Two cases of spontaneous middle cerebral arterial dissection causing ischemic stroke

Atherosclerosis-Like Spontaneous Middle Cerebral Artery Dissection

The standard of care for treating acute large vessel occlusion is endovascular therapy. The most frequent cause of occlusion is either embolic occlusion or in situ thrombotic occlusion. However, occlusion resulting from intracranial dissection is extremely rare, especially in the middle cerebral artery. Prior to a thrombectomy or endovascular therapy, understanding and interpreting the angiographic findings is crucial for planning the appropriate treatment and preventing complications.

Spontaneous middle cerebral artery dissection: a series of six cases and literature review

Middle cerebral artery (MCA) dissection is rare, and various clinical presentations, including hemorrhage, ischemia, or comorbidities, and the changes in imaging findings over time hinder treatment decisions. The European Stroke Organization guidelines exclude MCA dissection. Few cases have been reported with no review of the relevant literature. Therefore, we reviewed the relevant literature and our own experience with non-traumatic MCA dissection cases to determine appropriate treatment strategies. At our institution and affiliated institutions, we encountered six cases of MCA dissection-five with infarction and one with hemorrhage. Two patients underwent revascularization, and one underwent an aneurysmectomy. We reviewed English and Japanese articles in PubMed and Medical Journal Web and summarized the results based on the relationships among age, sex, location, the presence of an aneurysm, the presence of angiography, history, treatment, and mode of onset. The clinical course, changes in imaging, treatment strategies, and prognosis were discussed. Eighty cases were included in the review. Cerebral aneurysms were more common distal to the M2 area (p = 0.00) and were correlated with hemorrhage (p < 0.001). Most hemorrhagic cases with aneurysms were treated surgically, while ischemic cases were treated with antithrombotic agents, and both had a similar neurological prognosis. There were some cases of rebleeding after antithrombotic therapy, especially in older adults.Surgical treatment is recommended in cases of hemorrhage and confirmed aneurysms, particularly for lesions distal to the M2 area. Patients with aneurysm-associated ischemia should be followed up, and antithrombotic treatment should be considered with particular care in older adults.

Endovascular Approach in Patients with Acute Complete Occlusion Due to Middle Cerebral Artery Dissection

Objective

Dissection of the middle cerebral artery (MCA) is less common than dissection of vessels in the vertebrobasilar system or carotid artery. Acute complete occlusion related to MCA dissection is extremely rare. We report an endovascular approach in patients with acute complete occlusion due to MCA dissection.

Methods

We reviewed retrospectively the endovascular procedure and clinical results for acute-stroke patients who underwent recanalization from October 2014 through December 2018. Initial imaging findings and the endovascular procedure were analyzed for patients with acute complete occlusion due to MCA dissection.

Results

We undertook first-line aspiration thrombectomy using a Penumbra catheter in 294 patients with acute occlusion of the M1 segment. Of these patients, seven were confirmed to have acute complete occlusion due to MCA dissection. All patients had angiographic findings of an intimal flap at the proximal occlusion site of the MCA. One patient complained of severe headache during microcatheter passage through the occluded lesion and died due to massive bleeding caused by rupture of the false lumen. The remaining patients underwent initial contact aspiration thrombectomy without microcatheter passage. After aspiration thrombectomy, six patients had delayed flow through the MCA. One patient underwent stenting of the MCA because of progressive symptoms.

Conclusion

An intimal flap at the proximal portion of an occluded MCA can suggest the possibility of MCA dissection. Contrast aspiration thrombectomy without microcatheter passage can reduce the risk of false lumen rupture in cases of MCA dissection.

Coil and Single-Stent Placement for Ruptured Dissecting Aneurysm of Middle Cerebral Artery: A Case Report

BACKGROUND

Ruptured dissecting aneurysms located at the middle cerebral artery (MCA) are rare, and their standard treatment has not been defined. Furthermore, lenticulostriate artery involvement in the dissecting segment makes treatment extremely difficult, and no previous reports have described successful treatment for such conditions.

