Tarr-Intervention-for-Aortic-Dissection by Clark1968

Bridge Over Troubled Water: Intervention for Acute Dissection

Robert Tarr MD Professor, CWRU Section Head of Neuroradiology Shakeel Chowdhry MD Fellow – Endovascular Neurosurgery, Dept of Neuroradiology Resident – Dept of Neurological Surgery 1

Disclosures â&#x20AC;˘ Medical Consultant for Philips

Learning objectives • Be familiar with the epidemiology of cervical dissections • Understand the pathophysiology of cervical dissections • Be familiar with indications for endovascular therapy of cervical dissections • Be able to recite the career highlight of Simon and Garfunkel 3

Simon and Garfunkel • Childhood friends from Queens, New York • Began performing together as “Tom and Jerry” in High School • “Hey Schoolgirl” 1957 – First Hit

Simon and Garfunkel • “Sounds of Silence” 1964 – First Momentum Building Hit • Soundtrack for “The Graduate” - 1967

Bridge Over Troubled Waters • Title track for final album – 1970 • Garfunkel originally thought Simon should sing it. • Drum in elevator shaft • “Explosion” sound of Baby Grand slamming shut 6

Bridge Over Troubled Waters • No. 1 in US and UK • Won 5 Grammys in 1971 • BOTW one of the most “covered” songs in history (Aretha Franklin, The Supremes, Elvis Presley, The Jackson 5, Willy Nelson etc)

Simon and Garfunkel • Broke up in 1970 • Simon – celebrated solo career (Still Crazy/Graceland • Garfunkel – not so much (bit part in Catch-22, Watermark) • Several reunion appearances (last in 2010 at the New Orleans Jazz festival)

Dissection - History Jean Fernel - 1542

Dissection - History • Dratz and Woodhall (1947) – First clinical description of traumatic ICA dissection • Anderson and Schecter (1959) – First clinical and necropsy description of “spontaneous dissection of the ICA 10

Dissection - Pathophysiology • Intimal Tear (Anderson and Schecter – 1959 • Ruptured Vasa Vasorum (Nedwich – 1963)

Vascular Histology • Arterial dissections arise from a tear in the intimal layer – allows hemodynamic flow to enter the wall of the artery within the layers of the tunica media • Forms an intramural hematoma or false lumen

– Subintimal Dissections à Stenosis – Subadventitial Dissections à Pseudoaneurysms (different than true aneurysms) 12

Dissection - Epidemiology • Accounts for 2.5 % of all Strokes • Most common cause of Stroke < 45 yrs of age • Accounts for 20-25% of Strokes in patients <45 yrs of age

Dissection - Mechanisms • Trauma (Including Chiropractic manipulation, Amusement Park Rides)

• Spontaneous • Increased risk associated with heritable connective tissue disorders – Ehler-Danlos syndrome type IV, Marfan syndrome, adult polycystic kidney disease, osteogenesis imperfecta type I) • <1/5 of pts w/ spontaneous carotid/vert dissection believed to have connective tissue disorder>

– 15% of pts w/ spontaneous carotid or vert dissection have angiographically confirmed fibromuscular dysplasia

Extracranial Carotid Dissection – Clinical • Classic Triad (seen in less than 1/3 of pts) – Pain on one side of face, head, or neck – Partial Horner’s syndrome – Cerebral or retinal ischemia

Extracranial Carotid Dissection- Clinical • Ipsilateral head or neck pain – Most common symptom – Throbbing and constant w/ varying intensity

• Focal Neurologic Sx’s (TIA or overt CVA) – Usually due to stenosis of true lumen leading to hypoperfusion and thromboembolism – Tend to occur in subacute period

• Oculosympathetic Paresis – 3rd most common – Complete CN III palsy with pupillary involvement – However, sympathetic fibers on ECA not affected • So, preserved facial sweating except for small area in the frontosupraorbital region

• Pulsatile Tinnitus – Seen in up to 1/3 à signifies onset of dissection 16

Extracranial Vertebral Artery Dissection Presentation • Symptoms – 90% p/w ischemic symptoms • Brainstem – Often lateral medulla (Wallenburg syndrome)

• Thalamus • Posterior Cerebral Hemisphere • Cerebellar Hemisphere

• In one series of 46 patients… 85% p/w cerebral infarction 11% p/w TIA 4% p/w local signs 17

Dissection – Stroke Mechanisms • Embolic - Platelet aggregation induced by intimal injury - Thrombus propagation in occlusive dissections - Clot development in psuedoaneurysm

• Hemodynamic - Occlusion/Stenosis secondary to subintimal hematoma - Focal vasospasm 18

Dissection – Medical Therapy • Anticoagulation vs. antiplatelet • No clear benefit but antiplatelet may pose less risk (Cochrane Review -2006) • Timing?

