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PubMed1994

Radical lymph node dissection for cancer of the thoracic esophagus.

OBJECTIVE: The authors documented the localization and frequency of lymphatic spread in squamous cell carcinoma of the thoracic esophagus and evaluated the influence of radical systematic lymph node dissection on patient survival. SUMMARY BACKGROUND DATA: From accumulated surgical experience, it was suggested that some of the patients with lymph nodal involvement from cancer could be cured by its clearance. However, it is only recently that cancer of the esophagus has been evaluated in terms of analyzing lymphatic spread and results of lymphadenectomy. METHODS: Among 1298 patients admitted to the Toranomon Hospital between 1973 and 1993, 913 (70.3%) had resections, including curative and palliative procedures. For this study, 717 patients with TNM RO (resection with no residual tumor at operation in TNM classification) were analyzed. Survival was compared between groups of patients with less extensive thoracoabdominal (two-field) dissections and extensive collothoracoabdominal (three-field) dissections. RESULTS: Comparative study revealed that 5-year survival rate for TNM RO patients after free-field dissection (55.0%) was significantly better (log rank test, p = 0.0013) than the rate after two-field dissection (38.3%). The results were particularly significant in subgroups with stage III and IV (because of nodal factor). Overall 5-year survival rate after all resections was 42.4%. CONCLUSIONS: The role of radical lymph node dissection in cancer of the thoracic esophagus evaluated. Long-term survival was compared between two groups with two- and three-field dissection. It was concluded that survival rate was significantly better in patients with extensive three-field dissection.

Carcinoma, Squamous Cell↗

PubMed1998

Reassessment of the coronal incision and subgaleal dissection for foreheadplasty.

Thirty years ago, the aging upper face was generally ignored by surgeons performing facial rejuvenation surgery. Ultimately, the coronal incision forehead lift technique became an accepted procedure, with most surgeons raising the forehead flap at the subgaleal plane. These surgeons found the subgaleal plane to be the "natural" or most accessible dissection plane to use, and it continues to be the most commonly used dissection plane for foreheadplasty today. However, some surgeons have begun to advocate using the subperiosteal plane, and controversy surrounds the question of which dissection plane is more surgically sound for raising a forehead flap. On the basis of 25 fresh cadaver dissections and more than 20 years of clinical experience with foreheadplasty, the author concludes that dissection done at the subperiosteal rather than the subgaleal plane provides greater benefit to the patient. Although both subgaleal and subperiosteal planes can provide relative ease of dissection, elevation of the forehead flap at the subperiosteal plane can maximally preserve blood supply for the forehead flap and predictably preserve long-term frontoparietal scalp sensation. The deep division of the supraorbital nerve, which provides sensation to the frontoparietal scalp, is placed at risk for transection with subgaleal elevation of the forehead flap. The skin incision approach chosen for the forehead flap can also affect postoperative frontoparietal scalp sensation. The deep division of the supraorbital nerve will always be transected by a coronal incision approach for forehead flap elevation, with dissection done at either the subgaleal or the subperiosteal level. Only limited scalp incisions placed to avoid the course of the deep division of the supraorbital nerve can avoid transecting this nerve, and only subperiosteal dissection of the forehead flap can predictably preserve this nerve while elevating the forehead flap.

Endoscopy↗

PubMed2004

Anatomical extent of lymph node dissection: impact on men with clinically localized prostate cancer.

PURPOSE: This study evaluates the influence of the anatomical extent of pelvic lymph node dissection performed at radical prostatectomy on lymph node yield, staging accuracy and time to prostate specific antigen progression. MATERIALS AND METHODS: Between February 1992 and April 2003, 2 surgeons at 1 hospital performed 2,135 and 1,865 radical prostatectomies with pelvic lymph node dissection, respectively. One surgeon routinely performed an extended lymph node dissection while the second surgeon performed a limited pelvic lymphadenectomy. The number of lymph nodes extracted and the number of patients with positive lymph nodes detected were analyzed and compared. Kaplan-Meier analysis was used to compare the biochemical recurrence-free survival between the 2 groups of patients with occult nodal disease. RESULTS: Extended lymph node dissection removed more lymph nodes (mean 11.6 vs 8.9, p<0.0001) and detected more lymph node positive disease (3.2% vs 1.1%, p<0.0001) than the more anatomically limited technique. This finding held true for patients across all pathology groups. Among men with lymph node positive disease involving less than 15% of extracted nodes, the 5-year prostate specific antigen progression-free rate for extended lymph node dissection was 43% versus 10% for the more limited lymph node dissection (p = 0.01). CONCLUSIONS: Compared to limited lymph node dissection, extended pelvic lymphadenectomy appears to identify men with positive lymph nodes more frequently. A significant benefit in biochemical recurrence-free survival may exist for certain subgroups undergoing the extended dissection. However, because the results may be influenced by stage migration, longer followup is necessary to determine whether the apparent therapeutic effect persists.

