Concurrent subarachnoid haemorrhage and internal carotid artery dissection: a transcranial colour-coded sonography diagnosis

We report the case of a young woman affected by an aneurysmal subarachnoid haemorrhage (SAH) and numerous anatomic abnormalities. A Transcranial Colour-Coded Duplex Sonography, performed with the aim of monitoring the vasospasm, showed a non-pulsatile flow with loss of sharp systolic peak and lowering of mean flow velocities in the right extracranial Internal Carotid Artery (ICA) and all its intra-cranial branches. This event suggested a possible concomitant acute right ICA sub-occlusion with a lack of collateral circulation. This type of flow is typically found in systemic and brain arteries of patients undergoing to venous-arterial extracorporeal membrane oxygenation or to left ventricular assist devices. The absence of an adequate cerebral collateral circulation might be the explanation for this type of atypical flow. Aneurysms and arterial dissections contribute to SAH and ischemic stroke events, leading to long-term physical and cognitive disability. In our case, the prompt neurosonological diagnosis leaded to patient's good outcome.

Long-term outcome of cervical artery dissection

OBJECTIVE

The aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches.

METHODS

A retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022.

RESULTS

Thirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner's syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days.

CONCLUSIONS

The majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.

Carotid Artery Dissection and Aneurysm with Styloid Process Fracture

BACKGROUND

Mechanical stimulation may lead to internal carotid artery (ICA) dissection and aneurysm.

CASE DESCRIPTION

We encountered a rare case of ICA dissection and aneurysm with prolonged styloid process (SP) fracture. A 37-year-old sales worker presented with right-sided amaurosis fugax. After admission to a nearby optical clinic, he was admitted to our hospital. Computed tomography angiography (CTA) and digital subtraction angiography showed dissection and apparent aneurysmal change in the right cervical portion of the ICA. CTA also showed elongated SPs, so we diagnosed Eagle's syndrome, and fracture of the right-side process. After 2 weeks of antiplatelet therapy, the aneurysm enlarged and dissection remained, so we treated the patient with coil embolization and stenting.

CONCLUSION

We encountered a rare case of ICA dissection and aneurysm with Eagle's syndrome. Endovascular treatment was performed because the SP was fractured.

Diagnosis of ischemic optic neuropathy caused by dissection of the internal carotid artery: A case report

RATIONALE

Ischemic optic neuropathy (ION), due to diseases of the arteries supplying the optic nerve, is an ischemic damage of the optic nerve. This report highlights a case with monocular decreasing visual acuity caused by dissection of the internal carotid artery (ICA), which is a relatively rare cause for ION.

PATIENT CONCERNS

A 44-year-old woman presented with a decreasing visual acuity and defected visual field in the right eye for 1 week. The best corrected visual acuity (BCVA) was 20/400 in the right eye, and 20/20 in the left eye. In the right eye, the pupil showed little reaction to light with a relative afferent pupillary defect. The visual field test disclosed a defect in the inferior field connecting to the blind spot. Electroretinogram recording showed no obviously declined retinal function. No recognizable waveforms were presented in pattern visual-evoked potential (PVEP) examination, whereas the flash visual-evoked potential result revealed a delayed peak time and a reduced amplitude of P2-wave.

DIAGNOSIS

The patient was diagnosed as ION with the aid of computed tomographic angiography of the brain and neck, which revealed a stenosis in the right ICA and an occlusion in the right cerebral middle artery. The stenosis was verified as dissection of the ICA by digital subtraction angiography.

INTERVENTIONS

Based on the clinical findings, stent implantation inside the right ICA was performed.

OUTCOMES

The ICA was recanalized soon and the BCVA of the right eye was improved to be 20/25 five months later. A second PVEP examination revealed a recognizable waveform in the right eye, although the peak time and amplitude of the P100-wave was a bit abnormal compared to that of the left eye.

LESSONS

ION with the sign of decreasing monocular visual acuity could occur due to dissection of the ICA, with no obvious neurologic symptom at the beginning. The present case emphasizes the importance of suspicion of ICA problems as the underlying cause for ION, which could help to take in-time measure to save the vision and avoid further complications.

Forensic and Clinical Issues in a Case of Motorcycle Blunt Trauma and Bilateral Carotid Artery Dissection

Internal carotid artery dissection (ICAD) after motorcycle accidents is unusual but life threatening if not promptly diagnosed and treated. We report the case of a motorcyclist involved in a frontal collision with a car, suffering injuries due to direct blunt trauma and indirect trauma by sudden deceleration force. Bilateral ICAD was diagnosed by computed tomography angiogram 5 days after the accident. Here in, starting from a medicolegal case, we emphasized some clinical criteria to make a prompt diagnosis to prevent permanent neurological deficit in this pathology whose best management is still under the debate. An unusual case of ICAD is described with regard to both forensic and promptly diagnostic therapeutic management.

Endovascular therapy versus intravenous thrombolysis in cervical artery dissection-related ischemic stroke: a meta-analysis

BACKGROUND

The purpose of our meta-analysis is to evaluate the endovascular therapy (EVT) in patients with cervical artery dissection (CAD)-related acute ischemic stroke (AIS) by comparing its efficacy and safety with the ones of intravenous thrombolysis (IVT).

METHODS

A systematic search on EVT to CAD-related ischemic stroke is performed. The meta-analysis models are applied to calculate either the risk ratio (RR) with 95% confidence interval (CI) or pooled proportions with 95% CI of favorable functional outcome (mRS = 0-2), excellent functional outcome (mRS = 0-1), symptomatic intracranial hemorrhage (SICH), mortality and recurrent stroke between EVT and IVT in CAD-related stroke. The differences between the two treatment groups are analyzed by the pooled odds ratio value and Chi-squared test.

