Three cases of spontaneous extracranial vertebral artery dissection

Systemic lupus erythematosus is associated with an increased risk of cervical artery dissection

Limited evidence suggests that autoimmune diseases are associated with an increased risk of cervical artery dissection (CeAD). We hypothesized individuals with systemic lupus erythematosus (SLE) would have an increased risk of CeAD following SLE diagnosis compared to matched non-lupus controls. We queried a de-identified United States electronic medical records network (TriNetX, Inc.) for individuals aged 10 and older from 2012 to 2020, for two cohorts: (1) SLE and (2) non-lupus controls, excluding those with prior CeAD. We used propensity matching to control for confounding variables and calculated the risk ratio (RR) for CeAD occurring over four years' follow-up, secondarily exploring cumulative incidence. After matching, both cohorts contained 77,008 patients, who were mostly female (89%). The incidence and risk of CeAD was significantly greater among those with SLE compared to matched non-lupus controls [95% CI] (0.08% vs. 0.04%; RR = 2.33 [1.49;3.66]; P < 0.0001). These findings support the hypothesis that SLE is a risk factor for CeAD. Additional research is needed to identify the mechanisms that may underly the SLE-CeAD association and examine the potential association between other autoimmune diseases and CeAD.

Simultaneous intracranial and extracranial vertebral artery dissections: a case report

Vertebral artery dissection can occur in intracranial or extracranial vertebral arteries. However, the simultaneous dissection of both intracranial and extracranial vertebral arteries is extremely rare. We describe a 45-year-old man with simultaneous intracranial and extracranial vertebral artery dissections in separate sites. The patient visited a neurosurgical clinic because of headache; he was diagnosed with right vertebral artery dissection and referred to our hospital. Magnetic resonance imaging showed an intramural hematoma and mild dilation of the external lumen in the right vertebral artery distal to the posterior inferior cerebellar artery. Magnetic resonance angiography revealed poor delineation of the entire right vertebral artery, including the proximal portion from the posterior inferior cerebellar artery. Computed tomography angiography revealed right extracranial vertebral artery dissection. Careful imaging assessment is thus important for identifying simultaneous intracranial and extracranial vertebral artery dissections.

Bilateral Vertebral Artery Dissection: A Case Report with Literature Review

Vertebral artery dissection (VAD) is a rare cause of ischemic stroke in young patients. The largely nonspecific symptoms and delayed presentation pose a serious diagnostic challenge. Medical management with either anticoagulation or antiplatelet therapy is recommended, but there are no reports of successful dual therapy. We report a case of spontaneous bilateral vertebral artery dissections (VADs) treated with both anticoagulation and antiplatelet therapy and a literature review on clinical presentation and the current medical and surgical management options. A 37-year-old healthy female presented to the emergency department with worsening neck pain and headache for two weeks despite over-the-counter medication, block therapy, yoga, and deep tissue neck massage. She denied any trauma but admitted to multiple roller coaster rides over the past few months. CT angiography was concerning for VADs, and MRI brain revealed multiple strokes in the left posterior inferior cerebellar artery (PICA) territory. Cerebral arteriography confirmed the diagnosis of VADs. The patient was initiated on warfarin, along with atorvastatin and aspirin. She was discharged home with no complications and followed up with neurology as an outpatient. MR angiography after three months revealed complete resolution of the dissection. The patient did not report any bleeding complications from dual therapy.

A Study on the Clinical and Angiographic Spectrum of Spontaneous Extracranial Dissections in the Cerebral Vasculature

Aim:

To prospectively study the clinical profile, angiographic features, and functional outcomes, in consecutive cases of extracranial dissection seen at two tertiary stroke care centers in South India.

Materials and Methods:

In this observational study, spanning 4 years (December 12–December 16), a total of 442 patients presented with an acute ischemic stroke/transient ischemic attack (TIA) at our study centers. 14/546 (3.2%) of these patients had magnetic resonance angiography (MRA)/computed tomography angiography (CTA) evidence of extracranial dissections. All cases underwent detailed clinical evaluation on arrival, and data were recorded on a predesigned stroke pro forma. Contrast MRA was done on arrival in all cases as part of a standard stroke protocol, and CTA was done only if MRA was inconclusive. The pattern of the vessel involved and morphology of vessel dissection was analyzed as per a standard radiology protocol. All the cases were managed with short-term anticoagulation using low-molecular-weight heparin followed by oral anticoagulants for 3–6 months. All cases were followed up for 1–2 years and the functional outcomes were recorded using the modified Rankin Scale (mRS).

