Dissection recurrence is a first-week problem, and morphology says who

Design

multicentre retrospective cohort from a nationwide prospective registry (CRCS-K-NIH), 2011-2021, MRI-confirmed recurrence

Population

711 adults with acute ischaemic stroke or TIA and craniocervical dissection diagnosed within 7 days; mean age 49.0, 26.9% women, 76.1% intracranial

Primary outcome

recurrent ischaemic stroke at 1 year

Effect

recurrence 8.7% day 1, 17.4% by 1 week, 19.9% at 1 year; double lumen adjusted HR 1.87 (95% CI 1.15-3.04); stenosis without dilatation 1.69 (1.04-2.75)

A nationwide Korean registry identified 711 patients with craniocervical artery dissection among 75,903 admissions for ischaemic stroke or TIA between 2011 and 2021, all diagnosed within seven days of onset and with a median onset-to-arrival of 7.7 hours. Mean age was 49.0 years; 76.1% of dissections were intracranial. Recurrent stroke required MRI confirmation of new or extending infarction.

The temporal distribution is the finding. Recurrence was 8.7% by day 1 and 17.4% within one week, against 19.9% at one year — meaning nearly nine in ten of the year's recurrences had already happened by day 7. Incidence fell from 271.2 events per 1,000 person-days on day 1 to 0.1 beyond day 7. Intracranial versus extracranial location made no difference to risk. Two morphological features did: stenosis without dilatation (adjusted HR 1.69, 95% CI 1.04-2.75) and a double lumen (1.87, 1.15-3.04), with the double lumen clustering specifically at days 2 to 3 (adjusted IRR 3.84, 1.67-8.81).

This argues for front-loading the observation rather than spreading it. A patient with a dissection and a double lumen on angiography is at their highest risk while still in hospital, not at the follow-up appointment — which is where most surveillance effort currently goes. It also puts the antithrombotic decision in a narrower window: whatever is chosen, it needs to be running within hours, not settled at discharge.

• Look for the double lumen and for stenosis without dilatation on the index angiography, and record which is present
• Start antithrombotic therapy within hours of diagnosis rather than deferring to a discharge decision
• Observe the first 72 hours in hospital where feasible, particularly with a double lumen
• Reserve intensive imaging follow-up for the acute phase; beyond a week the event rate is close to zero
• Consider dissection in any young adult with stroke — under 1% of admissions here carried the diagnosis, and it is easily missed

Why it matters

Surveillance after dissection is currently spread over months when almost all the risk falls in the first few days.

Don't overread it

Retrospective, East Asian, and confined to patients who reached hospital within seven days — early recurrences before arrival are invisible to it.

The statistics, in plain English

An incidence rate of 271 events per 1,000 person-days on day 1 falling to 0.1 beyond day 7 is a difference of more than a thousandfold, which is why the timing matters more than the cumulative one-year figure. The hazard ratios for morphology (1.69 and 1.87) have lower bounds only just above 1.0, so the direction is secure but the size is not — and these are adjusted estimates from a retrospective registry.

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