Document Type : Review Article
- Loay Hassan Abdelnour 1
- Mohamed Eltahir Abdalla 1
- Samah Elhassan 2
- Elrasheid Ahmed Hassan Kheirelseid 2
1 General Internal Medicine, Ulster Hospital, Belfast, Northern Ireland
2 Department of Surgery, Beaumont Hospital and the Royal College of Surgeons, Dublin, Ireland
Background: Spontaneous cervical artery dissection (sCeAD) is an important cause of ischemic stroke in the young population and has a different cardiovascular risk profile from other causes of ischemic stroke. No study provided a comprehensive evidence for cardiovascular risk factors of sCeAD.
Methods: We searched PubMed, MEDLINE, and Embase without date or language restrictions for relevant studies. Bibliographies of included studies were also searched. We included case-control studies where patients with sCeAD were on one arm, and controls were on the other arm. The investigated risk factors were diabetes, hypertension, smoking, and hyperlipidemia. Data extraction and quality assessment were performed independently by two reviewers.
Results: Seventeen qualifying case-control studies were identified, comparing 2185 patients with sCeAD and 3185 healthy control subjects. Heterogeneity was low for diabetes, moderate for hypertension and hyperlipidemia, and high for smoking. The meta-analysis showed a significant association between hypertension and sCeAD [pooled odds ratio (OR) = 1.70, 95% confidence interval (CI): 1.40-2.07, P < 0.001]. There was no association between sCeAD and diabetes (pooled OR = 0.71, 95% CI: 0.50-1.01, P = 0.060) or smoking (pooled OR = 0.90, 95% CI: 0.68-1.20, P = 0.480). Hyperlipidemia was negatively-associated with sCeAD (OR = 0.65, 95% CI: 0.48-0.89, P = 0.007), but with sensitivity analysis, there was no association (OR = 0.72, 95% CI: 0.44-1.19, P = 0.200).
Conclusion: The meta-analysis reveals that sCeAD has a significant association with hypertension and no association with smoking, diabetes, or hyperlipidemia. These results should direct future research towards exploring biological mechanism of hypertension-induced arterial dissection.
- GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019; 18(5): 459-80.
- Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Executive summary: Heart disease and stroke statistics2015 Update. Circulation 2015; 131(4): 434-41.
- Yesilot BN, Putaala J, Waje-Andreassen U, Vassilopoulou S, Nardi K, Odier C, et al. Etiology of first-ever ischaemic stroke in European young adults: The 15 cities young stroke study. Eur J Neurol 2013; 20(11): 1431-9.
- Haneline MT, Lewkovich GN. An analysis of the etiology of cervical artery dissections: 1994 to 2003. J Manipulative Physiol Ther 2005; 28(8): 617-22.
- Vila N, Millan M, Ferrer X, Riutort N, Escudero D. Levels of alpha1-antitrypsin in plasma and risk of spontaneous cervical artery dissections: A case-control study. Stroke 2003; 34(9): E168-E169.
- Pezzini A, Del ZE, Archetti S, Negrini R, Bani P, Albertini A, et al. Plasma homocysteine concentration, C677T MTHFR genotype, and 844ins68bp CBS genotype in young adults with spontaneous cervical artery dissection and atherothrombotic stroke. Stroke 2002; 33(3): 664-9.
- Benninger DH, Herrmann FR, Georgiadis D, Kretschmer R, Sarikaya H, Schiller A, et al. Increased prevalence of hyperhomocysteinemia in cervical artery dissection causing stroke: a case-control study. Cerebrovasc Dis 2009; 27(3): 241-6.
- Arauz A, Hoyos L, Cantu C, Jara A, Martinez L, Garcia I, et al. Mild hyperhomocysteinemia and low folate concentrations as risk factors for cervical arterial dissection. Cerebrovasc Dis 2007; 24(2-3): 210-4.
- Grau AJ, Brandt T, Buggle F, Orberk E, Mytilineos J, Werle E, et al. Association of cervical artery dissection with recent infection. Arch Neurol 1999; 56(7): 851-6.