Results:

There were 11 males and 3 females in the study, and the mean age was 45.1 years (range = 27–65 years). Focal neurological symptoms occurred in all these patients (10 patients had a stroke, and 4 had TIA). Nearly 64.2% of these (9/14) were stroke in young (age <45 years). The internal carotid artery was the most common vessel involved in 85.7% (12/14) cases. Of the ten patients with completed stroke, a good functional outcome (mRS 1–2) was seen in 8/10 (80%). Digital subtraction angiography and revascularization procedures were needed only in a minority of cases 3/14 (21%).\

Conclusion:

This hospital-based study highlights the importance of suspecting arterial dissections in young strokes of unexplained etiology, and offering optimum anticoagulant therapy in the acute phase, to achieve good long-term outcomes.

Management of Cervical Arterial Dissection

Background

Clinical, pathological and radiological advances in recent years have considerably advanced our understanding of the incidence and underlying mechanisms producing dissection of the cervical arteries, which should have implications for medical and, surgical therapy in the near future. This review is a summary of progress to date.

Summary of review

Numerous published studies, primarily over the last decade, have generated a rapidly evolving data base especially in the areas of etiology, neuroimaging and more recently, arterial pathology and its genetic basis.

Conclusion

Dissection of the carotid and vertebral arteries, both intracranially and extracranially, is a major and frequently underdiagnosed cause of stroke, especially in the young. These advances in clinical epidemiological observations, and new radiological and pathological data, are gradually providing an evidence-based rationale for future trials of therapeutic interventions, using both drugs and devices.

Cervical subluxation associated with posterior cervical hemivertebra

PURPOSE

Hemivertebrae, associated with a failure in the formation and fusion of vertebral body ossification nuclei, are a common cause of thoracic or lumbar scoliosis. A cervical location is rare and even rarer as a cause of cervical subluxation in flexion and extension (for which only one previous case has been found).

CASE REPORT

We report on the case of a 7-year-old female patient, who was examined for a cervical fusion defect, consisting of a posterior C4 hemivertebra and a left hemiblock from C5 to C7. After performing surgery consisting of a C4 corpectomy and anterior fixation with intersomatic graft and plate, adequate cervical stabilization with only a self-limiting left C6 brachialgia and ipsilateral Horner syndrome occurs in the postoperative period.

CONCLUSION

Posterior cervical hemivertebra associated with instability is a very rare finding. The anterior approach with corpectomy and anterior plate enables suitable stabilization.

Three cases of Spontaneous Vertebral Artery Dissection (SVAD), resulting in two cases of Wallenberg syndrome and one case of Foville syndrome in young, healthy men

First patient, presented with sudden onset of headache, left hypoacusia and right hemiparesis, posteriorly developing gaze-evoked nystagmus and worsening right-sided weakness. Diagnosis of vertebral artery dissection and Foville Syndrome were made through clinical assessment and CT-carotid angiogram-MR angiography. Second patient, presented with four episodes of pain over left side of the nose and left eye pain over 1 month; admitted for acute facial pain without limb weakness. During admission, tingling over V1/V2 facial territory, vertigo, hypotension, uvula deviation and right lower limb numbness. CT-carotid angiogram confirmed vertebral artery with dissection. MRI revealed left lateral medullary infarct. Third patient, presented with sudden onset of left facial numbness and right upper limb weakness; 1 day after, right arm and leg hypoesthesia with hoarseness. MRA revealed dissection of left distal vertebral artery and MRI showed infarction in lower medulla oblongata.

Neurologic manifestations of inherited disorders of connective tissue

Inherited disorders of connective tissue are single gene disorders affecting structure or function of the connective tissue. Neurological manifestations are classic and potentially severe complications of many such disorders. The most common neurological manifestations are cerebrovascular. Ischemic stroke is a classic complication of vascular Ehlers-Danlos syndrome (type IV), homocystinuria, and arterial tortuosity syndrome, and may occasionally be seen in Marfan syndrome and pseudoxanthoma elasticum with distinct underlying mechanisms for each disease. Vascular Ehlers-Danlos syndrome can also lead to cervical artery dissection (with or without ischemic stroke), carotid-cavernous fistula, intracranial dissections and aneurysms potentially causing subarachnoid or intracerebral hemorrhage, and arterial rupture. Other neurological manifestations include nerve root compression and intracranial hypotension due to dural ectasia in Marfan and Loeys-Dietz syndrome, spinal cord compression in osteogenesis imperfecta, and mucopolysaccharidosis type I and VI, carpal tunnel syndrome in mucopolysaccharidosis type I, II, and VI. Impaired mental development can be observed in homocystinuria, mucopolysaccharidosis type II, and the severe form of mucopolysaccharidosis type I. For the neurologist, being aware of these complications and of the diagnostic criteria for inherited connective tissue disorders is important since neurological complications can be the first manifestation of the disease and because caution may be warranted for the management of these patients.

