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Radiology – Neurology

Management of Cervical Artery Dissection: Key Points From the AHA Scientific Statement

21 Jan, 2025 | 11:05h | UTC

Introduction:
This document summarizes the American Heart Association (AHA) scientific statement on cervical artery dissection (CAD), an important cause of ischemic stroke, especially in younger and middle-aged adults. Cervical artery dissection often presents with nonspecific symptoms—such as headache, neck pain, or partial Horner syndrome—but can lead to serious neurological deficits. Early recognition, targeted imaging, appropriate acute treatment, and well-informed decisions on antithrombotic therapy are essential to optimize patient outcomes.

Key Recommendations:

  • Epidemiology and Risk Factors
    • CAD accounts for up to 25% of ischemic strokes in adults under 50 years of age, with a slightly higher incidence in men but lower peak age in women.
    • Risk factors include genetic predispositions (eg, connective tissue disorders), anatomic variants (elongated styloid process, vascular tortuosity), minor cervical trauma, and comorbidities such as hypertension or fibromuscular dysplasia.
  • Diagnosis and Imaging
    1. Clinical Suspicion
      • Suspect CAD in younger adults with new or worsening neck pain, headache, pulsatile tinnitus, partial Horner syndrome, or cranial nerve involvement, especially if there is a history of recent minor neck trauma or manipulation.
      • Up to 8%–12% of patients may have isolated neck or head pain with no initial ischemic signs.
    2. Imaging Modalities
      • Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiography (MRA): High-resolution, fat-suppressed T1-weighted sequences are useful for detecting intramural hematoma.
      • Computed Tomography Angiography (CTA): Good sensitivity and specificity for luminal abnormalities and can detect intraluminal thrombus. Avoid false positives by distinguishing imaging artifacts from true double lumens or intimal flaps.
      • Conventional Digital Subtraction Angiography (DSA): Historically the gold standard but reserved for equivocal cases because of procedure-related risks (eg, iatrogenic dissection).
      • Ultrasound with Color Doppler: Operator-dependent but helpful for serial follow-up of vessel remodeling.
    3. Additional Diagnostic Testing
      • Connective Tissue Disorders: Consider genetic counseling if physical exam, family history, or recurrent dissections suggest a monogenic disorder (eg, vascular Ehlers-Danlos).
      • Screening for Fibromuscular Dysplasia (FMD): Patients with CAD, especially those with hypertension or evidence of FMD in other vascular beds, may warrant renal artery imaging.
      • Aortic and Intracranial Imaging: Aortic root dilation and cerebral aneurysms may be more prevalent in CAD; consider advanced imaging (eg, MRA) based on clinical judgment.
  • Hyperacute and Acute Stroke Management
    1. Intravenous Thrombolysis (IVT):
      • IVT (alteplase or tenecteplase) remains reasonable for otherwise eligible acute ischemic stroke patients, with no specific evidence of higher hemorrhagic risk in CAD. Caution is advised if there is intracranial extension of the dissection or other significant bleeding risk factors.
    2. Mechanical Thrombectomy:
      • Recommended for large-vessel occlusion in CAD patients who meet standard thrombectomy criteria. Tandem lesions (extracranial dissection and intracranial occlusion) can be addressed via retrograde (intracranial first) or antegrade (extracranial first) approach, with similar overall outcomes reported.
    3. Acute or Subacute Stenting:
      • May be considered in selected cases of severe flow-limiting stenosis leading to distal hypoperfusion or in persistent ischemia despite optimal medical therapy. Stenting in tandem occlusions can improve reperfusion but carries added risks (in-stent restenosis, stent thrombosis, or need for dual antiplatelet therapy).
  • Antithrombotic Therapy for Secondary Stroke Prevention
    1. Rationale for Early Treatment:
      • Artery-to-artery embolization underpins most CAD-related ischemic events. Early initiation of antithrombotics (ideally within the first 24–72 hours) reduces further embolic risk.
    2. Choice of Agent: Antiplatelet vs Anticoagulant
      • When to Prefer Anticoagulation:
        • Patients with high-risk imaging features: severe stenosis (>50%–70%), intraluminal thrombus, occlusion, multiple or early recurrent dissections.
        • Traditional option is heparin bridging to Vitamin K antagonist (target INR ≈2–3), but direct oral anticoagulants (DOACs) can be considered based on patient profile and preference.
      • When to Prefer Antiplatelet Therapy:
        • Patients with lower stroke risk (no significant stenosis, no intraluminal thrombus) or higher bleeding risk (large infarct, hemorrhagic transformation, intradural extension).
        • Aspirin monotherapy is typical; a short course of dual antiplatelet therapy (aspirin + clopidogrel) for 21–90 days can be considered if minor stroke/TIA criteria apply and bleeding risk is acceptable.
    3. Practical Start-Up and Monitoring:
      • Begin therapy as soon as deemed safe, ideally after hemorrhagic complications are excluded.
      • For VKA: bridge with heparin (IV unfractionated or low–molecular-weight) for at least 5 days until INR is therapeutic for ≥24 hours.
      • Regularly monitor clinical response and, if relevant, INR in anticoagulated patients.
    4. Duration of Therapy:
      • Minimum 3–6 months of antithrombotics, with vessel imaging at follow-up (eg, 3 or 6 months) to assess for healing or persistent dissection.
      • Decisions to extend antithrombotic therapy past the 6-month mark may be considered in the context of an individual’s overall vascular risk factor profile and in the context of neuroimaging features as remodeling occurs.
      • Consider extended or indefinite therapy (often antiplatelet) if persistent stenosis, high-risk anatomic factors, or recurrent dissections occur.
  • Risk of Recurrent Dissection and Lifestyle Precautions
    • Recurrence rates range from 1% to 2% per year but are higher in the first few months post-dissection. Fibromuscular dysplasia and younger age are associated with increased recurrence risk.
    • It is reasonable to advise patients to avoid high-risk neck activities (eg, contact sports, extreme neck manipulation) for 1–6 months or until imaging confirms vessel healing. In those with a known connective tissue disorder or recurrent dissection, lifelong caution is appropriate.
  • Follow-Up Imaging and Management of Dissecting Aneurysms
    • Recanalization most often occurs by 6–12 months; persistent occlusions or stenoses beyond 12 months rarely recanalize further.
    • Dissecting aneurysms form or enlarge in some cases but seldom rupture. Antithrombotic choice does not appear to affect aneurysm resolution rates.
    • Endovascular or surgical interventions are reserved for enlarging or symptomatic aneurysms causing compression or other complications.

