Improvement and Aggravation of Spontaneous Unruptured Vertebral Artery Dissection

Significance of headache in intracranial vertebrobasilar artery dissections: an observational study

Headache may represent acute phase of intracranial vertebrobasilar artery dissection (iVBAD). We aimed to evaluate its clinical significance in iVBAD. Consecutive acute iVBAD patients were grouped into ruptured iVBAD, unruptured iVBAD with no headache, isolated headache, or concurrent headache with neurological symptoms. Composite hemorrhagic/ischemic endpoints, and dynamic arterial changes were graded. Clinical characteristics of the four groups, and association between headache and composite outcomes was evaluated. Headaches were precedent in 79% of the ruptured iVBAD patients (maximal delay, 10D). In unruptured iVBAD, when patients with no headache (N = 69), concurrent headache (N = 111), and isolated headache (N = 126) were compared, concurrent headache was associated with ischemic endpoints (isolated headache as reference, adjusted odds ratio: 6.40, 95% confidence interval [2.03-20.19]). While there were no differences in hemorrhagic endpoints, dynamic arterial changes were higher in the isolated headache group (aOR: 3.98, 95% CI [1.72-9.18]) but not for the concurrent headache group (aOR: 1.59 [0.75-3.38]) compared to no headache group. Headache was more commonly severe (48.4% vs. 17.3%, p < 0.001) and ipsilateral (59.7% vs. 45.5%, p = 0.03) for isolated headache compared to concurrent headache, indicating a higher causal relationship. In iVBAD, isolated headache may be considered an acute-phase biomarker, associated with dynamic arterial changes.

Cerebellar infarction caused by vertebral artery dissection: A case report

RATIONALE

Vertebral artery dissection is an important cause of posterior circulation ischemic stroke in young and middle-aged people. We reported a young man with cerebellar infarction caused by dissection of the right vertebral artery.

PATIENT CONCERNS

A 34-year-old man presented with intermittent dizziness, blurred vision, nausea, and transient tinnitus 10 days before admission. All these symptoms were gradually aggravated and followed by vomiting and unfavorable movement of the right limbs. All these symptoms gradually aggravated.

DIAGNOSIS

Neurological examination on admission showed ataxia of the right limbs. Magnetic resonance imaging of the head revealed a right cerebellar infarction. High-resolution vessel wall magnetic resonance imaging showed dissection of the right vertebral artery. Whole-brain CT digital subtraction angiography revealed occlusion of the third segment (V3) of the right vertebral artery. This supports the diagnosis of vertebral artery dissection.

INTERVENTIONS

The patient received anticoagulant treatment with warfarin.

OUTCOMES

After 2 weeks of treatment, the patient showed remarkably alleviated dizziness and unfavorable movement of the right limbs. After 3 months of treatment, the modified Rankin Scale score was 0. MRI of the head revealed that the original right cerebellar focus was softened, and there were no newly formed infarct foci.

LESSONS

When young and middle-aged patients without atherosclerotic risk factors encounter sudden dizziness, tinnitus, and unfavorable limb movement, vertebral artery dissection may be considered. Careful inquiry into the medical history may help make a final diagnosis. Further high-resolution vessel wall magnetic resonance imaging is an effective means to find arterial dissection. Early diagnosis and treatment for vertebral artery dissection has a favorable prognosis.

Headache characteristics to screen for cervicocerebral artery dissection in patients with acute onset unusual headache

OBJECTIVES

The aim of this preplanned primary analysis was to investigate the clinical manifestations of headache to screen for CAD patients with acute onset headache only.

BACKGROUND

Spontaneous cervicocerebral artery dissection (CAD) with acute onset headache is not rare in clinical practice; however, it is underdiagnosed. On the other hand, subsequent infarction or subarachnoid hemorrhage mainly occurs within 1 week of headache onset.

METHODS

Between April 2017 and January 2022, we conducted a single-center, cross-sectional retrospective study on 197 consecutive referred patients from neurosurgical outpatient clinics with acute onset unusual headache (stronger or longer headache than usual). All patients underwent magnetic resonance imaging to screen for secondary headache and were diagnosed based on the diagnostic protocol. We examined patient background data and the following headache characteristics: distribution, condition at the onset of headache, accompanying vomiting or nausea, worsening headache, and analgesic effects against headache. These factors were analyzed to identify independent diagnostic predictors of CAD. In this study, the rate of missing data was 41% for improvement of headache by analgesia and multiple imputation by chained equations was performed.