Adult↗

PubMed2004

Improved survival for patients with upper and/or middle mediastinal lymph node metastasis of squamous cell carcinoma of the lower thoracic esophagus treated with 3-field dissection.

OBJECTIVE: To evaluate the outcomes with 2 and 3 lymph node dissection for patients with squamous cell carcinoma of the lower thoracic esophagus at a single institution. BACKGROUND: Extensive lymph node dissection, including the upper mediastinum, for carcinoma of the lower thoracic esophagus is advocated as a standard surgical procedure with curative intent in Japan. However, its efficacy remains controversial. METHODS: From January 1988 to December 1997, 532 patients with carcinomas of the thoracic esophagus underwent transthoracic esophagectomy and extensive lymph node dissection with curative intent at the National Cancer Center Hospital, Tokyo. Of these, 495 (93%) had squamous cell carcinomas. A total of 156 (29%) with tumors of the lower thoracic esophagus were retrospectively analyzed. RESULTS: Of the 156 patients, 55 (35%) underwent 2-field and 101 (65%) underwent 3-field lymph node dissection. The operative morbidity and 30-day and in-hospital mortality rates were 68.0%, 1.3%, and 2.6%, respectively. The overall 5-year survival rate for the entire series was 49.3%. One hundred and seven (69%) had lymph node metastases. Upper and/or middle mediastinal lymph node metastases occurred in 42% of the series. The 5-year survival rate for patients with lymph node metastases in the upper and/or middle mediastinum was 23.3%. Among them, the values after 2- and 3-field lymph node dissection were 5.6% and 30.0%, respectively (P = 0.005). Thirteen (27%) of 48 patients with upper and/or middle mediastinal lymph node metastases treated with 3-field dissection had simultaneous cervical lymph node metastases and their 5-year survival rate was 23.1%. CONCLUSION: The 3-field approach for extensive lymph node dissection provides better survival benefit for patients with squamous cell carcinoma of the lower thoracic esophagus compared to 2-field lymph node dissection when lymph node metastases are present in the upper and/or middle mediastinum.

Adult↗

PubMed1997

Sentinel node dissection in the treatment of melanoma. Report of three cases and review of the literature.

BACKGROUND: Elective lymph node dissection for treatment of cutaneous malignant melanoma is controversial. Sentinel node dissection involves removing the primary lymph node in a nodal basin that drains a particular cutaneous lesion. Theoretically, this node would collect regional metastases first. Therefore, if this node is negative, the chances are low that the melanoma would have spread either systemically or to other nodes within this basin. Removing one node would decrease the morbidity associated with radical lymph node dissection. However, the actual risk of widespread metastases in sentinel node-negative patients is yet to be determined, pending results of large, multicenter studies currently under investigation. OBJECTIVE: To present three cases of intermediate thickness cutaneous melanoma treated with selective lymph node dissection and to review the techniques of selective lymphadenectomy and lymphoscintigraphy. METHODS: In a nonrandomized prospective evaluation, patients with intermediate depth melanomas or in transit metastases without signs of systemic disease were given the opportunity for further investigation by sentinel node dissection to determine if additional lymph node dissection or adjunctive therapies would be advantageous. RESULTS: All three patients had negative sentinel node examinations. Two are without visceral or nodal metastases 1 year after the procedure. The third had in-transit metastases from the outset, had in-transit metastases on sentinel node/lymphatic examination, and now has systemic cutaneous metastases. Complications of sentinel node dissection were limited to transient postoperative lymphedema of the extremities and transient seroma formation. No postoperative wound infections or permanent nerve damage were noted. CONCLUSIONS: Our preliminary findings in this limited series suggests that sentinel node dissection appears to be a procedure of low morbidity and relatively high predictive value.

Aged↗

PubMed2002

Acute aortic dissection related to crack cocaine.