Conclusion: Cervical artery dissection warrants vigilant clinical recognition, prompt imaging, and individualized treatment strategies. Early antithrombotic therapy—whether anticoagulation or antiplatelet—plays a critical role in preventing stroke. Decisions should reflect both the patient’s hemorrhagic risk and the presence of imaging features predictive of stroke. Mechanical thrombectomy and, in selected cases, stenting are viable acute interventions for high-risk presentations. Although recurrences are uncommon, thoughtful follow-up imaging, patient education, and avoidance of high-risk neck activities are central to minimizing future dissections and optimizing outcomes.

Reference: Yaghi S, Engelter S, Del Brutto VJ, Field TS, Jadhav AP, Kicielinski K, Madsen TE, Mistry EA, Salehi Omran S, Pandey A, Raz E, on behalf of the American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Peripheral Vascular Disease. Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association. Stroke. 2024;55(3). DOI: https://doi.org/10.1161/STR.0000000000000457

 

Review: Endovascular Management of Acute Stroke

20 Oct, 2024 | 14:43h | UTC

Introduction: Stroke due to large vessel occlusion (LVO) remains a leading cause of disability and mortality worldwide. Endovascular therapy has revolutionized acute ischemic stroke management by enhancing recanalization rates and improving patient outcomes. This review outlines the evolution of endovascular treatments, expansion of therapeutic indications, current best practices, and ongoing research in the endovascular management of acute stroke.