RESULTS

A total of 93 patients (46 men and 47 women; mean age: 48 years, range: 25-73 years) were diagnosed with CAD. Univariate logistic regression analysis showed CAD was associated with current smoking, systolic blood pressure >140 mmHg, unilateral headache, worsening headache, and no headache improvement by analgesia. Unilateral, worsening headache and no headache improvement by analgesia remained independent diagnostic predictors in multivariable logistic regression after multiple imputation. No headache improvement by analgesia had the highest sensitivity (86%), while worsening headache had the highest specificity (84%).

CONCLUSIONS

CAD needs to be considered in patients with unilateral, worsening headache and no headache improvement by analgesia.

Acute hemicranial pain accompanied with a pearl and string type dissection of intracranial vertebral artery: Consideration for the time when to finish the medical observation

The International Classification of Headache Disorder (ICHD) clearly guides the suspicion of intracranial vertebral artery dissection (ICVAD) in headache patients, but guidelines on how observational or imaging studies should be performed to detect dangerous progression early are unclear. Fifty-six cases with pearl and string type intracranial vertebral artery dissection were divided into 3 groups: 39 in the headache group, 6 in the infarction group, and 11 in the hemorrhagic group. Clinical and angiographic data were analyzed and compared. Most headaches resolved within 2 weeks and did not exceed 8 weeks. Of the 33 patients (84.6%) who underwent continuous follow-up imaging, 18 (54.5%) returned to normal, but 3 (9%) had deteriorated. All the patients survived without subsequent bleeding or infarction. Image changes started before 3rd month and ended after 6 to 7 months. In acute ICVADs, image changes occur at the same time as the headache resolves and continue for several months after the headache has subsided. Since the dissection is likely to worsen even after the headache disappears, the image changes continue over several months, and prediction of rupture of unruptured ICVAD is unpredictable, it is desirable to conduct continuous imaging studies regularly after the initiation of dissection until stabilization is confirmed.

Morphological changes in vertebral artery dissections observed on 4D flow magnetic resonance images: case report

The morphology of vertebral artery (VA) dissections can change in the clinical course. A 58-year-old female with a 2-week headache was diagnosed with left VA dissection. Hemodynamic stress on the right VA detected on 4D flow MRI scans resulted in increased wall shear stress but the vessel was morphologically unchanged. Subsequent MRA revealed right VA dissection. Her bilateral dissections were treated conservatively and no neurological abnormality developed. Serial 4D flow MRI may be useful for observing morphological changes in VA dissections and help to clarify the mechanism(s) underlying VA dissections.

Usefulness of Ultrasonography in the Diagnosis and Follow-up of Extracranial Vertebral Artery Dissection

Extracranial vertebral artery dissection is a cerebrovascular disease that occurs most commonly in young people. A 32-year-old man experienced sudden cervical pain and was diagnosed with left vertebral artery dissection after arterial changes were identified by ultrasonography. The reduction in the size of an intramural hematoma in the left vertebral artery and in the peak systolic velocity were evaluated over time. Computed tomography, magnetic resonance imaging, and cerebral angiography are generally performed to diagnose and follow-up extracranial vertebral artery dissection; however, carotid ultrasonography has an advantage over these modalities by enabling the simultaneous observation of vascular morphology and hemodynamics.

Effects of the home-based exercise program with an augmented reality system on balance in patients with stroke: a randomized controlled trial

PURPOSE

To investigate the therapeutic potentials of the home-based exercise program (HEP) with an augmented reality (AR) system to improve balance in patients with stroke.

METHODS

Sixty-eight patients with stroke were recruited in this randomized controlled study with blind observer. Patients in the smart-rehab group underwent HEP with an AR system for four weeks, whereas patients in the control group underwent the written and pictorial HEP. Assessments of balance and fear of falling were performed three times: at baseline (T0), immediately (T1), and four weeks (T2) after cessation of HEP.

RESULTS

The change in balance from T0 to T1 was significantly higher in the smart-rehab group than in the control group (p < 0.017). The change in fear of falling from T0 to T1 and T2 was significantly higher in the smart-rehab group than in the control group, respectively (p < 0.017). One participant with vertebral artery dissection in the smart-rehab group discontinued participation due to a transient ischemic attack which resolved during the study period.