BACKGROUND: Although single case reports have described acute aortic dissection in relation to cocaine use, this condition is not widely recognized, and the features of cocaine-related aortic dissection have not been defined. METHODS AND RESULTS: We reviewed all available hospital charts from 1981 to 2001 with the ICD-9 diagnosis of aortic dissection. Among the 38 cases of acute aortic dissection, 14 (37%) were related to cocaine use. Crack cocaine was smoked in 13 cases and powder cocaine was snorted in 1 case. The mean interval between cocaine use and the onset of symptoms was 12 hours (range, 0 to 24). Patients with cocaine-related dissection were much younger and more likely to undergo surgery compared with patients with aortic dissection without cocaine use. Most in the cocaine group were black, with a history of untreated hypertension. However, the two groups did not differ in other respects, including dissection type. CONCLUSIONS: In an inner city population, acute aortic dissection in the setting of crack cocaine use is common, presumably as a consequence of abrupt, transient, severe hypertension and catecholamine release. This diagnosis should be considered in cocaine users with severe chest pain.

Acute Disease↗

PubMed2004

Axillary treatment in conservative management of operable breast cancer: dissection or radiotherapy? Results of a randomized study with 15 years of follow-up.

PURPOSE: Axillary dissection is the standard management of the axilla in invasive breast carcinoma. This surgery is responsible for functional sequelae and some options are considered, including axillary radiotherapy. In 1992, we published the initial results of a prospective randomized trial comparing lumpectomy plus axillary radiotherapy versus lumpectomy plus axillary dissection. We present an update of this study with a median follow-up of 180 months (range, 12 to 221 months). PATIENTS AND METHODS: Between 1982 and 1987, 658 patients with a breast carcinoma less than 3 cm in diameter and clinically uninvolved lymph nodes were randomly assigned to axillary dissection or axillary radiotherapy. All patients underwent wide excision of the tumor and breast irradiation. RESULTS: The two groups were similar for age, tumor-node-metastasis system stage, and presence of hormonal receptors; 21% of the patients in the axillary dissection group were node-positive. Our initial results showed an increased survival rate in the axillary dissection group at 5 years (P =.009). At 10 and 15 years, however, survival rates were identical in both groups (73.8% v 75.5% at 15 years). Recurrences in the axillary node were less frequent in the axillary dissection group at 15 years (1% v 3%; P =.04). There was no difference in recurrence rates in the breast or supraclavicular and distant metastases between the two groups. CONCLUSION: In early breast cancers with clinically uninvolved lymph nodes, our findings show that long-term survival does not differ after axillary radiotherapy and axillary dissection. The only difference is a better axillary control in the group with axillary dissection.

Adult↗

PubMed2006

Postradiotherapy neck dissection for lymph node-positive head and neck cancer: the use of computed tomography to manage the neck.

PURPOSE: To determine how to use node response on computed tomography (CT) to indicate the need for neck dissection. PATIENTS AND METHODS: Five hundred fifty patients with lymph node-positive head and neck cancer were treated between 1990 and 2002 with radiotherapy (RT) at a median dose of 74.4 Gy; 24% of these patients (n = 133) were treated with chemotherapy. Three hundred forty-one patients (62%) underwent planned post-RT neck dissection. Physical examination and contrast-enhanced CT were performed 30 days after completion of RT. CT images were reviewed in 211 patients for lymph node size (largest axial dimension) and presence of a focal abnormality (lucency, enhancement, or calcification). By correlating post-RT CT to neck dissection pathology, criteria associated with a low likelihood of residual disease were identified. A subset of patients who fit these criteria of radiographic response who did not undergo post-RT neck dissection was observed for recurrence. RESULTS: Radiographic complete response (rCR) was defined as the absence of any large (> 1.5 cm) or focally abnormal lymph node. Correlation of response with neck dissection pathology indicated a negative predictive value of 77% for complete clinical response and 94% for rCR. In 32 patients (median follow-up time, 3.2 years) with rCR who did not undergo post-RT neck dissection, the 5-year ultimate neck control rate (100%) and cause-specific survival rate (72%) were not significantly different from the rates of patients with a negative post-RT neck dissection. CONCLUSION: Patients with rCR 4 weeks after RT can be spared from a post-RT neck dissection regardless of initial node stage.

Adult↗

PubMed1999

Clinically benign parotid tumours: local dissection as an alternative to superficial parotidectomy in selected cases.