Key Recommendations:

  1. Early Time Window Therapy (0–6 Hours): Robust evidence from randomized controlled trials demonstrates that mechanical thrombectomy significantly improves functional outcomes in patients with anterior circulation LVO presenting within 6 hours of symptom onset. Patients are selected based on moderate-to-severe neurological deficits and small infarct cores identified via imaging.
  2. Extended Time Window Therapy (6–24 Hours): Trials such as DAWN and DEFUSE3 have extended thrombectomy benefits to patients up to 24 hours after symptom onset. Advanced imaging techniques, like CT perfusion and MRI, identify patients with substantial penumbral tissue, indicating potential for recovery.
  3. Large Ischemic Core Infarcts: Recent studies (e.g., SELECT2, ANGEL-ASPECT) suggest that patients with large core infarcts can benefit from endovascular therapy, challenging previous contraindications. Individualized patient selection is crucial to balance risks and benefits.
  4. Basilar Artery Occlusion: New evidence supports thrombectomy for basilar artery occlusions, especially in patients with moderate-to-severe symptoms. This intervention improves outcomes in a condition historically associated with high morbidity and mortality.
  5. Bridging Thrombolysis: The necessity of intravenous thrombolysis before thrombectomy in patients directly admitted to endovascular centers is under debate. Meta-analyses indicate that omitting thrombolysis may not adversely affect outcomes, although it remains standard for patients at non-thrombectomy centers.
  6. Simplified Imaging for Patient Selection: The use of non-contrast CT and CT angiography alone has proven effective for patient selection, reducing treatment delays and expanding access to thrombectomy, particularly in resource-limited settings.

Conclusion: Advancements in endovascular therapy have markedly improved outcomes for patients with acute ischemic stroke due to LVO. Expanded treatment indications and simplified imaging protocols have broadened patient eligibility for thrombectomy. Ongoing research into adjunctive therapies and optimization of management strategies holds promise for further reducing stroke-related disability and mortality.

Reference: Nguyen TN, et al. (2024) Endovascular management of acute stroke. Lancet. DOI: http://doi.org/10.1016/S0140-6736(24)01410-7

 

Cohort Study: One-Fourth of MS Relapses Occur Without MRI Activity, Highlighting ACES Phenomenon – JAMA Neurol

18 Aug, 2024 | 19:16h | UTC

Study Design and Population: This multicenter observational cohort study examined 637 clinical relapse events in 608 patients with relapsing-remitting multiple sclerosis (RRMS) from the French MS registry, spanning January 2015 to June 2023. The study included relapses with brain and spinal cord MRI performed within 12-24 months before and 50 days after the event.

Main Findings: Approximately 26% of relapses were classified as acute clinical events with stable MRI (ACES), showing no new T2 or gadolinium-enhanced T1 lesions. ACES were more likely in patients on highly effective disease-modifying therapies (DMTs), with longer disease duration, or with fatigue. ACES were associated with increased rates of relapse, confirmed disability accrual, and progression to secondary progressive MS, though their MRI stability was unaffected by DMTs.

Implications for Practice: The study suggests that MRI alone may not fully capture disease activity in RRMS, highlighting the need for comprehensive clinical assessment in therapeutic decision-making and clinical trial designs.

Reference: Gavoille, A., Rollot, F., Casey, R., et al. (2024). Acute clinical events identified as relapses with stable magnetic resonance imaging in multiple sclerosis. JAMA Neurology, 81(8), 814-823. DOI: 10.1001/jamaneurol.2024.1961.

 

Cohort Study: Efficacy of first-line color doppler ultrasound in diagnosing giant cell arteritis – Ann Intern Med

25 May, 2024 | 19:39h | UTC

This prospective multicenter study aimed to evaluate the efficacy of using color Doppler ultrasound of the temporal arteries as the first-line diagnostic tool for Giant Cell Arteritis (GCA) in 165 elderly patients with high clinical suspicion of the disease. The study followed participants over two years, comparing ultrasound results with temporal artery biopsy (TAB) and physician-based clinical diagnosis including other imaging tests. Key findings indicate that ultrasound confirmed GCA in 44% of cases, which was higher compared to TAB (17%) and clinical expertise (21%). The study showed that using ultrasound first can avoid the need for further invasive tests like TAB in patients with positive ultrasound results. The limitations of the study include its small sample size, unblinded test results, and the absence of a universally accepted objective diagnostic standard. However, it highlights the potential of ultrasound in the early and non-invasive diagnosis of GCA, potentially reducing the risk of severe complications by expediting treatment initiation.