CONCLUSIONS

The results of this study suggest that the HEP with the AR system might be effective to improve balance in patients with stroke. However, more careful precautions for the HEP using the AR system are also required. Implications for rehabilitationBalance was modestly improved in both home-based exercise programs, slightly more in AR home exercise group.AR home-based program was significantly better in reducing fear of falling compared to the control group.No falls were recorded, however, safety for patients with arterial dissection needs to be carefully considered due to the possibility of adverse effects.

Long-Term Sonographical Follow-Up of Arterial Stenosis Due to Spontaneous Cervical Artery Dissection

Purpose

Little is known about the long-term course of arterial stenosis after spontaneous cervical artery dissection (sCAD). We analyzed changes over time and evaluated factors potentially associated with these changes and recurring sCAD.

Materials and Methods

Adult patients with sCAD, admitted to our neurological department between 2004 and 2018, were included. All patients underwent initial and follow-up repetitive neurovascular ultrasound for a mean duration of 15.3 ± 21 months. Clinical and imaging data were registered for each patient.

Results

A total of 259 sCADs were diagnosed in 224 patients. Either internal carotid arteries (n = 133, 59.4%), vertebral arteries (n = 58, 25.9%), or multiple arteries (n = 33, 14.7%) were affected. In 93 out of 183 patients (51%), and in 117 out of 210 arteries under investigation (55.7%), vascular stenosis decreased over time. Occluded arteries recanalized early in 34 (54%) and stayed occluded in 29 patients (46.0%). Of 145 initially hemodynamically relevant stenosis, 77 (53.1%) improved over time. Overall, 12 patients (5.4 %) had a recurring sCAD during follow-up. Pseudoaneurysms were found in 19 patients.

Conclusion

The sonographical course of sCAD is highly dynamic within the first year after disease onset and should be monitored carefully. Decreasing degrees of stenosis and recanalization of occluded arteries occurred in half of all patients. Recurrent sCAD was a rare event in our cohort.

A Case of Intracranial Vertebral Artery Dissection Undetected by CT, MRI, and MRA at the Onset of Headache That Caused Subarachnoid Hemorrhage Seven Days Later

Objective

We report a patient with normal imaging findings at the onset of preceding headache who developed subarachnoid hemorrhage (SAH) due to intracranial vertebral artery dissection 7 days later.

Case Presentation

A 51-year-old woman with a history of chronic headache visited our emergency outpatient department with a complaint of mild to moderate right nuchal pain. CT, MRA, and MRI (diffusion-weighted image, T2-weighted image, FLAIR, MR cisternography, and basi-parallel anatomical scanning) were normal. Seven days later, she was admitted to our hospital with sudden disturbance of consciousness. CT revealed SAH and CTA demonstrated dilatation of the right vertebral artery (VA). The dilated lesion with an intimal flap on the right VA proximal to the posterior inferior cerebellar artery was confirmed on DSA. The dilated lesion and the proximal VA were occluded endovascularly using coils. The condition of the patient improved gradually, and she was transferred to the rehabilitation hospital on day 45 with a modified Rankin Scale score of 2.

Conclusion

The clinical course of the presented case, although rare, should be kept in mind in daily clinical practice.

Flow Diversion for Reconstruction of Intradural Vertebral Artery Dissecting Aneurysms Causing Subarachnoid Hemorrhage-A Retrospective Study From Four Neurovascular Centers

Objective: Dissecting aneurysms (DAs) of the vertebrobasilar territory manifesting with subarachnoid hemorrhage (SAH) are associated with significant morbi-mortality, especially in the case of re-hemorrhage. Sufficient reconstruction of the affected vessel is paramount, in particular, if a dominant vertebral artery (VA) is impacted. Reconstructive options include stent-assisted coiling and flow diversion (FD). The latter is technically less challenging and does not require catheterization of the fragile aneurysm. Our study aims to report a multicentric experience with FD for reconstruction of DA in acute SAH.

Materials and Methods: This retrospective study investigated 31 patients (age: 30–78 years, mean 55.5 years) who had suffered from SAH due to a DA of the dominant VA. The patients were treated between 2010 and 2020 in one of the following German neurovascular centers: University Hospital Leipzig, Katharinenhospital Stuttgart, BG Hospital Bergmannstrost Halle/Saale, and Heinrich-Braun-Klinikum Zwickau. Clinical history, imaging, implanted devices, and outcomes were reviewed for the study.

