Classification and management strategy of spontaneous carotid artery dissection

Abstract

Background and PurposeSpontaneous carotid artery dissections (sCAD) are the main cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 sCAD patients and proposed a new classification for sCAD with prognostic and therapeutic significance.MethodsThis is a retrospective review of prospectively collected data from June 2018 to June 2023 of sCAD patients treated at a large tertiary academic institution in an urban city in China. Depending on the degree of luminal narrowing and pseudoaneurysm formation on imaging, sCAD was classified into four types. Type IV dissections were divided into type IVA and type IVB dissections according to the presence of intracranial occlusion.ResultsA total of 179 patients and 197 dissected arteries met the inclusion criteria. More than two-thirds of type I dissections are completely recanalized after antithrombotic therapy, and only one case (1.8%) had recurrent ischemic stroke. A total of 38 % of type II dissections and 73% of type III dissections received endovascular treatment (EVT) for persistent flow-limited dissections, enlargement of pseudoaneurysm, or aggravation of clinical symptoms despite antithrombotic therapy. Type IV dissections are more likely to lead to the occurrence of ischemic stroke, and presented with more severe symptoms. About 33% of type IVB dissections received emergent intervention due to intracranial occlusion or aggravation of symptoms after medical treatment.ConclusionsThis study proposes a novel and more comprehensive classification method and management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD like type I. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA. Urgent procedure with neurovascular intervention might be needed in those with type IVB SCAD. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcome should be elucidated.