 

Reference (link to abstract – $ for full-text):

Guillaume Denis et al. (2023). Diagnostic Strategy Using Color Doppler Ultrasound of Temporal Arteries in Patients With High Clinical Suspicion of Giant Cell Arteritis: A Prospective Cohort Study. Annals of Internal Medicine. DOI: 10.7326/M23-3417.

 

RCT | Endovascular treatment vs. no treatment after 6-24h in ischemic stroke patients with collateral flow on CT angiography

5 Apr, 2023 | 13:38h | UTC

Endovascular treatment versus no endovascular treatment after 6–24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial – The Lancet (link to abstract – $ for full-text)

 

Applying AI to MRI | A promising approach for detecting severe mental illness risk

4 Apr, 2023 | 13:25h | UTC

Detecting individuals with severe mental illness using artificial intelligence applied to magnetic resonance imaging – eBioMedicine

 

Cohort Study | Long-term changes in the size of pituitary microadenomas

3 Mar, 2023 | 13:49h | UTC

Summary: The prevalence of pituitary lesions in radiologic studies is estimated to be 10% to 38.5%. However, it is unclear how frequently incidental lesions should be monitored by serial pituitary MRI. A retrospective longitudinal cohort study was conducted to evaluate changes in pituitary microadenomas over time. During the study period (from 2003 to 2021), 414 patients with pituitary microadenomas were identified, and 177 patients had more than 1 MRI. Approximately two-thirds of the microadenomas demonstrated no change or a decrease in size, while the rest exhibited a slow growth rate, indicating that less frequent monitoring could be considered safe.

Article: Long-Term Changes in the Size of Pituitary Microadenomas – Annals of Internal Medicine (link to abstract – $ for full-text)

News Release: Fewer surveillance MRIs may be appropriate for patients with incidental pituitary lesions – American College of Physicians

 

Commentary on Twitter

 

Consensus Paper | Use of cerebral CT angiography to support a clinical diagnosis of death using neurological criteria

10 Feb, 2023 | 13:48h | UTC

The use of cerebral computed tomographic angiography as an ancillary investigation to support a clinical diagnosis of death using neurological criteria: a consensus guideline – Anaesthesia

 

Review | Brain enlarged perivascular spaces as imaging biomarkers of cerebrovascular disease

31 Jan, 2023 | 13:37h | UTC

Brain Enlarged Perivascular Spaces as Imaging Biomarkers of Cerebrovascular Disease: A Clinical Narrative Review – Journal of the American Heart Association

 

Commentary on Twitter

 

Cohort Study | Brain cancer after radiation exposure from CT examinations of children and young adults

18 Jan, 2023 | 14:36h | UTC

Brain cancer after radiation exposure from CT examinations of children and young adults: results from the EPI-CT cohort study – The Lancet Oncology (link to abstract – $ for full-text)

Commentaries:

Large Multinational Study Shows Link Between CT Radiation Exposure and Brain Cancer in Children and Young Adults – Diagnostic Imaging

New cancer risk analysis prompts experts to call for ‘careful justification’ of pediatric head CTs – Health Imaging

CT brain cancer risk quantified for children and young adults – medwire News

 

Review | Multimodality imaging of neurodegenerative disorders with a focus on multiparametric magnetic resonance and molecular imaging

18 Jan, 2023 | 14:11h | UTC

Multimodality imaging of neurodegenerative disorders with a focus on multiparametric magnetic resonance and molecular imaging – Insights into Imaging

 

Review | Safety and management of implanted epilepsy devices for imaging and surgery.

27 Nov, 2022 | 22:03h | UTC

Safety and Management of Implanted Epilepsy Devices for Imaging and Surgery – Mayo Clinic Proceedings

 

M-A | Use of CT of the head in patients with acute atraumatic altered mental status.

22 Nov, 2022 | 13:38h | UTC

Use of Computed Tomography of the Head in Patients With Acute Atraumatic Altered Mental Status: A Systematic Review and Meta-analysis – JAMA Network Open 

 

Commentary on Twitter 

 

Consensus Paper | State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease.