In a personal series of 162 tumours, 101 were pleomorphic adenomas 28 of which were removed by elective local extra capsular dissection and 73 by a conventional nerve dissection. There were no recurrences in either group after a mean follow-up 10.3 years, range 3-21 years for local dissection and 8.3 years, range 3-22 years for nerve dissection. Frey's syndrome did not occur after local dissection but was present in 25% of patients after a nerve dissection. Of the 162 parotid lumps, 17 proved to be a carcinoma but only one was deemed suitable for a local removal, a low grade muco epidermoid carcinoma of the accessory lobe and no recurrence has occurred after 8 years. In benign disease, local dissection gives similar results to conventional nerve dissection with less morbidity and confirms that tumour recurrence cannot be ascribed to any properties of the tumour but lies in the hands of the surgeon and depends on the care with which the tumour is removed.

Adenoma, Pleomorphic↗

PubMed2001

Acute myocardial infarction caused by aortic dissection.

Clinical presentation of aortic dissection is similar to that of acute myocardial infarction (AMI). Clinical differential diagnoses from lethal chest pain in emergency department include AMI, aortic dissection, pulmonary embolism, tension pneumothorax, etc. Thrombolytic therapy for recanalization of thrombotic occluded coronary artery in AMI must be considered, but it is absolutely contraindicated for aortic dissection. However, AMI secondary to aortic dissection is a rare condition, which might be caused by compression of the coronary arteries by a hematoma or extension of the dissection into the coronary arterial wall. Surgery is the first choice for AMI secondary to aortic dissection caused by extension of dissection into the coronary arterial wall. We present a case of inferior wall AMI caused by type I aortic dissection with presentation of chest pain and hemiparaplegia of right lower limb.

Aortic Diseases↗

PubMed2002

When is total aortic arch replacement indicated in patients with acute aortic dissection?

BACKGROUND: The purpose of this preliminary study was to evaluate the effectiveness of our surgical strategy for acute aortic dissection with special emphasis on curative resection of the dissected segments of the aorta. MATERIAL/METHODS: Between January 1995 and April 1999, 29 patients underwent surgery for acute aortic dissection. In 16 patients (Group 1) the dissection was limited to the ascending aorta (8 patients - Group 1a) or involved the ascending aorta and the entire aortic arch (8 patients - Group 1b). Complete resection of all dissected aortic segments (ascending aorta or ascending aorta with complete aortic arch) was performed in these cases, extending to the healthy tissue border. 13 patients (Group 2) presented with dissection of the entire aorta). These patients underwent replacement of the proximal part only of the dissected aorta. RESULTS: Early mortality (within 30 days) and the incidence of perioperative cerebrovascular events was 3.4% and 10.3% respectively. These events all occurred in Group 2. During the follow-up period of up to six years, there were no significant differences between the surviving patients in regards to long-term mortality and morbidity, although a persisting patent false lumen was observed in seven patients from Group 2. CONCLUSIONS: Extension of ascending aorta replacement to include the complete aortic arch can be accomplished in patients amenable to complete resection of the dissected aorta without increasing operative risk and with good mid-term results. We believe that total aortic arch replacement is indicated in these cases.

Aged↗

PubMed1995

Outpatient pelvic lymph node dissection.

PURPOSE: Staging pelvic lymph node dissection is an important part of the evaluation of most patients with prostatic carcinoma. While laparoscopic pelvic lymph node dissection provides an alternative to standard pelvic lymph node dissection, it has been associated with a significant learning curve, high major complication rate, frequent hospitalization and greater expense. We sought to modify the technique of pelvic lymph node dissection to allow its performance as an outpatient procedure. MATERIALS AND METHODS: Pelvic lymph node dissection was performed through bilateral 3 cm. incisions overlying the obturator fossa in 11 patients. RESULTS: Nodes sampled ranged from 5 to 26 per patient that differed insignificantly from those undergoing standard pelvic lymph node dissection. Four patients had lymph node metastases. Nine procedures were performed entirely on an outpatient basis. One complication (external vein injury) was repaired with a single suture after extending the incision to 6 cm. CONCLUSIONS: Outpatient pelvic lymph node dissection through small incisions provides an attractive alternative to standard or laparoscopic lymph node dissection. With further experience it may become the procedure of choice for staging prostatic carcinoma in patients with a high risk of pelvic lymph node metastases.

Aged↗

PubMed1996

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous germ cell tumors: indications and limitations.

