Complex cervicocephalic artery dissections with wide intimal inlet: determinants and implications for endovascular recanalization.

Background and purpose: Cervicocephalic artery dissection (CCAD) is a well-recognized cause of ischemic stroke. However, complex forms of CCAD, characterized by a wide intimal inlet without a visible intramural hematoma, pose diagnostic challenges and complicate endovascular access to the true lumen when recanalization is required. We aimed to analyze the clinical presentation, outcomes, and feasibility of endovascular treatment of complex CCAD and to propose a novel morphological classification.

Methods: We retrospectively analyzed consecutive patients treated for acute CCAD at Lariboisière Hospital between 2012 and 2023. Simple CCAD was mainly defined by the presence of a classic intramural hematoma, and complex CCADs by an intraluminal flap. We compared both types using univariate analysis and binary logistic regression for clinical presentation and outcomes.

Results: Among the 496 CCADs, 71 (14%; 95% confidence interval (CI): 11 to 17%) were complex. Compared with simple CCAD, complex cases were associated with older age, male sex, anterior circulation, iatrogenic cause, intracranial CCAD, vessel occlusion, and ischemic stroke (P<0.01). Complex CCAD was an independent risk factor for ischemic presentation (odds ratio (OR)=3.0; 95% CI:1.4 to 6.5, P=0.006), early ischemic recurrence (OR=2.0; 95% CI: 1.0 to 3.9, P=0.049), unfavorable outcome (OR=2.0; 95% CI: 1.0 to 5.0, P=0.051) and no recanalization at 3 months (OR=5.2; 95% CI: 2.4 to 11.5, P<0.001). Stenting, possibly combined with angioplasty and intimal fenestration, yielded the highest recanalization rates.

Conclusion: Complex CCADs exhibit distinct morphology, clinical presentation, and outcomes compared with simple forms. Recognizing the different morphological subtypes may help optimize diagnosis and guide tailored endovascular strategies.