Cervical carotid artery dissection: current review of diagnosis and treatment

Carotid artery dissection is a cause of stroke, especially in young and middle-aged patients. A dissection occurs when there is an intimal tear or rupture of the vasa vasorum, leading to an intramural hematoma, which is thought to result from trauma or can occur spontaneously, and is likely multifactorial, involving environmental and intrinsic factors. The clinical diagnosis of carotid artery dissection can be challenging, with common presentations including pain, partial Horner syndrome, cranial nerve palsies, or cerebral ischemia. With the use of noninvasive imaging, including magnetic resonance and computed tomography angiography, the diagnosis of carotid dissection has increased in frequency. Treatment options include thrombolysis, antiplatelet or anticoagulation therapy, endovascular or surgical interventions. The choice of appropriate therapy remains controversial as most carotid dissections heal on their own and there are no randomized trials to compare treatment options.

Intracranial artery dissection in an adolescent with Marfan syndrome

Marfan syndrome is an autosomal dominant connective tissue disorder commonly due to mutation of the fibrillin-1 (FBN-1) gene that causes disruption of elastic fibers in large- and medium-size arteries and predisposes to aneurysm formation and arterial dissection. Cardiovascular complications occur in most patients with Marfan syndrome, but interestingly, neurovascular complications of Marfan syndrome are rare. We present a novel case of an adolescent with Marfan syndrome with spontaneous intracranial cerebral artery dissection and ischemic stroke with hemorrhagic transformation. This case is novel in that it reports spontaneous intracranial dissection in a young patient with Marfan syndrome and highlights the rare intrinsic neurovascular complications that can occur in these patients.

Successful endovascular reconstruction of acutely ruptured pseudoaneurysm of the vertebral artery, complicated by isolated vertebrobasilar circulation and symptomatic vasospasm

The management of a ruptured pseudoaneurysm of intracranial vertebral artery (VA), which is the sole supplier to an isolated vertebrobasilar system, is challenging. The authors report on such a case in a 49-year-old man who suffered a grade III subarachnoid hemorrhage (SAH) caused by a dissecting fusiform pseudoaneurysm of the left VA. The right VA terminated in the posterior inferior cerebellar artery and posterior communicating arteries were absent. The patient developed symptoms consistent with vasospasm on day 9 after SAH, which was treated by intra-arterial vasolytic therapy, followed by stent placement and "in-stent" balloon angioplasty. Angiography 2 weeks later showed near-complete resolution of the pseudoaneurysm. At discharge, the patient's modified Rankin score was one. In this complicated case in which an isolated vertebrobasilar circulation precluded parent vessel sacrifice, we detail the successful management using a combination of intra-arterial vasolytic therapy, stent reconstruction, and balloon angioplasty.

Cervical artery dissection: pathology, epidemiology and management

BACKGROUND

Cervical artery dissection is often treated with anticoagulants to prevent ischemic stroke. The risk-benefit ratio of anticoagulation versus antiplatelet therapy is unclear.

OBJECTIVES

To provide an educational review of current data on the disease to explain the rationale for the treatment options and to explore the results of management studies in order to determine if anticoagulation is justified.

METHODS

We searched the databases MEDLINE and EMBASE as well as bibliographies for information on anticoagulants and antiplatelet agents in cervical, i.e. carotid and/or vertebral artery, dissection.

RESULTS

There are no randomized controlled trials on the treatment. One systematic review from 2003 identified 20 case series or cohort studies. We identified 9 additional studies with a total of 1,033 patients. Of those, 731 received anticoagulation sometimes followed by platelet inhibition vs. 282 patients treated with antiplatelet agents alone. The rate of ischemic stroke was 2.3% vs. 6.9% and bleeding complications were reported in 0.7% vs. 0%.