- Guillon B, Berthet K, Benslamia L, Bertrand M, Bousser MG, Tzourio C. Infection and the risk of spontaneous cervical artery dissection: A case-control study. Stroke 2003; 34(7): e79-e81.
- Muthusami P, Kesavadas C, Sylaja PN, Thomas B, Harsha KJ, Kapilamoorthy TR. Implicating the long styloid process in cervical carotid artery dissection. Neuroradiology 2013; 55(7): 861-7.
- Amorim JM, Pereira D, Rodrigues MG, Beato-Coelho J, Lopes M, Cunha A, et al. Anatomical characteristics of the styloid process in internal carotid artery dissection: Case-control study. Int J Stroke 2018; 13(4): 400-5.
- Raser JM, Mullen MT, Kasner SE, Cucchiara BL, Messe SR. Cervical carotid artery dissection is associated with styloid process length. Neurology 2011; 77(23): 2061-6.
- Renard D, Azakri S, Arquizan C, Swinnen B, Labauge P, Thijs V. Styloid and hyoid bone proximity is a risk factor for cervical carotid artery dissection. Stroke 2013; 44(9): 2475-9.
- Saba L, Argiolas GM, Sumer S, Siotto P, Raz E, Sanfilippo R, et al. Association between internal carotid artery dissection and arterial tortuosity. Neuroradiology 2015; 57(2): 149-53.
- Giossi A, Mardighian D, Caria F, Poli L, De G, V, Costa P, et al. Arterial tortuosity in patients with spontaneous cervical artery dissection. Neuroradiology 2017; 59(6): 571-5.
- Kim BJ, Yang E, Kim NY, Kim MJ, Kang DW, Kwon SU, et al. Vascular tortuosity may be associated with cervical artery dissection. Stroke 2016; 47(10): 2548-52.
- Brandt T, Orberk E, Weber R, Werner I, Busse O, Muller BT, et al. Pathogenesis of cervical artery dissections: association with connective tissue abnormalities. Neurology 2001; 57(1): 24-30.
- Hausser I, Muller U, Engelter S, Lyrer P, Pezzini A, Padovani A, et al. Different types of connective tissue alterations associated with cervical artery dissections. Acta Neuropathol 2004; 107(6): 509-14.
- Debette S, Metso T, Pezzini A, Abboud S, Metso A, Leys D, et al. Association of vascular risk factors with cervical artery dissection and ischemic stroke in young adults. Circulation 2011; 123(14): 1537-44.
- Pezzini A, Caso V, Zanferrari C, Del ZE, Paciaroni M, Bertolino C, et al. Arterial hypertension as risk factor for spontaneous cervical artery dissection. A case-control study. J Neurol Neurosurg Psychiatry 2006; 77(1): 95-7.
- Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010; 8(5): 336-41.
- Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Online]. [cited 2021]; Available from: URL: https://www.ohri.ca//programs/clinical_epidemiology/oxford.asp
- Arnold M, Pannier B, Chabriat H, Nedeltchev K, Stapf C, Buffon F, et al. Vascular risk factors and morphometric data in cervical artery dissection: A case-control study. J Neurol Neurosurg Psychiatry 2009; 80(2): 232-4.
- Artto V, Metso TM, Metso AJ, Putaala J, Haapaniemi E, Wessman M, et al. Migraine with aura is a risk factor for cervical artery dissection: A case-control study. Cerebrovasc Dis 2010; 30(1): 36-40.
- D'Anglejan-Chatillon J, Ribeiro V, Mas JL, Youl BD, Bousser MG. Migraine--a risk factor for dissection of cervical arteries. Headache 1989; 29(9): 560-1.
- Gallai V, Caso V, Paciaroni M, Cardaioli G, Arning E, Bottiglieri T, et al. Mild hyperhomocyst(e)inemia: A possible risk factor for cervical artery dissection. Stroke 2001; 32(3): 714-8.
- Genius J, Dong-Si T, Grau AP, Lichy C. Postacute C-reactive protein levels are elevated in cervical artery dissection. Stroke 2005; 36(4): e42-e44.
- Guillon B, Tzourio C, Biousse V, Adrai V, Bousser MG, Touboul PJ. Arterial wall properties in carotid artery dissection: An ultrasound study. Neurology 2000; 55(5): 663-6.
