherwise healthy man with acute onset abdominal pain and no identifiable causes of dissection. The patient was successfully managed medically. Although endovascular treatment or surgical intervention is the procedure of choice for complicated cases, medical management with close observation is an acceptable management strategy for stable, uncomplicated cases of spontaneous celiac artery dissection.

Topics: Abdominal Pain; Analgesics, Opioid; Anticoagulants; Aortic Dissection; Aspirin; Celiac Artery; Diagnosis, Differential; Drug Therapy, Combination; Enoxaparin; Humans; Male; Meperidine; Middle Aged; Platelet Aggregation Inhibitors; Splenic Artery; Splenic Infarction; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

The risk/benefit ratio of warfarin therapy changes in the over 75s, when haemorrhagic side-effects become more common. These may not always be reported in the literature.. A woman of 80 years, on long-term warfarin therapy presented with an acute dissecting thoracic aortic aneurysm; on investigation the only precipitating factor found was an international normalised ratio of 4.8. This patient, who also had an abdominal aortic aneurysm, survived, on discontinuation of her anticoagulant therapy.. We describe a previously unreported complication of warfarin therapy in a patient over 75 years of age, to add to the cautions in prescribing this drug in patients of this age group.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aorta; Aortic Aneurysm, Thoracic; Aortic Dissection; Atrial Fibrillation; Chest Pain; Female; Follow-Up Studies; Humans; Smoking; Tomography, X-Ray Computed; Warfarin

A case of a 63-year-old man with isolated dissection of the superior mesenteric artery (SMA), demonstrated by enhanced computed tomography (CT) and abdominal angiography, was admitted to our hospital. The severity of this disease varies from mild to severe; the severe cases require surgery. But the mild cases, like the one presented here, only need conservative therapy. This case demonstrated the usefulness of anticoagulation therapy and the indications for surgical and radiological intervention.

Topics: Angiography; Anticoagulants; Aortic Dissection; Celiac Artery; Constriction, Pathologic; Humans; Male; Mesenteric Artery, Superior; Middle Aged; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Isolated spontaneous renal artery dissection is a rare condition that can result in renal parenchymal loss and severe hypertension. Although several risk factors have been identified in association with renal artery dissection, the natural history is not well defined. The rarity and nonspecific presentation of the disease often lead to diagnostic delay. That, coupled with the anatomic limitations imposed by dissection into small branch arteries, frequently precludes successful revascularization. Over a 12-month period, four cases of spontaneous renal artery dissection (SRAD) were treated at a single institution. The patients (ages 44-58 years) presented with acute onset of abdominal/flank pain, fever, and hematuria. Diagnostic work-up included an abdominal CT scan revealing segmental renal infarction. Angiographic evaluation was diagnostic for renal artery dissection in all cases. In one case there was evidence of fibromuscular dysplasia (FMD), and in a second there was acute dissection superimposed upon atherosclerotic disease. Diagnosis was made within 12-72 hr of the onset of symptoms. All patients were managed expectantly with anticoagulation. Two patients were known to have a history of hypertension prior to admission. All four patients have required antihypertensive treatment following dissection, but the condition has been easily controlled. Renal function has remained stable in all cases. None of the four cases required exploration. Two of the four patients underwent repeat angiographic evaluation for recurrent symptoms of pain. In the case of the patient with FMD, a new dissection was seen in the contralateral renal artery, and in the second, repeat angiogram revealed proximal remodeling of the dissected artery. Management strategies for SRAD include surgical revascularization, endovascular intervention, and observation with or without anticoagulation. The available literature does not demonstrate a clear benefit of treatment with any of these modalities. In the short term, the combination of anticoagulation and expectant management appears to produce satisfactory outcomes for this difficult problem.

Topics: Adult; Anticoagulants; Antihypertensive Agents; Aortic Dissection; Female; Flank Pain; Heparin; Humans; Hypertension; Male; Middle Aged; Renal Artery; Tomography, X-Ray Computed; Warfarin

We have presented a unique case of isolated renal artery dissection in an otherwise healthy young man, whose diagnosis was demonstrated by renal angiography. He was anticoagulated with warfarin for one year with resolution of the false channel in his renal artery as demonstrated by magnetic resonance angiography. Duplex ultrasonography of his renal artery was important in monitoring his renal artery flow velocities.

