The treatment of spontaneous carotid and vertebral artery dissections

Spontaneous dissections of the carotid and vertebral arteries in the neck a re a common cause of stroke in young and middle-aged people. Moreover, they are increasingly recognized as the cause of a wide variety of other, more subtle, neurologic signs and symptoms. The cause of these arterial dissecti ons largely remains unexplained but probably involves a combination of gene tic and environmental factors. Magnetic resonance imaging has largely surpa ssed angiography as the imaging study of choice. The treatment of carotid a nd vertebral artery dissections is based on rather incomplete evidence. Ant icoagulation with heparin followed by warfarin remains the treatment of cho ice in most major medical centers and is supported by the demonstration of emboli as the most common cause of stroke in these patients. The burgeoning interest in endovascular techniques has resulted in many patients being tr eated for carotid and vertebral artery dissections with percutaneous angiop lasty and stent deployment. Although the treatment of dissections is genera lly well tolerated and the radiographic results are impressive, most dissec tions heal spontaneously and the associated aneurysms never rupture and rar ely cause delayed ischemic symptoms, Surgical treatment of dissections, con sisting of an in situ interposition graft or extracranial-intracranial bypa ss, is indicated only for those patients with persistent symptoms refractor y to maximal medical therapy who are not candidates for endovascular treatm ent. Curr Opin Cardiol 2000, 15:316-321 (C) 2000 Lippincott Williams & Wilk ins, Inc.