CASE DESCRIPTION

We herein report the case of a 74-year-old woman who presented with sudden severe headache from subarachnoid hemorrhage due to dissection in the proximal M1 segment of left MCA involving lenticulostriate arteries. Digital subtraction angiography on day 6 showed that the dissecting aneurysm had enlarged despite strict blood pressure control. On day 8, the patient was treated successfully with a self-expanding closed cell stent and coil embolization, preserving blood flow in the lenticulostriate arteries as well as the MCA.

CONCLUSIONS

Follow-up digital subtraction angiography performed 5 weeks after endovascular therapy showed healing of the dissecting lesion, and the patient was discharged neurologically intact.

Republished: Monotherapy with stenting in subarachnoid hemorrhage (SAH) after middle cerebral artery dissection

Isolated middle cerebral artery dissection is a rare clinical entity, with descriptions limited to a few case reports and case series. Symptomatic dissection in the anterior circulation can present as an ischemic stroke in a young population; however, it is rarely associated with subarachnoid hemorrhage. We describe a young patient who presented with acute headache from a subarachnoid hemorrhage that was ultimately determined to be due to a vascular dissection in the middle cerebral artery. The initial angiogram showed vascular irregularities in this area with stenosis. Repeat imaging 4 days after presentation identified a pseudoaneurysm proximal to the stenosis. The patient was successfully treated with a self-expanding nitinol stent and followed up with serial angiography during postoperative recovery in the hospital; additional angiograms were performed approximately 1 and 6 months after treatment. Serial angiograms demonstrated incremental healing of the dissection. The patient was discharged and remains neurologically intact at the 6-month follow-up.

Monotherapy with stenting in subarachnoid hemorrhage (SAH) after middle cerebral artery dissection

Isolated middle cerebral artery dissection is a rare clinical entity, with descriptions limited to a few case reports and case series. Symptomatic dissection in the anterior circulation can present as an ischemic stroke in a young population; however, it is rarely associated with subarachnoid hemorrhage. We describe a young patient who presented with acute headache from a subarachnoid hemorrhage that was ultimately determined to be due to a vascular dissection in the middle cerebral artery. The initial angiogram showed vascular irregularities in this area with stenosis. Repeat imaging 4 days after presentation identified a pseudoaneurysm proximal to the stenosis. The patient was successfully treated with a self-expanding nitinol stent and followed up with serial angiography during postoperative recovery in the hospital; additional angiograms were performed approximately 1 and 6 months after treatment. Serial angiograms demonstrated incremental healing of the dissection. The patient was discharged and remains neurologically intact at the 6-month follow-up.

Intracranial versus extracranial artery dissection cases presenting with ischemic stroke

BACKGROUND

To compare the clinical and radiologic characteristics, possible stroke mechanisms, and prognosis of intracranial artery dissections (IADs) with those of extracranial artery dissections (EADs) presenting with cerebral infarction.

METHODS

Among 3250 adult patients with acute ischemic stroke (cerebral infarction), we prospectively recruited and categorized patients with cerebral infarction secondary to spontaneous cerebral artery dissection into IAD or EAD groups. The clinical and radiologic characteristics, possible stroke mechanisms according to the distributions of the infarctions based on diffusion-weighted imaging, and prognosis were analyzed for both groups.

RESULTS

There were 48 and 50 patients experiencing IAD and EAD, accounting for 1.5% and 1.5% of all ischemic stroke patients, respectively. Compression of the perforating artery was the most common possible stroke mechanism (33.3%) in IADs; thromboembolism was more common in EADs than that in IADs (36 of 50 versus 12 of 48; P < .001). Magnetic resonance imaging and angiography were used to investigate the arterial dissections in all IAD patients and 46 EAD patients. Based on magnetic resonance imaging and angiography, the IADs more frequently displayed dissecting aneurysm (6 of 48 versus 0 of 46; P = .027) and intimal flap or double lumen (21 of 48 versus 4 of 46; P < .001) than EADs. For the clinical characteristics and prognosis, there was no significant difference between the 2 groups.