PURPOSE: We describe our experience with laparoscopic retroperitoneal lymph node dissection in 26 patients with nonseminomatous germ cell tumors: 17 had stage I disease with no clinical (computerized tomography, ultrasound or tumor markers) evidence of metastases and 9 (2 with stage IIb and 7 with stage IIc disease) had residual tumor after chemotherapy but with negative tumor markers. Laparoscopic dissection was performed to assess more fully pathological status of the relevant retroperitoneal lymph nodes in both groups. MATERIALS AND METHODS: The patient was positioned and trocars were introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position with 3, 10 mm. and 2, 5 mm. ports). After the white line of Toldt was incised and the colon was reflected anteromedially, the retroperitoneal space was exposed. The landmarks of lymph node dissection were then isolated, including the ureter, aorta, inferior vena cava and both renal veins. Lymph node dissection was performed identical to that for open surgery, with a modified template including the paracaval, interaortocaval, upper preaortic and right common iliac nodes for right tumors, and para-aortic and upper preaortic nodes for left tumors. Lymph node chains were retrieved with a small organ bag. RESULTS: The procedure was completed successfully in 16 of 17 patients with stage I disease (mean duration 268 minutes for the left and 312 minutes for the right sides). No intraoperative complications were encountered. One patient had delayed ureteral stenosis requiring operative repair, 1 had a pulmonary embolism with an uneventful outcome and 1 who underwent laparoscopic retroperitoneal lymph node dissection on the right side later had retrograde ejaculation. Embryonal carcinoma was found in 1 of the 17 patients. Average postoperative hospital stay was 4.5 days for patients without complications or conversion to an open procedure. After a median followup of 27 months no patient had regional relapse but 2 had pulmonary metastases that were treated successfully with 3 cycles of platinum based chemotherapy. Laparoscopic dissection was significantly more difficult in patients with stage II tumors after chemotherapy. Only in 2 patients with stage IIb disease was laparoscopic lymphadenectomy successful. In 5 of the 7 patients with stage IIc cancer portions of the dissection had to be done after conversion to an open (conventional) operation via a small incision (suprainguinal or pararectal). In 1 patient the laparoscopic approach was completely abandoned and converted to an open operation via a standard midline incision. In all 9 cases histopathological examination revealed complete necrosis. No patient has evidence of disease. CONCLUSIONS: Our preliminary experience suggests that a modified laparoscopic retroperitoneal lymph node dissection is feasible for stage I tumors. However, it cannot be recommended after previous chemotherapy (stages IIb and IIc disease).

Follow-Up Studies↗

PubMed1996

Merkel cell cancer: is prophylactic lymph node dissection indicated?

Our objective was to determine prognostic factors and the role of prophylactic lymph node dissection in Merkel cell cancer. A retrospective chart review of 15 patients from Loma Linda University Medical Center, Loma Linda, and Kaiser Permanente, Fontana, was used. The most important predictor of survival was presence of lymph node metastasis (P = 0.03). Lymph node metastasis was the first sign of recurrence in 60 per cent of patients and preceded distant metastasis. Age at presentation, tumor size, and location had no influence on survival. Gross presurgical determination of tumor extent was misleading. Microscopically positive margins necessitated reexcision in 60 per cent of patients. Local recurrence occurred in 27 per cent of patients. Recurrence at lymph node basins was lower in patients with elective lymph node dissection (0%) compared with therapeutic node dissection (57%)(P < 0.05). Incidence of micrometastases in patients undergoing prophylactic lymph node dissection was 100 per cent. No difference in survival was seen between prophylactic and therapeutic node dissection. Because Merkel cell cancer spreads in a "cascade" fashion, elective node dissection may provide a chance for a cure. Elective node dissection provides better locoregional control compared with therapeutic node dissection and helps to determine prognosis.

Aged↗

PubMed1997

[Lymph node dissection during a video-assisted lobectomy is inferior to that in a standard lobectomy].

The indications for a video-assisted lobectomy are currently ill-defined. Clinicians recommend based on the extent of lymph node involvement. Fifty-nine patients with clinical stage I non-small cell lung cancer underwent lobectomies with systemic lymph node dissections through a standard thoracotomy (Group C), and 26 patients underwent lobectomies with lymph node dissections using the video-assisted procedure (Group V). The number of dissected lymph nodes at all node levels were compared between the two groups. There was no significant difference between groups in the total number of dissected lymph nodes in patients with right lung cancer. The number of dissected hilar and interlobar lymph nodes, however, was less in Group V than that in Group C (hilar: 1.2 +/- 0.4 vs. 2.8 +/- 0.6, interlobar: 1.1 +/- 0.4 vs. 2.1 +/- 0.4). The total number of dissected lymph nodes in patients with left lung cancer was significantly less in Group V than that in Group C (18.5 +/- 0.3 vs. 28.7 +/- 2.4). In addition, the number of dissected lymph nodes in pratracheal, pretracheal, tracheobronchial, subcarinal, hilar, and interlobar lymph nodes were significantly less in the group V than those in Group C. Although there was no significant difference in the actual survival rates between the groups in this preliminary study, a sufficiently small number of dissected lymph nodes in the video-assisted lobectomy may have resulted in inaccurate staging and poor prognosis in these patients.