Results: Reconstruction with flow-diverting stents was performed in all cases. The p64 was implanted in 14 patients; one of them required an additional balloon-expandable stent to reconstruct severe stenosis in the target segment. One case demanded additional liquid embolization after procedural rupture, and in one case, p64 was combined with a PED. Further 13 patients were treated exclusively with the PED. The p48MW-HPC was used in two patients, one in combination with two additional Silk Vista Baby (SVB). Moreover, one patient was treated with a single SVB, one with a SILK+. Six patients died [Glasgow Outcome Scale (GOS) 1]. Causes of death were periprocedural re-hemorrhage, thrombotic occlusion of the main pulmonary artery, and delayed parenchymal hemorrhage. The remaining three patients died in the acute–subacute phase related to the severity of the initial hemorrhage and associated comorbidities. One patient became apallic (GOS 2), whereas two patients had severe disability (GOS 3) and four had moderate disability (GOS 4). Eighteen patients showed a complete recovery (GOS 5).

Conclusion: Reconstruction of VA-DA in acute SAH with flow-diverting stents is a promising approach. However, the severity of the condition is reflected by high overall morbi-mortality, even despite technically successful endovascular treatment.

Magnetic resonance vessel wall imaging predicts morphological deterioration in unruptured intracranial artery dissection

OBJECTIVE

The mechanism involved in progression of unruptured intracranial artery dissection (IAD) is poorly understood. We investigated the relationship between contrast enhancement of dissecting lesions on magnetic resonance vessel wall imaging (MR-VWI) and unruptured IAD progression on the hypothesis that this finding might predict its instability.

METHODS

A total of 49 unruptured IADs were investigated retrospectively. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after injection of contrast medium, and the dissecting lesion/pituitary stalk contrast enhancement ratio (CR_stalk) was calculated. Unruptured IAD progression was defined as morphological deterioration; progressive dilatation or stenosis. The relations between unruptured IAD progression and potential risk factors were statistically investigated.

RESULTS

Morphological deterioration was demonstrated in eleven of 49 unruptured IADs (22 %). The CR_stalk value and male predominance was significantly higher in progressed IADs than stable ones (1.0 vs. 0.65; p = 0.0035, 82% vs 37%; p= 0.015, respectively). On stepwise multivariable logistic regression analysis, the CR_stalk value was independently associated with unruptured IAD progression with odds ratio of 102.5 (95% CI, 2.59-4059, P=0.0013). The optimal cutoff value of CR_stalk to estimate IADs with progression was 0.87 (sensitivity, 0.82; specificity, 0.74). Multimodalic images showed contrast enhancement on VWI corresponded to residual stagnant flow in dissecting lesions.

CONCLUSIONS

Quantitative analysis of contrast enhancement on VWI could predict instability of unruptured IADs. Contrast enhancement in dissecting lesions would be a clue to understand the mechanism of unruptured IAD progression.

Investigation of the characteristics of headache due to unruptured intracranial vertebral artery dissection

BACKGROUND AND PURPOSE

It is sometimes difficult to diagnose intracranial vertebral artery dissection in patients with headache as the only symptom. Knowledge of the characteristics of the headache would facilitate the diagnosis. In this study, we aimed to clarify the characteristics of intracranial vertebral artery dissection-related headache using our original self-administered questionnaire.

METHODS

Via the questionnaire, we ascertained headache characteristics and investigated whether they differed between two types of unruptured intracranial vertebral artery dissection, headache type and ischemic type, based on analysis of the responses. Then, we tried to validate the consistency of commonly used criteria for intracranial artery dissection by comparing them with our results.

RESULTS

Thirty-seven patients were analyzed. Our results identified the following seven headache characteristics in patients with intracranial vertebral artery dissection: (i) occurring in the occipitonuchal region (89%); (ii) unilateral (81%); (iii) pulsatile (70%); (iv) of acute onset (70%); (v) severe (73%); (vi) without nausea or vomiting (73%); and (vii) with concomitant clinical symptoms unrelated to ischemia (81%). Comparison of headache characteristics between the two types of intracranial vertebral artery dissection headache showed that the pain was significantly more severe in headache type than ischemic type intracranial vertebral artery dissection ( p = 0.01). Concomitant clinical symptoms occurred significantly more often in ischemic type than headache type intracranial vertebral artery dissection ( p = 0.03). Our results generally satisfied the established headache diagnostic criteria.

CONCLUSION

The pain characteristics of headache type and ischemic type intracranial vertebral artery dissection shown in our study may facilitate its diagnosis.