• CADISS (Cervical Dissection in Stroke Study) - Randomized open treatment trial - Heparin/Coumadin vs Aspirin, Dypyridamole and/or Clopidogrel w/in 7days for at least 3 months w/ 12 mo f/u - 80/250 randomized 19

Dissection-Response to Medical Therapy â&#x20AC;˘ More than 85% of patients with spontaneous dissection have no additional events and have angiographic evidence of healing on medical Tx -Morki B et. al. Spontaneous dissection of the cervical internal carotid artery. Ann Neurol. 1986; 19: 126-138,

Spontaneous Cervical DissectionStent/Angioplasty Rationale • Recurrent sxs despite medical therapy • Contraindication to anticoagulant therapy • Expanding or symptomatic psuedoaneurysm • Hypoperfusion syndrome • Interventional Management of Hyperacute Stroke syndromes 21

Dissection â&#x20AC;&#x201C; Surgical Management â&#x20AC;˘ 9-12% incidence of stroke and death - Muller BT et. a.l. Surgical treatment of 50 carotid dissections: indications and results. J Vasc Surg 2000;31: 980-8. - El-Sabrout R et. al. Extracranial carotid artery aneurysm: Texas Heart Institute experience. J Vasc Surg 2000; 31: 702-12

Dissection – Stent Angioplasty Malek et.al. AJNR 2000; 21: 1280-92 • 10 pts (5 male, 5 female) • Mixture of acute (<12hrs), subacute(3-10 days), and chronic (3 weeks to 10 years) • Mixture of spontaneous (5 pts.), iatrogenic (3 pts.) and traumatic (2 pts.) • Mixture of stent types

Dissection – Stent Angioplasty Malek et.al. AJNR 2000; 21: 1280-92 • Avg. stenosis improved from 75% to 5% • One retroperitoeal hematoma, No procedural related stroke or death • 8 – 24 mo. f/u – one stroke

Dissection – Stent Angioplasty Edgell RC, et.al. J Vasc Surg 2005; 42: 854-60 • 7/135 pts with spontaneous carotid dissection treated in a 2 year period • 5 female/ 2 male • Total of 12 vessels treated • Mixture of self expanding an balloon mounted stents used • Pts. Pretreated with Clopidogrel, post –tx – Clopidogrel/asprin x 6wks then aspirin idefinitely. 25

Dissection – Stent Angioplasty Edgell RC, et.al. J Vasc Surg 2005; 42: 854-60 • No symptomatic procedural complications (one asymptomatic new dissection) • No vessel occlusion, or recurrent neurological sxs. Avg 14 mo. f/u

Dissection – Stent Angioplasty Cothren CC, et.al. Arch Surg 2005; 140: 480-6 • 46 patients with traumatic dissections • Entrance into study: Persistent psuedoaneurysm at 7-10 days • 23 pts: stent plus antithrombotics; 23 patients: antithrombotics alone • Magic Wallstent (BSC) used in all stent cases 27

Dissection – Stent Angioplasty • • • •

Cothren CC, et.al. Arch Surg 2005; 140: 480-6 3/23 (13%) procedural related stroke rate in stented group 1/23 (4%) short term f/u stroke rate in nonstented group 8/18 (45%) vessel occlusion rate in stent group 1/20 (5%) vessel occlusion rate in nonstented group 28

Dissection – Stent/Angioplasty in BAT Setting: Rationale • Provide catheter access to occluded intracranial branches • Increased collateral flow to ischemic territories • Augment thrombolysis with increased flow

Dissection- Stent/Angioplasty in the BAT Setting: Limitations • Antithrombotic Therapy Necessary (ReoPro) • May Increase time of Procedure • May limit use of Mechanical Thrombectomy Devices

45 yo left handed male • • • • •

Presents to ER 60 min post ictus Left hemiparesis/Expressive Aphasia Initial NIHSS =25 CT/ Perfusion-Diffusion MR Angio at 1 hr/45min

CT Pre

Diffusion/Perfusion MR

RCA Pre

LCCA Pre

RVA

S/p tPA/Reopro

S/P stent 1

LCCA s/p stent, tpa, reopro

RICA reocclusion

S/P stent2 neck

RCCA s/p Stent2 head â&#x20AC;&#x201C; 6hrs post ictus

Ct Post Post tPA 24 hr. post tPA

45 yo left handed male 48 hrs post • Extubated • Mild dysarthria, mild left facial • NIHSS = 2

7 year f/u • Professor of Radiology • Section Head of Cardiovascular Imaging at CMC, Vice Chairman of Radiology Research • 8 hcp golfer

Dissection - Conclusions â&#x20AC;˘ Medical Therapy is efficacious in preventing recurrent neurological symptoms in the vast majority of cases â&#x20AC;˘ Endovascular therapy is relatively safe but should only be considered under special circumstances