Department of Neuroradiology, Université Paris-Descartes, Sorbonne Paris Cité, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, France.
Cerebrovasc Dis. 2013;35(2):175-81. doi: 10.1159/000346592. Epub 2013 Feb 21.
In case of spontaneous cervical artery dissection (CAD), a medical treatment with anticoagulant or antiplatelet (AP) drugs would avoid the occurrence of an ischemic stroke. Although immediate anticoagulation (AC) is advocated, evidence from randomized trials is lacking. Since CAD is characterized by a mural accumulation of blood, the dissecting hematoma may enlarge under AC, with subsequent lumen narrowing. Although direct evidence of mural hematoma enlargement is lacking in the literature, such a complication may not only be theoretical. Magnetic resonance imaging (MRI) of the mural hematoma on transverse sections through the neck is the current diagnostic gold standard. Our aim was to compare the evolution of the mural hematoma in CAD during the first week after treatment initiation (AP agent: groupAP, AC: groupAC), using dedicated cervical MRI of the arterial wall.
The study was -approved by the Ethics Committee of Ile de France III. Informed consent was waived. The manuscript was prepared in accordance with the STROBE statement. Fast spin-echo T1-weighted fat-suppressed axial sequences were performed at admission (MRI1) and during the first week after initiation of the treatment (MRI2). Two readers measured volumes, craniocaudal length of the mural hematoma and lumen patency, and searched for early recurrent CAD. They also searched for extension or recurrence of ischemic brain lesions and for hemorrhagic transformation on diffusion-weighted imaging (DWI) and gradient echo T2 (T2*) sequences, respectively.
The population included 44 patients (31 in groupAC, 13 in groupAP) with 49 CAD (35 carotid, 14 vertebral). Recurrent CAD and reduction of the lumen did not occur in either group. We did not observe recurrent DWI lesions or occurrence of hemorrhagic transformation. Interobserver agreement [intraclass correlation coefficient (95% CI)] was excellent for volume measurement [0.98 (0.97-0.99) and 0.99 (0.98-1.0) for volume1 and volume2, respectively]. While mean volumes and length of the mural hematoma decreased after treatment in both groups (volume: groupAC -13 ± 22%, groupAP -12 ± 24%, p = 0.33; length: groupAC -10 ± 27%, groupAP -10 ± 20%, p = 0.18), approximately one third of patients in each group had some growth of the mural hematoma as well as an increase in length.
Limited growth of the mural hematoma was seen with both treatments in approximately one third of patients during the first week after treatment initiation. However, neither AC nor AP agents promote reduction of the lumen or recurrent dissection.
在自发性颈内动脉夹层（CAD）的情况下，使用抗凝或抗血小板（AP）药物进行治疗可以避免发生缺血性中风。尽管主张立即抗凝（AC），但缺乏随机试验的证据。由于 CAD 的特征是血液在血管壁上的积聚，因此在 AC 下，夹层血肿可能会扩大，随后管腔变窄。尽管文献中缺乏关于壁血肿增大的直接证据，但这种并发症可能不仅是理论上的。通过颈部横断面上的磁共振成像（MRI）对壁血肿进行检测，是目前的诊断金标准。我们的目的是使用专门的动脉壁颈 MRI 来比较 CAD 患者在治疗开始后第一周内壁血肿的演变情况（AP 药物组：groupAP，AC 组：groupAC）。
本研究得到法兰西岛第三大学伦理委员会的批准。豁免了知情同意。手稿的准备符合 STROBE 声明。在入院时（MRI1）和治疗开始后的第一周内（MRI2）进行快速自旋回波 T1 加权脂肪抑制轴向序列。两位读者测量了血肿体积、血肿的颅尾长度和管腔通畅性，并对早期复发 CAD 进行了检查。他们还分别在弥散加权成像（DWI）和梯度回波 T2（T2*）序列上检查了脑缺血性病变的扩展或复发和出血性转化。
该人群包括 44 名患者（31 名在 groupAC 组，13 名在 groupAP 组），共有 49 例 CAD（35 例颈动脉，14 例椎动脉）。两组均未发生复发性 CAD 和管腔狭窄。我们未观察到复发性 DWI 病变或出血性转化。观察者间的一致性[组内相关系数（95%CI）]在体积测量方面非常好[volume1 和 volume2 的分别为 0.98（0.97-0.99）和 0.99（0.98-1.0）]。两组治疗后血肿体积和长度均减小（体积：groupAC -13 ± 22%，groupAP -12 ± 24%，p = 0.33；长度：groupAC -10 ± 27%，groupAP -10 ± 20%，p = 0.18），但每组约三分之一的患者的壁血肿有一定程度的增长，长度也有所增加。
在治疗开始后第一周内，两种治疗方法均有约三分之一的患者的壁血肿有一定程度的增长。然而，AC 和 AP 药物均不能促进管腔狭窄的减少或复发性夹层。