Topics: Adult; Angiography; Anticoagulants; Aortic Dissection; Humans; Male; Renal Artery; Ultrasonography, Doppler, Duplex; Warfarin

A 50-year-old man presented spontaneous internal carotid artery dissection with ischemic stroke. He had a history of deep venous thrombosis, and an activated protein C resistance due to factor V Leiden mutation was documented. He showed no other vascular risk factor. This unusual case puts the question whether this coagulation defect may be related to the stroke occurrence.

Topics: Anticoagulants; Aortic Dissection; Brain Ischemia; Carotid Artery, Internal; Carotid Stenosis; Cerebrovascular Disorders; Factor V; Follow-Up Studies; Heparin; Humans; Male; Middle Aged; Point Mutation; Protein C; Thrombophlebitis; Warfarin

To describe the atypical localization and unusual clinical manifestation of an internal carotid artery dissection.. We examined a 43-year-old woman who had sudden onset of left ptosis and miosis with vague dysesthesia around her eye.. Her examination showed an intrapetrous carotid artery dissection.. The intrapetrous segment is an extremely rare localization for an internal carotid artery dissection. The differential diagnosis of acute Horner syndrome should include carotid dissection, which is usually accompanied by other neurologic manifestations.

Topics: Adult; Anticoagulants; Aortic Dissection; Blepharoptosis; Carotid Artery Diseases; Carotid Artery, Internal; Cerebral Angiography; Diagnosis, Differential; Female; Heparin; Horner Syndrome; Humans; Petrous Bone; Warfarin

Dissection of the carotid and vertebral arteries is most accurately diagnosed with conventional angiography. MR techniques are sensitive for detecting the abnormalities associated with dissection but may lack specificity. We hypothesized that MR may be useful for serial monitoring of dissection and may therefore guide therapy.. All patients with angiographically proven carotid and/or vertebral artery dissection from July 1994 to June 1996 were followed for a median duration of 10.5 months. Of these 29 patients (44 vessels), 18 were concurrently evaluated with MR, and a target group of 9 patients (17 vessels) was prospectively followed with MR at 3-month intervals.. In the 18 patients with both imaging studies at baseline, angiography revealed 30 dissected vessels while MR detected 27 (90%). In the target group of 9 patients, initial MR identified 15 of the 17 dissections diagnosed with angiography. Serial MR revealed complete healing in 5 vessels, improvement in 6 vessels, no change in 4 vessels, and worsening in 2 vessels. The radiographic features most likely to resolve were stenosis and mural hematoma, while occlusion and luminal irregularity tended to persist. Late ischemic events occurred in 2 patients, both with persistent MR evidence of dissection, one while subtherapeutic on warfarin therapy and the other occurring 1 week after warfarin was discontinued.. MR is a reliable noninvasive method for following the vascular response to treatment and may guide the course of a clinical trial comparing medical therapies for carotid and vertebral artery dissection.

Topics: Adolescent; Adult; Anticoagulants; Aortic Dissection; Carotid Arteries; Cerebral Angiography; Child; Female; Humans; Intracranial Aneurysm; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Male; Middle Aged; Prospective Studies; Vertebral Artery; Warfarin; Wound Healing

A subject with dissection of the internal carotid artery (ICA) may present with a variety of symptoms, from headache to stroke. Thus far, it has not been possible to identify the subset of patients at risk for cerebral ischemia. Because the majority of these ischemic events are secondary to embolic phenomena, we used transcranial Doppler (TCD) evaluation with emboli monitoring to study 17 consecutive patients with ICA dissection treated at Harborview Medical Center, Seattle, Wash, during a 2-year period from 1992 until 1994.. Ten patients with ICA dissection secondary to trauma and seven with spontaneous ICA dissection were diagnosed by carotid angiography and studied by TCD from the time of diagnosis through initiation of therapy. Emboli monitoring was performed in the middle cerebral artery (MCA) ipsilateral to the dissection at the initial evaluation and intermittently thereafter to ensure that the emboli stopped with treatment.. Emboli were detected in the MCA distal to the dissection in 10 of 17 patients (59%). Patients with microemboli detected by TCD presented with a stroke (70%) much more frequently than those without emboli (14%) (P=.0498). The presence of a pseudoaneurysm did not increase the risk of either microemboli or stroke.. We have demonstrated a high incidence of intracranial microemboli in the MCA distal to carotid dissections and a significant correlation between the presence of emboli and stroke. TCD can therefore be used as an adjunctive tool to manage patients with suspected carotid dissection and may prove useful in evaluating the efficacy of treatment in reducing microemboli and subsequent stroke.