CONCLUSION

It cannot be excluded that there is a net benefit from anticoagulant therapy in cervical dissection, but the studies are flawed by considerable bias. Very ill patients at a high risk of ischemic stroke may have been given aspirin due to fear of hemorrhagic complications. A randomized controlled trial is planned and will be crucial to resolve this issue.

Segmental disruption of internal elastic lamina in spontaneous vertebral artery dissection combined with redundancy of multiple cervical arteries

A 49-year-old man developed a spontaneous vertebral artery dissection leading to cerebellar and brain stem infarction. Cerebral angiograph demonstrated redundancy, including kinks, loops and coils, in multiple cervicocephalic arteries, in addition to the dissecting artery. Histological examination of the superficial temporal artery revealed segmental disruptions of the internal elastic lamina and intimal abnormalities. These ultrastructural abnormalities may impair vessel wall integrity and predispose to nontraumatic arterial dissection and vascular tortuosity.

Dissection of the Extracranial Vertebral Artery: Clinical Findings and Early Noninvasive Diagnosis in 24 Patients

Dissection of cervical arteries causes ischemic stroke in young adults. This reports the clinical, ultrasonographic, and neuroradiological findings in 24 patients with 28 vertebral artery dissections in the neck (4 occurring bilaterally). In 20 patients (83%), the dissection was temporally related to trauma. No patients had an underlying vascular disease, for example, atherosclerosis or fibromuscular dysplasia. In all, the major initial manifestation was pain in the occipital or neck region. The next most common symptoms were vertigo and nausea (in 17 patients). Clinical manifestations were vertebrobasilar transient ischemic attack (TIA) (5 patients: in 2 patients vestibulocerebellar TIA, in 1 patient visual TIA, in 1 patient motor TIA, and in 1 patient brain stem TIA with perioral paresthesia), cerebellar infarction (10 patients, in 4 patients bilateral), brainstem infarction (5 patients), posterior cerebral artery territory infarction (1 patient), and multiple vertebrobasilar ischemic lesions (3 patients). Typical angiographic findings were irregular narrowing of the vessel lumen or a tapering stenosis with distal occlusion. Magnetic resonance imaging showed a thickened vessel wall with hematoma signal at the site of the dissection. Duplex color-flow imaging was valuable for the early diagnosis of extracranial vertebral artery dissection and for follow-up examinations. The distal V1- and the proximal V2-segment (at the level of C6 vertebra) was the most frequent localization of dissections (in 43%). The outcome was favorable except for 2 patients with basilar artery occlusion. Embolism to the basilar artery may be avoided by early administration of anticoagulants.

[Fatal outcome after severe cerebellar infarction due to spontaneous dissection of the vertebral artery]

Cerebellar infarction due to vertebrobasilar ischemia in spontaneous vertebrobasilar dissection is infrequent in children and adolescents. The commonest pathogenic mechanism of cerebellar infarction is arterial occlusion. Although usually favorable, outcome can be fatal, as in the present case. A previously healthy 4-year-old girl was admitted to the emergency room with sensory failure and trembling. The previous week she had suffered from a transitory ischemic attack that resolved spontaneously. On admission to the emergency department, the Glasgow Coma Scale score was 10/15 and she presented irregular polypneic breathing, anisocoric reactive pupils, enhanced reflexes, lower limb clonus and bilateral pyramidal signs. Cranial computed tomography revealed marked hypodensity in both cerebellar hemispheres and white supratentorial substance with obliteration of the quadrigeminus cisterns. Cerebral angiography showed left vertebral artery dissection with distal pseudoaneurysm and marked basilar occlusion. Despite aggressive antiedemic treatment and early instauration of intravenous continuous sodium heparin infusion, the patient developed a bilateral cerebellar infarction and supratentorial hydrocephalus. Brain death was diagnosed after 48 hours. Postmortem pathologic examination revealed previous thrombus the in superior left cerebellar artery and basilar artery occlusion. We discuss the absence of predisposing factors and the transitory ischemic attack in this patient 1 week before she developed massive cerebellar infarction.