- Hori S, Hori E, Umemura K, Shibata T, Okamoto S, Kubo M, et al. Anatomical variations of vertebrobasilar artery are closely related to the occurrence of vertebral artery dissection-an MR angiography study. J Stroke Cerebrovasc Dis 2020; 29(4): 104636.
- Kim ST, Brinjikji W, Lehman VT, Carr CM, Luetmer PH, Rydberg CH. Association between carotid artery tortuosity and carotid dissection: A case-control study. J Neurosurg Sci 2018; 62(4): 413-7.
- Konrad C, Muller GA, Langer C, Kuhlenbaumer G, Berger K, Nabavi DG, et al. Plasma homocysteine, MTHFR C677T, CBS 844ins68bp, and MTHFD1 G1958A polymorphisms in spontaneous cervical artery dissections. J Neurol 2004; 251(10): 1242-8.
- Longoni M, Grond-Ginsbach C, Grau AJ, Genius J, Debette S, Schwaninger M, et al. The ICAM-1 E469K gene polymorphism is a risk factor for spontaneous cervical artery dissection. Neurology 2006; 66(8): 1273-5.
- Ruiz-Franco A, Barboza MA, Jara-Prado A, Canizales-Quinteros S, Leon-Mimila P, Arguelles-Morales N, et al. TGFBR2 mutation and MTHFR-C677T polymorphism in a Mexican mestizo population with cervico-cerebral artery dissection. J Neurol 2016; 263(6): 1066-73.
- Strege RJ, Kiefer R, Herrmann M. Contributing factors to quality of life after vertebral artery dissection: a prospective comparative study. BMC Neurol 2019; 19(1): 312.
- Tamayo T, Brinks R, Hoyer A, Kuss OS, Rathmann W. The Prevalence and Incidence of Diabetes in Germany. Dtsch Arztebl Int 2016; 113(11): 177-82.
- Siegal EM. Acute aortic dissection. J Hosp Med 2006; 1(2): 94-105.
- Carlson RG, Lillehei CW, Edwards JE. Cystic medial necrosis of the ascending aorta in relation to age and hypertension. Am J Cardiol 1970; 25(4): 411-5.
- HIRST AE, Jr., JOHNS VJ, Jr. Experimental dissection of media of aorta by pressure. Its relation to spontaneous dissecting aneurysm. Circ Res 1962; 10: 897-903.
- Spittell PC, Spittell JA, Jr., Joyce JW, Tajik AJ, Edwards WD, Schaff HV, et al. Clinical features and differential diagnosis of aortic dissection: Experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993; 68(7): 642-51.
- Larson EW, Edwards WD. Risk factors for aortic dissection: A necropsy study of 161 cases. Am J Cardiol 1984; 53(6): 849-55.
- Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): New insights into an old disease. JAMA 2000; 283(7): 897-903.
- Golledge J, Eagle KA. Acute aortic dissection. Lancet 2008; 372(9632): 55-66.
- Okamoto T, Miyachi S, Yoshida J. Animal models of cervical artery dissection. Front Neurol Neurosci 2005; 20: 1-11.
- Lerman LO, Chade AR, Sica V, Napoli C. Animal models of hypertension: An overview. J Lab Clin Med 2005; 146(3): 160-73.
- Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001; 344(12): 898-906.
- Plouin PF, Baguet JP, Thony F, Ormezzano O, Azarine A, Silhol F, et al. High Prevalence of multiple arterial bed lesions in patients with fibromuscular dysplasia: The ARCADIA Registry (Assessment of Renal and Cervical Artery Dysplasia). Hypertension 2017; 70(3): 652-8.
- Olin JW, Froehlich J, Gu X, Bacharach JM, Eagle K, Gray BH, et al. The United States Registry for Fibromuscular Dysplasia: Results in the first 447 patients. Circulation 2012; 125(25): 3182-90.
- Gornik HL, Persu A, Adlam D, Aparicio LS, Azizi M, Boulanger M, et al. First International Consensus on the diagnosis and management of fibromuscular dysplasia. Vasc Med 2019; 24(2): 164-89.