CONCLUSIONS

These results indicate that IAD is an important cause of ischemic stroke, and it displays unique radiologic characteristics and specific stroke mechanisms compared with EAD.

Isolated middle cerebral artery dissection: a systematic review

Acute stroke can be missed in the emergency department, particularly in younger patients and in those with more vague symptoms such as headache or dizziness. Cervicocephalic dissections are one group of etiologies for acute stroke in the young. While cervicocephalic dissections are not uncommon in clinical practice, isolated middle cerebral artery dissection (MCAD) has been rarely reported as a cause for stroke. We sought to review the clinical implications and pathophysiology of an isolated MCAD. We searched the medical literature for isolated MCAD in clinical stroke patients using MEDLINE, HighWire, and Google Scholar databases from 1966 to 2013 using the keywords 'middle cerebral artery dissection,' 'intracerebral artery dissection,' and 'middle cerebral artery dissection stroke.' We reviewed cases to learn various characteristics of isolated MCAD. A total of 61 cases (62.3% male, mean age 44.16 ± 19.17 years) were reviewed from 54 publications. Most cases were reported from Asian countries (78.7%). Ischemic strokes were more common than hemorrhagic strokes (68.9%). Digital subtraction angiography was the most common imaging modality used to diagnose isolated MCAD (75.4%). Surgery was the preferred form of therapeutic intervention (39.3%). Males (n = 27/48, p = 0.0008) and those who presented with only ischemic syndromes (n = 22/48, p = 0.0009) had significantly higher rates of favorable outcome. Isolated MCAD is a rare disease that can contribute to the stroke burden of young patients. Further studies are needed to better characterize optimal treatment strategies and define outcomes for this rare condition.

Vascular disorders--magnetic resonance angiography: brain vessels

Magnetic resonance angiography (MRA) of the brain obtained at 3 T imaging has made a significant clinical impact. MRA benefits from acquisition at higher magnetic field strength because of higher available signal-to-noise ratio and improved relative background suppression due to magnetic field strength-related T1 lengthening. Parallel imaging techniques are ideally suited for high-field MRA. Many of the developments that have made 3 T MRA of the brain successful can be regarded as enabling technologies that are essential for further development of 7 T MRA, which brings additional challenges.

Spontaneous intra-cranial arterial dissection frequently causes anterior cerebral artery infarction

BACKGROUND AND PURPOSE

Spontaneous intra-cranial arterial dissection (SICAD) without history of head and neck injury is now recognized as an important cause of stroke. However, the frequency of SICAD involving the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) territories remains unclear. This study therefore investigated the distribution of SICAD.

METHODS

Subjects comprised 194 patients (126 men, 68 women; median age, 68.0 years) with infarct isolated to the ACA, MCA or PCA territories who underwent conventional angiography. Diagnosis of SICAD was based on clinical and neuroradiological findings. Frequency of SICAD was compared among ACA, MCA, and PCA infarcts. All patients were divided into SICAD and non-SICAD groups, and clinical characteristics were compared between groups.

RESULTS

Infarcts involved the ACA in 14 cases (7.2%), MCA in 165 cases (85.1%), and PCA in 15 cases (7.7%). SICAD was diagnosed in 17 of 194 cases (8.8%), with cerebral angiography showing main findings of the string sign in 11 patients (64.7%), the pearl and string sign in 6 patients (35.3%), and pseudoaneurysm formation in 2 patients (11.7%). SICAD most frequently involved the ACA (ACA, 64.3%; MCA, 4.2%; PCA, 6.7%; P<0.001).

CONCLUSION

SICAD was seen in 64.3% of patients with ACA infarct. The mechanisms of ACA infarction may thus differ from those of MCA and PCA infarction.