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. 2025 Sep 2:svn-2025-004186.
doi: 10.1136/svn-2025-004186. Online ahead of print.

Risk factors for cervical artery dissection: a systematic review with meta-analysis

Wilco Jacobs  1   2 , Debbie S Wright  3 , Katherine Pohlman  3 , Rob Rosenbaum  4 , Barbara A Hutten  5 , Gwendolyne Gm Scholten-Peeters  6 , Scott Haldeman  7 , Johannes Cf Ket  8 , Sidney M Rubinstein  2
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Free article

Risk factors for cervical artery dissection: a systematic review with meta-analysis

Wilco Jacobs et al. Stroke Vasc Neurol. .
Free article

Abstract

Background: Cervical artery dissection (CAD) is a rare cause of stroke. This is an update of an earlier systematic review, which focuses on the risk of CAD in the general population. The objective was to identify the risk factors for CAD.

Methods: A comprehensive search was conducted in MEDLINE, EMBASE and Web of Science on 20 September 2024. Observational studies (cohort, case-control studies and case-crossover studies) that studied patients with CAD and a control group were included. Risk of bias was assessed with the ROBINS-E tool, and certainty of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). The results were stratified by healthy controls (primary analyses) and other control groups, notably ischaemic non-CAD stroke (secondary analyses).

Findings: In total, 128 study reports were identified, of which 54 used one or more healthy control groups. Of these reports, 49 (91%) used a case-control design. The risk of bias was generally high (93%). For the following categories, effects were identified: (1) genetic factors or factors with a familial predisposition: migraine, methylenetetrahydrofolate reductase (MTHFR), TT homozygosity, matrix metalloproteinases (MMP) concentration, and connective tissue disorders; (2) external factors: recent infection, winter or autumn-winter season and oral contraceptive use; (3) minor trauma; (4) cardiovascular factors: hypertension, hypercholesterolaemia, relative vasodilatation of internal carotid, coronary artery disease and other cardiac diseases. For other risk factors (5), there were no significant pooled estimates. The certainty of the evidence was moderate for migraine and MTHFR TT, low for minor trauma and very low certainty for all others.

Interpretation: This is the first review that comprehensively examined the risk of CAD in the general population. Genetic factors, cardiovascular risk factors, recent infection and minor trauma are risk factors for CAD. Caution is needed in interpretation as the evidence is overall low to very low certainty, except for migraine and MTHFR TT homozygosity.

Keywords: Dissection; Meta-Analysis; Risk Factors; Stroke; Systematic Review.

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Conflict of interest statement

Competing interests: Pending return of ICMJE forms from co-authorsDISCLOSURESDebbie Wright: Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: Past Chair, Canadian Chiropractic Association unpaid.Katherine A Pohlman: Grants or contracts from any entity: RAND REACH Center Small grant to implement a pilot study; Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: Royal College of Chiropractic $200 honorarium; Support for attending meetings and/or travel; Chiropractic Future October 2024 – two night hotel, Canadian Chiropractic Association: Flight (general) & two night hotel.Scott Haldeman: NCIMC Grant to World Spine Care for an unrelated research project; Canada Health; Grant to World Spine Care Canada for an unrelated research project. Support for attending meetings and/or travel: For invited presentations or Board of Directors meeting. None with personal honorarium. Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: World Spine Care (USA, Canada, UK) Boards of Directors, Canadian Memorial Chiropractic Association Board of DirectorsSidney Rubinstein: All support for the present manuscript: NCMIC insurance company in the United States. 2023 https://www.ncmic.com/ 126,481; Grants or contracts from any entity: DBRIC. https://dbric.eu/ Grant # A24-01. 2025. €95.609; Grant # A24-02. DBRIC. https://dbric.eu/ 2025. €93.899; Canadian Chiropractic Research Foundation. 2024. $59,760.00 CAD (€41,317-) https://canadianchiropracticresearchfoundation.ca/ Other financial or non-financial interests: work in clinical practice as a chiropractor.Gwendolyne GM Scholten-Peeters: Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: Chair of the safety committee Manual Therapy: No payments related to this manuscript, Content expert in the physiotherapy and exercise therapy guideline neck pain and headache No payments related to this manuscriptRob E Rosenbaum, Barbara A Hutten, Hans CF Ket and Wilco CH Jacobs declare no Conflict of interest.

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