Topics: Adolescent; Adult; Anticoagulants; Aortic Dissection; Carotid Artery Diseases; Carotid Artery, Internal; Cerebral Angiography; Cerebral Arteries; Cerebrovascular Disorders; Child; Female; Heparin; Humans; Intracranial Embolism and Thrombosis; Male; Middle Aged; Ultrasonography, Doppler, Transcranial; Warfarin; Washington

Afibrinogenemia, a rare coagulation disorder, has not been associated with vertebral artery dissections.. A 28-year-old woman with afibrinogenemia developed spontaneous neck pain followed by a right medullary infarction, and MR angiography showed extensive bilateral vertebral artery dissection. She was treated with fibrinogen replacement and anticoagulants and showed a favorable evolution, with only mild residual right upper arm incoordination.. In this patient spontaneous bilateral vertebral artery dissection complicated afibrinogenemia. Since anticoagulant therapy is usually indicated for arterial dissection, this association created a therapeutic problem. This patient received anticoagulants with fibrinogen replacement, which resulted in a favorable evolution.

Topics: Adult; Afibrinogenemia; Anticoagulants; Aortic Dissection; Contraindications; Female; Fibrinogen; Heparin; Humans; Intracranial Embolism and Thrombosis; Magnetic Resonance Imaging; Neck Pain; Vertebral Artery; Warfarin

A 50-year-old man with myelopathy secondary to basilar impression developed bilateral vertebral artery dissection after undergoing treatment with 8 pounds of cervical traction. The vertebral artery dissection resulted in vertebrobasilar insufficiency and posterior circulation stroke. In this report, the current management philosophies in the treatment of basilar impression are discussed, and the pertinent neurovascular anatomy is illustrated. This report suggests that vertebral artery injury may result from attempted reduction of severe basilar impression. Regardless of the cause of cranial settling, the risk of vertebral artery injury with cervical traction should be considered in patients with severe basilar impression.

Topics: Aortic Dissection; Humans; Intracranial Aneurysm; Magnetic Resonance Imaging; Male; Middle Aged; Platybasia; Thrombolytic Therapy; Traction; Urokinase-Type Plasminogen Activator; Vertebral Artery; Vertebrobasilar Insufficiency; Warfarin

Topics: Aortic Dissection; Carotid Artery Diseases; Carotid Artery, Internal; Diagnosis, Differential; Fibromuscular Dysplasia; Follow-Up Studies; Heparin; Humans; Male; Middle Aged; Recurrence; Warfarin

Cervical internal carotid dissection is not rare. Doppler ultrasound screening of young patients presenting with stroke, identified 10 patients with reduced common and internal carotid blood flow without any evidence of atheroma. Eight, on angiography proved to have a dissection of the cervical internal carotid artery. All were managed conservatively. Seven received anticoagulant therapy, stopping any further neurological symptoms.

Topics: Adolescent; Adult; Aortic Dissection; Carotid Artery Diseases; Carotid Artery, Internal; Cerebral Angiography; Cerebral Infarction; Echoencephalography; Female; Follow-Up Studies; Heparin; Humans; Intracranial Aneurysm; Ischemic Attack, Transient; Male; Middle Aged; Tomography, X-Ray Computed; Warfarin

Facial numbness and dysesthesia have not been emphasized as presenting features in spontaneous internal carotid artery dissection. Progressive facial pain, accompanied by oculosympathetic paresis, altered taste, and facial numbness suggest the possibility of basal skull neoplasm. We describe a patient, with previously undiscovered fibromuscular dysplasia, who presented with severe neck and face pain, dysgeusia, oculosympathetic paresis, and markedly reduced facial sensation due to a spontaneous vascular dissection. Altered facial sensation should now be included in the symptomatology of internal carotid artery dissection.

Topics: Aortic Dissection; Carotid Artery Diseases; Carotid Artery, Internal; Face; Facial Pain; Female; Heparin; Humans; Middle Aged; Nervous System Diseases; Radiography; Sensation; Taste Disorders; Warfarin