Vertebral artery dissection presenting with isolated neck pain

Unilateral pain in the cervical region and limitation of neck movements are nonspecific symptoms frequently encountered in daily medical practice. Vertebral artery dissection is rarely considered as a diagnostic possibility unless brainstem or cerebellar ischemia follows the acute pain. Three cases of vertebral artery dissection (VAD) having the sole complaint of pain of acute onset in the posterior neck region are presented. None of the patients had ever reported a similar pain, and the neurological examination was unremarkable in all of them. Doppler ultrasonography suggested VAD in 2 cases, and the diagnosis was confirmed with T1 fat-suppressed magnetic resonance imaging technique in all patients. Severe neck pain and/or occipital headache frequently accompanies ischemic symptoms in cases with VAD. The cases in this report emphasize that spontaneous and often unilateral posterior cervical pain of acute onset can be the only manifestation of a VAD. A high degree of suspicion especially in young patients with no past history of a similar pain can help to establish the diagnosis, thereby preventing erroneous and potentially hazardous therapeutic interventions such as physiotherapy or neck manipulation.

Cervical manipulation to a patient with a history of traumatically induced dissection of the internal carotid artery: a case report and review of the literature on recurrent dissections

OBJECTIVE

To describe the use of rotational cervical manipulation in treating a patient who had undergone a traumatically induced dissection of the internal carotid artery and to review the literature on recurrent cervical artery dissections.

CLINICAL FEATURES

A 21-year-old woman with hemiparesis from an internal carotid artery dissection that occurred as the result of a motor vehicle accident had neck pain and headaches. Moderate range of motion restrictions in the neck were present along with articular restrictions to movement palpation.

INTERVENTION AND OUTCOME

After a year of soft-tissue treatment, we obtained detailed, informed consent from the patient to attempt diversified manipulation to the neck. The patient described greater and more immediate relief and longer pain-free periods than could be achieved by soft-tissue treatment alone.

CONCLUSION

Patients with previous cervical artery dissections may present with unrelated neck pain and headaches and request treatment. In selected cases, with complete informed consent, manipulation of the neck may relieve these symptoms. A review of published case reports on recurrent dissections suggests that trauma is not a significant factor in the second dissection. Care must be taken in extrapolating the results from this case to any other patient with a history of cervical artery dissection.

Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation

STUDY DESIGN

Potential precipitating events and risk factors for vertebrobasilar artery dissection were reviewed in an analysis of the English language literature published before 1993.

OBJECTIVES

To assess the literature pertaining to precipitating neck movements and risk factors for vertebrobasilar artery dissection in an attempt to determine whether the incidence of these complications can be minimized.

SUMMARY OF BACKGROUND DATA

Vertebrobasilar artery dissection and occlusion leading to brain stem and cerebellar ischemia and infarction are rare but often devastating complications of cervical, manipulation and neck trauma. Although various investigators have suggested potential risk factors and precipitating events, the basis for these suggestions remains unclear.

METHODS

A detailed search of the literature using three computerized bibliographic databases was performed to identify English language articles from 1966 to 1993. Literature before 1966 was identified through a hand search of Index Medicus. References of articles obtained by database search were reviewed to identify additional relevant articles. Data presented in all articles meeting the inclusion criteria were summarized.

RESULTS

The 367 case reports included in this study describe 160 cases of spontaneous onset, 115 cases of onset after spinal manipulation, 58 cases associated with trivial trauma, and 37 cases caused by major trauma (3 cases were classified in two categories). The nature of the precipitating trauma, neck movement, or type of manipulation that was performed was poorly defined in the literature, and it was not possible to identify a specific neck movement or trauma that would be considered the offending activity in the majority of cases. There were 208 (57%) men and 158 (43%) women (gender data not reported in one case) with an average age of 39.3 +/- 12.9 years. There was an overall prevalence of 13.4% hypertension, 6.5% migraines, 18% use of oral contraception (percent of female patients), and 4.9% smoking. In only isolated cases was specific vascular disease such as fibromuscular hyperplasia noted.

CONCLUSIONS

The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.

Case report of fibromuscular dysplasia presenting as stroke in a 16-year-old boy

Fibromuscular dysplasia of the carotid artery is uncommon, but not rare. Although the true incidence and prevalence of the disease are not known, reported figures in adults range between 0.6% by angiography and 1.1% at autopsy. Most case reports of stroke caused by carotid fibromuscular dysplasia describe findings in adult subjects, although there are a few reports of the disease in children. In the present case, we describe a 16-year-old boy with fibromuscular dysplasia confined to one internal carotid artery and its branches, and in whom the disease declared itself by stroke. This case serves as a basis for considering diagnostic methods, treatment options, and future research in pediatric patients with cerebrovascular disease caused by fibromuscular dysplasia.

