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Lounsbury et al.
391
Figure 1. Overall incidence of recurrent cervical artery dissection for each study and overall, presented with their confidence
intervals and measure of heterogeneity.
and were reported in some studies in which some but not
all patients had long-term follow-up. The latest reported
recurrences occurred at 10 years.11,18 The risk of ischemia
from recurrent dissections was approximately 2% (95%
CI = 1-3%) (Figure 4).
In the subgroup of studies that included routine surveillance
imaging, recurrence occurred in 5% of patients
(95% CI = 3-9%), and in studies without routine imaging,
recurrence occurred in 3% of patients (95% CI = 2-7%)
(Figure 5). There were insufficient data to be able to collect
or analyze recurrence rates in any of the pre-specified
clinical subgroups. In individual studies, the following
variables were associated with statistically significantly
higher recurrence rates: fibromuscular dysplasia, arterial
tortuosity, younger age, longer follow-up period, and family
history of arterial dissection.
Low risk of bias was identified in 22 of the 29 included
studies (75.9%). Within this subgroup, recurrence occurred
in 5% of patients (95% CI = 3-8%) (Figure 6). A sensitivity
analysis was also performed by excluding the studies that
most significantly influenced the I2. In the remaining studies,
recurrence occurred in 3% of patients (95% CI = 2-4%)
(Figure S1).
Discussion
This meta-analysis provides our best estimate of the incidence
of recurrent CAD. Recurrence appears to be infrequent,
and stroke related to recurrent dissection is even
rarer. This distinction suggests that many recurrent dissections
may be associated with local symptoms only or may
be entirely asymptomatic. It is interesting to note that the
study reporting the highest recurrence rate by far, at 29%,12
also employed the most rigorous follow-up imaging protocol,
including initial daily ultrasounds for all patients, followed
by monthly imaging for 6 months, then every
International Journal of Stroke, 19(4)

WSO - April 2024

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