Aged↗

PubMed2006

[Cervical arteries dissection: diagnostic Color Doppler US criteria at the acute phase].

PURPOSE: To estimate the value of duplex color-coded ultrasonography in the initial diagnosis of acute cervical artery dissection. MATERIAL AND METHOD: Retrospective study of 31 patients, mean age 45, sex ratio=1, referred for clinical suspicion of cervical artery dissection, confirmed by MRI. 46 dissected arteries were imaged. Ten patients presented multiple dissections. The evaluated sonographic diagnostic criteria were the direct signs of intra-mural hematoma: localized increased diameter of the artery, narrowed lumen, hypo and/or isoechoic intra-mural hematoma, intimal flap. The associated criteria studied were: the location of intra-mural hematoma and in case of an occlusion, the dissection of an other artery. RESULTS: We analyzed separately the arterial segments visualized in B-mode ultrasound (supra-bulbar internal carotid artery, vertebral artery from V0 to V3) and the arterial segments evaluated only by pulsed Doppler (intrapetrosal carotid artery, V3-V4 of the vertebral artery). With the above criteria, on arterial segments visualized in B-mode ultrasound, the diagnosis of dissection was done in 83% of cases during the initial examination but in only 30% of the arterial segments non visualized on ultrasonography. CONCLUSION: The direct signs of intra-mural hematoma on internal carotid and vertebral segments imaged by B-mode ultrasonography have a good sensitivity. Because results were compared to MRI, the specificity could not be assessed. In case of occlusion of an artery, multiple dissections are a strong argument for the diagnosis.

Acute Disease↗

PubMed2000

The treatment of spontaneous carotid and vertebral artery dissections.

Spontaneous dissections of the carotid and vertebral arteries in the neck are 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 dissections largely remains unexplained but probably involves a combination of genetic and environmental factors. Magnetic resonance imaging has largely surpassed angiography as the imaging study of choice. The treatment of carotid and vertebral artery dissections is based on rather incomplete evidence. Anticoagulation with heparin followed by warfarin remains the treatment of choice 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 treated for carotid and vertebral artery dissections with percutaneous angioplasty and stent deployment. Although the treatment of dissections is generally well tolerated and the radiographic results are impressive, most dissections heal spontaneously and the associated aneurysms never rupture and rarely cause delayed ischemic symptoms. Surgical treatment of dissections, consisting of an in situ interposition graft or extracranial-intracranial bypass, is indicated only for those patients with persistent symptoms refractory to maximal medical therapy who are not candidates for endovascular treatment.

Angioplasty, Balloon↗

PubMed2001

[Dissection of cervical arteries].

INDICENCE: Cervical artery dissection (CAD) is one of the major cause of cerebral infarction before 45 years of age. The average annual incidencerate is between 2.5 and 3 per 100,000, but the reported incidence of CAD is probably underestimated because of frequent asymptomatic forms, or producing only minor and local symptoms. Dissection of the internal carotid artery (ICA) is more frequent than dissection of the vertebral artery (VA) and intracranial dissection is less frequent than extracranial dissection. PATHOGENESIS: Traumas and primary diseases of the arterial wall are the main predisposing factors, but the pathogenesis of spontaneous DAC remains unknown in most cases, although the possibility of an underlying arteriopathy is suspected. CLINICAL AND RADIOLOGICAL MANIFESTATIONS: The clinical presentation of ICA dissections includes isolated local signs (Homer's sign, headaches) followed by a few hours or days later by signs of cerebral or retinal ischemia. Brainstem infarcts and occipital or cervical pain are the most strinking clinical feature of VA dissection. Recent progress in neuroradiology (i.e. CT-scan, MRI, magnetic resonance ongiography) and neurosonology (i.e. transcranial Doppler) allows a non invasive approach in the diagnosis and follow-up of CAD. MANAGEMENT: The prognosis is highly variable, but remains usually good. Heparin in the acute stage, followed by an oral anticoagulant or aspirin treatment for 3 to 6 months is most commonly used, although it has never been proved by a randomized trial.

Adolescent↗