Vertebrobasilar artery territory infarction as an initial manifestation of systemic lupus erythematosus

Cerebral infarction is a well-documented complication of systemic lupus erythematosus (SLE), that usually occurs several years after the diagnosis of SLE. To our knowledge, however, strokes associated with vertebrobasilar artery involvement were not reported to present as an initial manifestation of SLE. We report two patients, who presented with vertebrobasilar territory infarction as an initial manifestation of SLE. Patient 1 was a 16-year-old girl, who developed dysarthria and ataxia. MRI showed multiple infarcts in the pons, cerebellum and thalamus. Four-vessel cerebral angiography showed multifocal stenoses in the vertebral and basilar arteries with beaded appearance. Patient 2 was a 26-year-old woman, who developed headache associated with dysarthria, dizziness and ataxia. MRI showed multiple infarcts in the cerebellum, medulla, pons, midbrain and thalamus. Cerebral angiography revealed occlusion of both vertebral arteries at the first cervical vertebral level with non-visualization of the basilar artery. Both patients were diagnosed as having SLE supported by laboratory results. Although rare, posterior circulation stroke can present as an initial manifestation of SLE, which may be attributed to vasculitis or dissection in the vertebral/basilar artery.

Intracranial aneurysms in Marfan's syndrome: an autopsy study

OBJECTIVE

Marfan's syndrome is a heritable connective tissue disorder that has been associated with intracranial aneurysms. However, the prevalence of intracranial aneurysms in Marfan's syndrome is unknown and pathological studies of affected vessels have not been reported. We therefore examined the neuropathological findings in a group of patients with Marfan's syndrome.

METHODS

We identified all patients with Marfan's syndrome in whom postmortem examination had been performed at the Mayo Clinic between 1969 and 1993.

RESULTS

Autopsy included examination of the brain in seven patients with Marfan's syndrome (five men and two women with a mean age of 28 yr). Each of two patients had one or more intracranial aneurysms. The first patient, a 32-year-old man who died as a result of aortic dissection, was observed to have an incidental saccular supraclinoid carotid artery aneurysm (7 mm). Microscopic examination of the remainder of the cerebral arteries revealed duplication and fragmentation of the internal elastic lamina. The second patient, a 20-year-old man who died as a result of a subarachnoid hemorrhage, had ruptured saccular supraclinoid carotid artery (3 mm) and anterior cerebral artery (20 mm) aneurysms as well as unruptured fusiform middle cerebral artery (18 mm) and posterior cerebral artery (13 mm) aneurysms. Microscopic examination of the cerebral arteries revealed widespread changes consisting of intimal proliferation, medial degeneration, and fragmentation of the internal elastic lamina.

CONCLUSION

These findings confirm an association between Marfan's syndrome and intracranial aneurysms. Microscopic involvement of cerebral arteries in Marfan's syndrome may be variable, even among those with intracranial aneurysms.

Tissue plasminogen activator in a vertebral artery dissection

BACKGROUND

Spontaneous dissection of the vertebral artery is uncommon.

METHOD

Case study.

RESULTS

We report a 49-year-old woman who presented with the rapidly progressing basilar artery syndrome who was given an intravenous dose of tissue plasminogen activator seven hours after the onset of first symptoms. Thirty minutes after the injection, a dramatic recovery of the patient's consciousness and neurological signs was noted.

CONCLUSION

To our knowledge, this is the first reported case of intravenous tissue plasminogen activator use in acute vertebral artery dissection.

Spontaneous vertebral dissection: clinical, conventional angiographic, CT, and MR findings

OBJECTIVE

The purpose of this study was to determine if typical clinical and neuroradiologic patterns exist in patients with spontaneous vertebral artery (VA) dissection.

MATERIALS AND METHODS

The medical records and neuroradiologic examinations of 14 patients with spontaneous VA dissection were reviewed. The medical records were examined to exclude patients with a history of trauma and to record evidence of a nontraumatic precipitating event ("trivial trauma") and presence of possible risk factors such as hypertension. All patients underwent conventional angiography, 13 either CT or MRI (11 both CT and MRI), and 3 MRA. Conventional arteriograms were evaluated for dissection site, evidence of fibromuscular dysplasia, luminal stenosis or occlusion, and pseudoaneurysm formation. CT examinations for the presence of infarction or subarachnoid hemorrhage. MR examinations for the presence of infarction or arterial signal abnormality, and MR angiograms for abnormality of the arterial signal column.

