Cervical Artery Dissection May Lack Pain, Mechanical Trigger Over Age 60

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You think you'd notice a huge artery in your neck ripping
Pain and mechanical trigger for cervical artery dissection (CeAD) were more often missing in patients over age 60.  If a patient over age 60 lacks typical features for CeAD - neck pain, mechanical triggering event, or migraine - but has other symptoms concerning for it, keep CeAD in the differential diagnosis.  Symptoms of CeAD include headache, unilateral neurological deficits, or brainstem or cerebellar ischemic symptoms such as vertigo, vomiting, or nystagmus.  Patients may present with Wallenberg syndrome.  What's that?  Do not miss the LiTFL Brainstem Rules of 4.  This excellent post is neuroanatomy you can actually remember.  Then take the quiz - Brush up on your brainstem syndromes - a fantastic teaching tool from LiTFL.

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Think about cervical artery dissection in patients over 60 even if they lack some of the usual features - neck pain, mechanical trigger, or migraine.


Abstract

Neurology. 2017 Mar 3. pii: 10.1212/WNL.0000000000003788. doi: 10.1212/WNL.0000000000003788. [Epub ahead of print]

Cervical artery dissection in patients ≥60 years: Often painless, few mechanical triggers.

Traenka C1, Dougoud D2, Simonetti BG2, Metso TM2, Debette S2, Pezzini A2, Kloss M2, Grond-Ginsbach C2, Majersik JJ2, Worrall BB2, Leys D2, Baumgartner R2, Caso V2, Béjot Y2, Compter A2, Reiner P2, Thijs V2, Southerland AM2, Bersano A2, Brandt T2, Gensicke H2, Touzé E2, Martin JJ2, Chabriat H2, Tatlisumak T2, Lyrer P2, Arnold M2, Engelter ST2; CADISP-Plus Study Group.

Author information:

1 From the Department of Neurology and Stroke Center (C.T., H.G., P.L., S.T.E.), University Hospital Basel and University of Basel; Department of Neurology (D.D., B.G.S., M.A.), University Hospital Berne; Ospedale San Giovanni (B.G.S.), Bellinzona, Switzerland; Department of Neurology (T.M.M., T.T.), Helsinki University Central Hospital, Finland; Department of Neurology (S.D.), Bordeaux University Hospital; Inserm U1219 (S.D.), Bordeaux; Bordeaux University (S.D.), France; Department of Neurology (S.D.), Boston University School of Medicine, MA; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia, Italy; Department of Neurology (M.K., C.G.-G.), Heidelberg University Hospital, Germany; Department of Neurology (J.J.M.), University of Utah, Salt Lake City; Departments of Neurology and Public Health Sciences (B.B.W., A.M.S.), University of Virginia Health System, Charlottesville; Univ Lille 2 (D.L.), INSERM U 1171, CHU Lille, France; Neuro Center (R.B.), Clinic Hirslanden, Zurich, Switzerland; Stroke Unit and Division of Internal and Cardiovascular Medicine (V.C.), University of Perugia, Italy; Centre Hospitalier Universitaire Le Bocage (Y.B.), Dijon, France; Department of Neurology and Neurosurgery (A.C.), Brain Centre Rudolf Magnus, University Medical Centre Utrecht, the Netherlands; Department of Neurology (P.R., H.C.), Lariboisière Hospital, Paris 7 University, DHU Neurovasc Sorbonne Paris Cité, France; Florey Institute of Neuroscience and Mental Health (V.T.); Department of Neurology (V.T.), Austin Health, Heidelberg, Australia; Cerebrovascular Unit (A.B.), IRCCS Foundation C. Besta Neurological Institute, Milan, Italy; Clinics for Neurologic Rehabilitation (T.B.), Kliniken Schmieder, Heidelberg, Germany; Normandie Univ (E.T.), UNICAEN, Inserm U919, Department of Neurology, CHU Caen; Department of Neurology (E.T.), CH Sainte-Anne, University Paris Descartes, France; Department of Neurology (J.J.M.), Sanatorio Allende, Cordoba, Argentina; Department of Neurology (T.T.), Sahlgrenska University Hospital and Institute for Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland. christopher.traenka@usb.ch.

