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. 2025 May;5(3):e001704.
doi: 10.1161/SVIN.124.001704. Epub 2025 Mar 8.

Risk Prediction of Cerebrovascular Ischemic Events Following Cervical Artery Dissections Using High-Intensity Transient Signals: A Systematic Review, Meta-Analysis and a single center experience

Seyed Behnam Jazayeri  1 , Behnam Sabayan  2   3 , Yasaman Pirahanchi  4 , Vikas Ravi  4 , Julián Carrión-Penagos  4 , Jeffery Bowers  4 , Royya Modir  4 , Kunal Agrawal  4 , Thomas Hemmen  4 , Brett Meyer  4 , Dawn Meyer  4 , Reza Bavarsad Shahripour  4
Affiliations

Risk Prediction of Cerebrovascular Ischemic Events Following Cervical Artery Dissections Using High-Intensity Transient Signals: A Systematic Review, Meta-Analysis and a single center experience

Seyed Behnam Jazayeri et al. Stroke Vasc Interv Neurol. 2025 May.

Abstract

Background: Predicting and managing spontaneous Cervical Artery Dissections (CeAD) is challenging due to the absence of tools for early identification of high-risk individuals. This study seeks to gather evidence on the predictive value of high-intensity transient signals (HITS) detected by Transcranial Doppler for recurrent ischemic events (IEs) following CeAD.

Methods: We performed a systematic review and meta-analysis of published studies along with the data from our cohort. Following PRISMA guidelines, we searched Pubmed, Embase and Scopus to identify studies that evaluated HITS in patients with CeAD with the aim of predicting IEs. Data were pooled using a random effects model, with odds ratio (OR) and its 95% confidence interval (CI) as the effect size. Heterogeneity was assessed with the Q statistic and I2 test, while subgroup analysis evaluated the impact of dissected artery (carotid vs vertebral) on the relationship between HITS and ischemic events. Our retrospective study included consecutive patients diagnosed with CeAD, followed for 90 days to record IEs. Univariable and multivariable analyses were performed to identify factors associated with recurrent TIAs or strokes within 90 days post-CeAD.

Results: Our systematic review included five prior studies, which, combined with our center's sample size, provided data for a total of 306 patients. The meta-analysis indicated that HITS is a significant predictor of IEs (OR: 13.25, 95% CI [2.97-59.13], p<0.01) with low heterogeneity (I2 = 42%, p = 0.13). However, subgroup analysis indicated that HITS are a significant predictor only for carotid artery dissections (p<0.01), and not for vertebral artery dissections (p=0.11). The cohort consisted of 34 patients (mean age: 46.8 years, 55.9% male). The incidence of IEs was 20% in our cohort and all of them (100%) had HITSs in TCD. In multivariable analysis, the presence of HITS (p=0.006) and intra-luminal thrombosis (p=0.02) were significant predictors of IEs.

Conclusions: The presence of HITS detected by TCD is a strong predictor of IEs in patients with Carotid artery dissections. This highlights the clinical value of TCD in identifying high-risk patients and emphasizes the need for proactive management strategies to reduce the risk of future IEs in this subgroup.

Keywords: Transcranial Doppler; dissection; high-intensity transient signals; ischemic events; microembolic signals; stroke.

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Conflict of interest statement

Conflicts-of-interest: None

Figures

Figure 1
Figure 1
Preferred Reporting Items for Systematic Reviews and Meta‐Analyses flow chart of study selection. IE indicates ischemic event; and TCD, transcranial Doppler.
Figure 2
Figure 2
Forest plot of ischemic events following CeAD based on presence or absence of HITS. CeAD indicates cervical artery dissections; HITS, high‐intensity transient signals; IEs, ischemic events; and MH, Mantel–Haenszel.
Figure 3
Figure 3
Subgroup analysis of the results based on dissected artery. HITS indicates high‐intensity transient signals; and OR, odds ratio.
See this image and copyright information in PMC

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