RESULTS

Seven patients had precipitating events within 24 h of onset of symptoms that may have been causative of dissection and five had hypertension. At catheter angiography, two patients had dissections in two arteries (both VAs in one patient, VA and internal carotid artery in one patient), giving a total of 15 VAs with dissection. Dissection sites included V1 in four patients, V2 in one patient, V3 in three patients, V4 in six patients, and both V3 and V4 in one patient. Luminal stenosis was present in 13 VAs, occlusion in 2, pseudoaneurysm in 1, and evidence of fibromuscular dysplasia in 1. Posterior circulation infarcts were found on CT or MR in five patients. Subarachnoid hemorrhage was found on CT in two patients and by lumbar puncture alone in two patients. Abnormal periarterial signal on MRI was seen in three patients. MRA demonstrated absent VA signal in one patient, pseudoaneurysm in one, and a false-negative examination in one. Repeat catheter angiography of nine VAs at an interval ranging from 2 weeks to 1 year showed progression to occlusion in two arteries, unchanged appearance in 4, and angiographic resolution in three, which did not closely correlate with clinical outcome.

CONCLUSION

No preferred site of dissection along the course of the VA was found in this study. CT and MR examinations of the head are frequently normal in patients with VA dissections. No correlation between clinical outcome and findings at repeat angiography was demonstrated.

Dissection of the vertebral artery with cervical nerve root lesions

Vertebral artery dissection may cause upper limb peripheral motor deficit. We report three young patients presenting with nuchal pain followed by a nearly painless proximal paresis of the arm several days later. The cause, as detected by colour-coded Duplex sonography and MRI, was an extracranial dissection of the vertebral artery. The proximity of the intervertebral segment to the vertebral artery and the nerve roots indicated that compression by an intramural haematoma was the likely cause of the disorder. Subsequent examinations during anticoagulation treatment showed almost complete disappearance of the intramural haematoma and of the neurological deficits within a few weeks. We believe that the occurrence of an upper limb peripheral motor deficit should be added to the spectrum of potentially misleading signs of vertebral artery dissection.

Proximal balloon occlusion for dissecting vertebral aneurysms accompanied by subarachnoid hemorrhage

Five patients with spontaneous dissecting vertebral aneurysms presenting with subarachnoid hemorrhage were treated with endovascular proximal balloon occlusion after a successful balloon Matas' test. Occlusion was performed in the extracranial portion of the vertebral artery after the potentially dangerous period of cerebral vasospasm. Two patients rebled preoperatively during the waiting period. Although angiograms demonstrated residual aneurysmal dilatation for four of the five patients, postoperative hemorrhages or progression of the dissection were not observed during the 19- to 48-month follow-up period. Only one patient experienced transient postoperative ischemic complication. Although the timing of the procedure and the site of occlusion remain controversial, proximal balloon occlusion of the vertebral artery appears to be a safe and effective therapy for patients with dissecting vertebral aneurysms presenting with subarachnoid hemorrhages. This method provides an important, less invasive alternative for this condition.

Recurrent spontaneous cervical-artery dissection

BACKGROUND

Spontaneous dissection of the internal carotid and vertebral arteries is increasingly recognized as a cause of ischemic stroke in young people. An underlying arteriopathy is often suspected in the pathogenesis of such dissection, but the frequency of recurrent dissection is unknown.

METHODS

We describe the long-term follow-up of 200 consecutive patients (104 women and 96 men) with spontaneous cervical-artery dissections evaluated at the Mayo Clinic between 1970 and 1990. All diagnoses were confirmed by angiography.

RESULTS

The mean age of the patients was 44.9 years (range, 16 to 76). Internal carotid arteries were affected in 150 patients, vertebral arteries in 37, and both in 13. Multivessel dissections were present in 28 percent of the patients. The mean follow-up was 7.4 years. Recurrent dissection occurred only in arteries not previously involved by dissection. A recurrent arterial dissection developed in 16 patients (8 percent)--within a month after the initial dissection in 4 patients (2 percent) and between 1.4 and 8.6 years later in 12 patients (a rate of 1 percent per year). The cumulative rate of recurrent dissection among patients followed for 10 years was 11.9 percent. Younger patients had a greater risk of recurrent dissection.

CONCLUSIONS

Although dissections in multiple cervical vessels are common at presentation, after the first month the risk of recurrent dissection is only about 1 percent per year.

Use of histomorphometry in the assessment of fatal vertebral artery dissection

AIM

To assess morphometrically the structural changes, which occur with ageing, along the length of the vertebral artery.