2 From the Department of Neurology and Stroke Center (C.T., H.G., P.L., S.T.E.), University Hospital Basel and University of Basel; Department of Neurology (D.D., B.G.S., M.A.), University Hospital Berne; Ospedale San Giovanni (B.G.S.), Bellinzona, Switzerland; Department of Neurology (T.M.M., T.T.), Helsinki University Central Hospital, Finland; Department of Neurology (S.D.), Bordeaux University Hospital; Inserm U1219 (S.D.), Bordeaux; Bordeaux University (S.D.), France; Department of Neurology (S.D.), Boston University School of Medicine, MA; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia, Italy; Department of Neurology (M.K., C.G.-G.), Heidelberg University Hospital, Germany; Department of Neurology (J.J.M.), University of Utah, Salt Lake City; Departments of Neurology and Public Health Sciences (B.B.W., A.M.S.), University of Virginia Health System, Charlottesville; Univ Lille 2 (D.L.), INSERM U 1171, CHU Lille, France; Neuro Center (R.B.), Clinic Hirslanden, Zurich, Switzerland; Stroke Unit and Division of Internal and Cardiovascular Medicine (V.C.), University of Perugia, Italy; Centre Hospitalier Universitaire Le Bocage (Y.B.), Dijon, France; Department of Neurology and Neurosurgery (A.C.), Brain Centre Rudolf Magnus, University Medical Centre Utrecht, the Netherlands; Department of Neurology (P.R., H.C.), Lariboisière Hospital, Paris 7 University, DHU Neurovasc Sorbonne Paris Cité, France; Florey Institute of Neuroscience and Mental Health (V.T.); Department of Neurology (V.T.), Austin Health, Heidelberg, Australia; Cerebrovascular Unit (A.B.), IRCCS Foundation C. Besta Neurological Institute, Milan, Italy; Clinics for Neurologic Rehabilitation (T.B.), Kliniken Schmieder, Heidelberg, Germany; Normandie Univ (E.T.), UNICAEN, Inserm U919, Department of Neurology, CHU Caen; Department of Neurology (E.T.), CH Sainte-Anne, University Paris Descartes, France; Department of Neurology (J.J.M.), Sanatorio Allende, Cordoba, Argentina; Department of Neurology (T.T.), Sahlgrenska University Hospital and Institute for Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden; and Neurorehabilitation Unit (S.T.E.), University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland.

Abstract

OBJECTIVE:

In a cohort of patients diagnosed with cervical artery dissection (CeAD), to determine the proportion of patients aged ≥60 years and compare the frequency of characteristics (presenting symptoms, risk factors, and outcome) in patients aged <60 vs ≥60 years.

METHODS:

We combined data from 3 large cohorts of consecutive patients diagnosed with CeAD (i.e., Cervical Artery Dissection and Ischemic Stroke Patients-Plus consortium). We dichotomized cases into 2 groups, age ≥60 and <60 years, and compared clinical characteristics, risk factors, vascular features, and 3-month outcome between the groups. First, we performed a combined analysis of pooled individual patient data. Secondary analyses were done within each cohort and across cohorts. Crude and adjusted odds ratios (OR [95% confidence interval]) were calculated.

RESULTS:

Among 2,391 patients diagnosed with CeAD, we identified 177 patients (7.4%) aged ≥60 years. In this age group, cervical pain (ORadjusted 0.47 [0.33-0.66]), headache (ORadjusted 0.58 [0.42-0.79]), mechanical trigger events (ORadjusted 0.53 [0.36-0.77]), and migraine (ORadjusted 0.58 [0.39-0.85]) were less frequent than in younger patients. In turn, hypercholesterolemia (ORadjusted 1.52 [1.1-2.10]) and hypertension (ORadjusted 3.08 [2.25-4.22]) were more frequent in older patients. Key differences between age groups were confirmed in secondary analyses. In multivariable, adjusted analyses, favorable outcome (i.e., modified Rankin Scale score 0-2) was less frequent in the older age group (ORadjusted 0.45 [0.25, 0.83]).

CONCLUSION:

In our study population of patients diagnosed with CeAD, 1 in 14 was aged ≥60 years. In these patients, pain and mechanical triggers might be missing, rendering the diagnosis more challenging and increasing the risk of missed CeAD diagnosis in older patients.

© 2017 American Academy of Neurology.

PMID: 28258079