Cervical artery dissection after sports - An analytical evaluation of 190 published cases

Abstract

Introduction: Cervical artery dissections may be preceded by mechanical trigger events, often related to sports.

Methods: Using the MEDLINE database, we identified case reports and case series of sports-related cervical artery dissections. Information of the type of sport, age and gender of the patient, affected vessels, associated infarction, time delay, and neurological sequelae were extracted. Demographic and clinical characteristics were compared between sport groups using analysis of variance and Chi square tests. Differences were further assessed with adjusted post hoc tests and homogenous subsets.

Results: A total of 115 reports describing 190 patients with cervical artery dissections related to 45 different sports were identified. The mean age of all patients was 35 years; 26% of all patients were women. Anterior and posterior circulation, as well as left and right side were affected with similar frequency. Patients belonging to different sport categories differed significantly with regard to age (p < 0.001), gender (p < 0.001), and affected circulation (anterior vs. posterior, p = 0.02). The posterior circulation was most often affected in golf players (88%) and least often in individuals engaging in exercise (23%) and scuba divers (29%). Laterality (left vs. right) and mortality were similar between sport groups.

Discussion: We performed a comprehensive review and analytical evaluation of case reports describing patients with cervical artery dissections after sport. Confirmation of our findings in prospective studies is needed.

Conclusion: Cervical artery dissection has been described in relation to a wide variety of sports. The risk of injury to particular neurovascular structures may depend on the type sport involved. Discipline-specific incidence rates are not known.

Keywords: Stroke; athletic injuries; brain infarction; carotid artery dissection; sports; vertebral artery dissection.

Figure 1.

Demographic and clinical characteristics of patients with cervical artery dissection according to type of sport. Displayed are means (age) and proportions (gender, affected circulation) with 95% confidence intervals. The dotted vertical lines represent the average values from all 190 patients. The solid vertical lines next to the vertical axis represent results of post-hoc analysis derived classification into homogenous subsets. P-values are derived from univariable analysis of variance (Panel A) and Chi-squared test for categorical data (Panel B and Panel C). Values belonging to sports marked with two stars (**) are significantly different from 0.5 in one-sample analyses at a Bonferroni corrected significance level of 0.05/8 = 0.00625.

Figure 2.

Side of affected vessels, outcome, and time delay before stroke symptoms of CAD patients according to type of sport. The distributions of the side of affected vessels (Panel A), of outcome (Panel B), and of the time interval between sportive activity and onset of stroke symptoms (Panel C) were not significantly different between groups (p > 0.05). CAD stands for cervical artery dissection.