METHODS

A series of 36 vessels were removed at necropsy from subjects aged between 9 months and 86 years. Image analysis was used to measure the medial width, the circumference, the intimal: medial area ratio and the adventitial: medial area ratio along each artery. The artery from a case of fatal vertebral artery dissection, which occurred after a game of cricket and then chiropractic neck manipulation, was also examined in the same manner. The proteoglycan accumulation in the media was quantified using an eyepiece graticule.

RESULTS

The vertebral arteries were, on average, larger around the origin of the vessel from the subclavian artery, and the adventitia were relatively thicker at this point, and also after piercing the dura mater. The media were much thinner within the intracranial segment and pronounced intimal thickening occurred with increasing age. The dissected artery showed undoubtable pre-existent structural abnormalities, in the form of massive proteoglycan accumulation, which predisposes an artery to dissection.

CONCLUSIONS

These data should help pathologists faced with the task of assessing the underlying structural integrity of the vessel wall in cases of vertebral artery injury.

Endovascular treatment of vertebral artery dissections and pseudoaneurysms

Sixteen patients with dissecting aneurysms or pseudoaneurysms of the vertebral artery, 12 involving the intradural vertebral artery and four occurring in the extradural segment, were treated by endovascular occlusion of the dissection site. Patients with vertebral fistulas were excluded from this study. The dissection was caused by trauma in three patients (two iatrogenic) and in the remaining 13 no obvious etiology was disclosed. Nine patients presented with subarachnoid hemorrhage (SAH), two of whom had severe cardiac disturbances secondary to the bleed. The nontraumatic dissections occurred in seven women and six men, with a mean age on discovery of 48 years. Fifteen patients were treated with endovascular occlusion of the parent artery at or just proximal to the dissection site. One patient had occlusion of a traumatic pseudoaneurysm with preservation of the parent artery. Four patients required transluminal angioplasty because of severe vasospasm produced by the presenting hemorrhage, and all benefited from this procedure with improved arterial flow documented by transcranial Doppler ultrasonography and arteriography. In 15 patients angiography disclosed complete cure of the dissection. One patient with a long dissection of extracranial origin extending intracranially had proximal occlusion of the dissection site. Follow-up angiography demonstrated healing of the vertebral artery dissection but persistent filling of the artery above the balloons, which underscores the need for embolic occlusion near the dissection site. No hemorrhages recurred. One patient had a second SAH at the time of therapy which was immediately controlled with balloons and coils. This patient and one other had minor neurological worsening resulting from the procedure (mild Wallenberg syndrome in one and minor ataxia in the second). Symptomatic vertebral artery dissections involving the intradural and extradural segments can be effectively managed by endovascular techniques. Balloon test occlusion and transluminal angioplasty can be useful adjuncts in the management of this disease.

Headache to worry about

The headache to worry about is one that is unique or different from headaches which the patient has suffered in the past. The association with the headache of meningismus or of focal neurologic symptoms of oculoparesis, other cranial nerve palsies, hemiparesis, or loss of consciousness are particularly worrisome, especially if onset is recent and acute. Headaches related to arteritis or vasculitis usually have a slower subacute course but may also produce focal neurologic deficits. For subjects over 50 years old, temporal arteritis is always a consideration and any new type of headache requires testing of the sedimentation rate to rule out this treatable but potentially devastating problem.

Angiographic frequency of saccular intracranial aneurysms in patients with spontaneous cervical artery dissection

The pathogenesis of intracranial aneurysms and spontaneous cervical artery dissection is incompletely understood but a primary arteriopathy, possibly similar in both disorders, may be of importance. To investigate the frequency of intracranial aneurysms in patients with spontaneous cervical artery dissection, the angiograms of 164 patients who were diagnosed at the Mayo Clinic as having spontaneous extracranial carotid or vertebral artery dissection were reviewed. Thirteen intracranial aneurysms were detected in nine (5.5%) of the 164 patients: eight (8.8%) of the 91 female patients and one (1.4%) of the 73 male patients. The frequency of intracranial aneurysms in these patients was significantly higher (p less than 0.01) than that observed in a recent angiographic study from the same institution, estimating the frequency of intracranial aneurysms in the general population (1.1%). The significance of these findings is discussed.

Fatal bilateral vertebral artery dissection in a patient with cystic medial necrosis

A 38-year-old man experienced severe neck pain while playing badminton. This was followed by symptoms of vertebrobasilar ischaemia, seizure and coma. Autopsy showed bilateral vertebral artery dissection and cystic medial necrosis.