Spontaneous bilateral carotid and vertebral artery dissections associated with multiple disparate intracranial aneurysms, subarachnoid hemorrhage and spontaneous resolution. Case report and literature review

Unraveling the Links between Chronic Inflammation, Autoimmunity, and Spontaneous Cervicocranial Arterial Dissection

Advances in imaging techniques have led to a rise in the diagnosis of spontaneous cervicocranial arterial dissection (SCCAD), which is now considered a common cause of stroke in young adults. However, our understanding of the pathophysiological mechanisms underlying SCCAD remains limited. Prior studies have proposed various factors contributing to arterial wall weakness or stress as potential causes for SCCAD. A combination of biopsies, case reports, and case-control studies suggests that inflammatory changes and autoimmunity may play roles in the cascade of events leading to SCCAD. In this review, we examine the close relationship between SCCAD, chronic inflammation, and autoimmune diseases, aiming to explore potential underlying pathophysiological mechanisms connecting these conditions. While some relevant hypotheses and studies exist, direct evidence on this topic is still relatively scarce. Further investigation of the underlying mechanisms in larger clinical cohorts is needed, and the exploration of animal models may provide novel insights.

Posttraumatic subarachnoid hemorrhage related to concomitant carotid artery dissection and ruptured basilar trunk aneurysm: A case report and literature review

Background:

Carotid artery dissections (CADs) are a relatively rare disorder, whereas intracranial aneurysms (IAs) form a common cerebrovascular pathology. Since both vascular entities share similar risk factors and associations with connective tissue and vascular disorders, a common pathogenesis has been suggested. Here, we present a case of the concomitant occurrence of a CAD and a ruptured basilar trunk aneurysm (BTA). In the discussion, we elaborate on both vascular entities and have reviewed the literature on their concomitant incidence and potential shared pathogenesis.

Case Description:

We present a case of a 40-year-old female patient who was admitted to our hospital because of subarachnoid hemorrhage following a minor head trauma. Imaging revealed a BTA and unilateral extracranial dissection of the internal carotid artery. Despite coiling of the aneurysm, stenting of the dissection, and antithrombotic therapy, the patient died due to extensive cerebral ischemia sequelae.

Conclusion:

CAD and BTAs have both been associated with a vascular vulnerability but their concomitant occurrence has not been described previously. The previous studies have suggested an increased incidence of IAs in patients with a CAD and vice versa. However, the number of studies and reports on this mutual increased incidence is limited. Therefore, a shared pathogenesis seems rather speculative. In our case, we suggest that a posttraumatic CAD-induced hemodynamic alterations resulting in rupture of the saccular BTA.

Spontaneous dissection of bilateral internal carotid and vertebral arteries

Spontaneous dissection of the major arteries of the neck is known to increase the risk of stroke or transient ischaemic attack in young and middle-aged adults. Most of the reported cases of arterial dissections in the neck involve one or both paired extracranial carotid or vertebral arteries. Spontaneous dissection of the bilateral internal carotid and vertebral arteries is extremely rare. We report a case of spontaneous bilateral internal carotid artery and vertebral artery dissection while using a prescribed pill for weight loss which contained amphetamine derivative. A review of literature is also provided.

Carotid artery dissection-related intracranial aneurysm development: case report

BACKGROUND AND IMPORTANCE

We analyzed the physiopathology of the association between cervical artery dissections (CADs), intracranial aneurysms (IAs), and aneurysmal subarachnoid hemorrhage.

CLINICAL PRESENTATION

A 43-year-old woman presented with diffuse subarachnoid hemorrhage (Fisher 3; Hunt-Hess 1). computed tomography angiography revealed a cervical internal carotid artery dissection and 2 IAs: right paraclinoid and right posterior communicating artery. The patient underwent surgical clipping of the 2 aneurysms. CAD was managed conservatively. Postoperative course was initially uneventful. After 24 hours, digital subtraction angiography (DSA) documented the exclusion of the aneurysms and an improvement of the CAD. After 3 days, the patient's neurological condition suddenly worsened; CT scan documented a subarachnoid rebleeding (Hunt-Hess 4) and DSA revealed the recurrence of CAD and a new right internal carotid artery aneurysm. The patient underwent clipping of the new aneurysm and decompressive craniectomy because of severe brain swelling. Postoperative neurological conditions remained poor. DSA showed the exclusion of the aneurysms and improvement of CAD. Three days later, CT scan performed after a sudden raise in intracranial pressure documented a wide intracerebral hematoma. Computed tomography angiography did not show new vascular malformations. Surgical removal of the hematoma was performed, but poor neurological conditions persisted.

CONCLUSION

CAD-related hemodynamic changes may play a role in the development of IAs. The presence of IAs must be screened carefully in case of CAD, because the dynamic behavior of CAD definitively increases the risk of IA formation, enlargement, and rupture.

Therapeutic and diagnostic implication of inadequate circle of willis in a patient with acute spontaneous bilateral internal carotid artery dissection: case report and review of the literature

Background and Purpose

Emphasizing the therapeutic and diagnostic implications of concomitant inadequate collaterals from the circle of Willis in a rare case of spontaneous acute bilateral internal carotid artery dissection (BICAD) following 5 days of isolated rigorous cough (pertussis like).

Case Description

A 45-year-old male has been referred to our department with rapid neurological deterioration consisting of dysarthria and severe left hemiparesis following 5 days of isolated rigorous cough. CTA demonstrated BICAD, a tiny anterior communicating artery and no bilateral posterior communicating artery. The patient had no personal or familial risk factors. Infectious, traumatic, vascular and connective tissue diseases were ruled out.

Results

Neurological deterioration persisted despite immediate provision of continuous ‘full-heparinization’ with concomitant rigorous control of blood pressure. Endovascular treatment consisting of bilateral stenting was undertaken. Ten days later, the patient was discharged with mild hemiparesis and resuming normal activity after 3 months.

Conclusions

BICAD with concomitant inadequate collaterals from the circle of Willis may predispose to hypoperfusion which might not respond to the usual conservative treatment prompting for flow reestablishment. Moreover, isolated rigorous cough can cause acute spontaneous BICAD even among patients without any risk factors.

Quadruple spontaneous cervical artery dissection following aneurysm embolization: a rare posttreatment complication

We present a unique case of multiple sCADs occurring after a ruptured intracranial aneurysm embolization. We discuss the impact of head extension during embolization as the prevailing factor in multiple artery dissections in this case and point out another cause of new-onset neurologic deficit in patients with aneurysmal SAH.

Spontaneous arterial dissection: phenotype and molecular pathogenesis

Arterial dissection (AD) is defined as the longitudinal splitting up of the arterial wall caused by intramural bleeding. It can occur as a spontaneous event in all large and medium sized arteries. The histological hallmark of AD is medial degeneration. Histological investigations, gene expression profiling and proteome studies of affected arteries reveal disturbances in many different biological processes including inflammation, proteolytic activity, cell proliferation, apoptosis and smooth muscle cell (SMC) contractile function. Medial degeneration can be caused by various rare dominant Mendelian disorders. Genetic linkage analysis lead to the identification of mutations in different disease-causing genes involved in the biosynthesis of the extracellular matrix (FBN1, COL3A1), in transforming growth factor (TGF) beta signaling (FBN1, TGFBR1, TGFBR2) and in the SMC contractile system (ACTA2, MYH11). Genome wide association studies suggest that the CDKN2A/CDKN2B locus plays a role in the etiology AD and other arterial diseases.