7 Nov, 2022 | 12:44h | UTC

State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease: standardization of scanning protocols and measurements—a consensus document by the European Society of Cardiovascular Radiology (ESCR) – European Radiology

 

Cohort Study | Clinical diagnosis and magnetic resonance imaging in patients with transient and minor neurological symptoms.

31 Oct, 2022 | 13:31h | UTC

Clinical Diagnosis and Magnetic Resonance Imaging in Patients With Transient and Minor Neurological Symptoms: A Prospective Cohort Study – Stroke

 

Commentary on Twitter

 

Cohort study | MRI visible perivascular spaces and risk of incident dementia.

27 Oct, 2022 | 12:25h | UTC

MRI Visible Perivascular Spaces and Risk of Incident Dementia: The Framingham Heart Study – Neurology (PDF)

 

Commentary on Twitter

 

Differentiating multiple sclerosis from AQP4-neuromyelitis optica spectrum disorder and MOG-antibody disease with imaging.

26 Oct, 2022 | 14:24h | UTC

Differentiating Multiple Sclerosis From AQP4-Neuromyelitis Optica Spectrum Disorder and MOG-Antibody Disease With Imaging – Neurology (PDF)

 

Commentary on Twitter

 

Cohort Study | Carotid plaque characteristics predict recurrent ischemic stroke and transient ischemic attack.

14 Oct, 2022 | 14:08h | UTC

Carotid Plaque Characteristics Predict Recurrent Ischemic Stroke and TIA: The PARISK (Plaque At RISK) Study – JACC: Cardiovascular Imaging

 

Radiological assessment of dementia | Consensus for a practical and clinically oriented guide to image acquisition, evaluation, and reporting.

13 Sep, 2022 | 13:13h | UTC

Radiological assessment of dementia: the Italian inter-society consensus for a practical and clinically oriented guide to image acquisition, evaluation, and reporting – La radiologia medica

 

European recommendations on practices in pediatric neuroradiology.

6 Sep, 2022 | 14:33h | UTC

European recommendations on practices in pediatric neuroradiology: consensus document from the European Society of Neuroradiology (ESNR), European Society of Paediatric Radiology (ESPR) and European Union of Medical Specialists Division of Neuroradiology (UEMS) – Pediatric Radiology

 

Systematic Review | Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments.

1 Sep, 2022 | 11:36h | UTC

Duplex ultrasound for diagnosing symptomatic carotid stenosis in the extracranial segments – Cochrane Library

Summary: How accurate is duplex ultrasound (DUS) imaging for diagnosing carotid artery stenosis in symptomatic patients? – Cochrane Library

 

Review | Role of imaging in CNS infections.

9 Aug, 2022 | 12:26h | UTC

Role of imaging in CNS infections – Indian Journal of Pathology & Microbiology

 

Consensus on magnetic resonance imaging of endolymphatic hydrops in patients with suspected hydropic ear disease (Meniere).

26 Jul, 2022 | 12:40h | UTC

Consensus on MR Imaging of Endolymphatic Hydrops in Patients With Suspected Hydropic Ear Disease (Meniere) – Frontiers in Surgery

Editorial: Editorial: Hydropic Ear Disease: Imaging and Functional Evaluation – Frontiers in Surgery

Commentary: Guidance Issued for MR Imaging of Endolymphatic Hydrops – HealthDay

 

Brain volume abnormalities and clinical outcomes following pediatric traumatic brain injury.

15 Jul, 2022 | 12:41h | UTC

Brain volume abnormalities and clinical outcomes following paediatric traumatic brain injury – Brain

News Release: Head injuries in children linked to reduced brain size and learning difficulties – Imperial College London

Commentary: Experts use MRI to pinpoint link between pediatric TBI and cognitive impairment – Health Imaging

 

Commentary on Twitter

 

Retrospective Cohort Study | Magnetic resonance imaging prognostic findings for visual and mortality outcomes in acute invasive fungal rhinosinusitis.

6 Jul, 2022 | 11:16h | UTC

Magnetic Resonance Imaging Prognostic Findings for Visual and Mortality Outcomes in Acute Invasive Fungal Rhinosinusitis – Ophthalmology

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