RESULTS

A total of 190 patients given EVT and 139 IVT-alone patients are included. By comparing EVT alone and IVT alone, patients treated with EVT alone are more likely to experience favorable outcomes than those treated with IVT alone (71.2% vs 53.4%). Besides, there is no significant difference in excellent functional outcome, SICH, mortality and recurrent stroke between the EVT-alone and IVT-alone groups (all P > 0.05). Towards general EVT (EVT with or without IVT), the outcomes are not significantly different from those of IVT alone except for a higher mortality rate (10.2% vs 3.2%).

CONCLUSION

Based on our findings, EVT is considered to be more efficacious than IVT for CAD-related AIS patients. Although EVT alone tends to be safe and promising, its safety needs to be further evaluated, particularly for EVT separating from IVT therapy.

Bilateral Internal Carotid and Left Vertebral Artery Dissection after Blunt Trauma: A Case Report and Literature Review

Multi-vessel cervical arterial injury after blunt trauma is rare, and its pathophysiology is unclear. Although blunt cerebrovascular injury is a common cause of cerebral ischemia, its management is still controversial. We describe a 23-year-old man in previously good health who developed three-vessel cervical arterial dissections due to blunt trauma. He was admitted to our emergency and critical care center after a motor vehicle crash. Computed tomography showed a thin, acute subdural hematoma in the right hemisphere and fractures of the odontoid process (Anderson type III), pelvis, and extremities. He was treated conservatively, and about 1 month later, he developed bleariness. Computed tomography angiography showed bilateral internal carotid and left vertebral artery dissection. Aspirin therapy was started immediately, and then clopidogrel was added to the regimen. Two weeks later, magnetic resonance angiography (MRA) showed improved blood flow of the vessels. Only aspirin therapy was continued. About 3 months after discharge, MRA demonstrated further improvement of the blood flow of both internal carotid arteries, but the dissection flap on the right side remained. Therefore, we extended the duration of antiplatelet therapy. On the basis of our experience with this case, we think that antithrombotic therapy is crucial for the management of multi-vessel cervical arterial injury, and agents should be used properly according to the injury grade and phase; however, further study is needed to confirm this recommendation.

Contrast-enhanced transoral carotid ultrasonography for the diagnosis and follow-up of extracranial internal carotid artery dissection: A case report

A 56-year-old woman was admitted to our hospital because of amaurosis fugax. The carotid angiogram showed irregularly stenotic lesions of the left and right internal carotid arteries (ICAs), suggestive of dissection. Follow-up evaluation was performed by transoral carotid ultrasonography (TOCU) with contrast enhancement (CE), which yielded better vessel lumen and intramural hematoma visualization than color Doppler imaging. CE-TOCU is useful for evaluating ICA dissections that extends to the high cervical portion.

Dissection of the internal carotid artery and stroke after mandibular fractures: a case report and review of the literature

BACKGROUND

We present a report of a patient with blunt trauma and mandibular fractures who developed a significant cerebral infarction due to an initially unrecognized injury of her left internal carotid artery. We believe that increased knowledge of this association will facilitate early recognition and hence prevention of a devastating outcome.

CASE PRESENTATION

A 41-year-old ethnic Norwegian woman presented to our Emergency Room after a bicycle accident that had caused a direct blow to her chin. At admittance, her Glasgow Coma Scale was 15. Initial trauma computed tomography showed triple fractures of her mandible, but no further pathology. She was placed in our Intensive Care Unit awaiting open reduction of her mandibular fractures. During the following 9 hours, she showed recurrent episodes of confusion and a progressive right-sided hemiparesis. Repeated cerebral computed tomography revealed no further pathology compared to the initial scan. She had magnetic resonance angiography 17 hours after admittance, which showed dissection and thrombus formation in her left internal carotid artery, total occlusion of her left medial cerebral artery, and left middle cerebral artery infarction was detected.

CONCLUSIONS

Carotid artery dissection is a rare but life-threatening condition that can develop after trauma to the head and neck. There should be a high index of suspicion in patients with a mechanism of injury that places the internal carotid artery at risk because blunt vascular injury may show delayed onset with no initial symptoms of vascular damage. By implementing an algorithm for early detection and treatment of these injuries, serious brain damage may be avoided.

[Spontaneous carotid and vertebral dissections]

Dissections of the cervical arteries account for approximately 15-20 % of all strokes in young patients. Clinically they present with laterocervical and/or hemicranial pain associated to a Horner syndrome in case of carotid dissection and a posterior cervical pain associated to headache in the occipital area in case of vertebral dissection. A multifactorial origin is often suggested, resulting from the combination of a weakness of the arterial wall, hereditary or not, of environmental factors such minor trauma or a previous infection and also of the presence of a certain number of vascular risk factors such as high blood pressure or migraines. The diagnosis is best established with MRI which shows specifically the intramural hematoma. Treatment includes anticoagulants or antiplatelets agents.

Spontaneous carotid artery dissection: a rare cause of stroke in pregnancy and approach to diagnosis and management

Acute onset of neurological symptoms in a pregnant female is a rare medical emergency. We report a case of a 38-year-old female who presented with a stroke secondary to carotid artery dissection. Our case illustrates the need to consider vascular imaging before administering thrombolytic therapy in peripartum females to avoid unnecessary risks to either the mother or the fetus. Management is controversial and is discussed briefly.

Spontaneous craniocervical arterial dissection: a clinical and vascular neuroimaging study

BACKGROUND

Spontaneous craniocervical arterial dissection (SCAD) is an important cause of stroke in the young and middle-aged population. However clinical data of SCAD is limited in Thailand. This present study aims to describe the clinical profiles of SCAD in a tertiary care center in Thailand.

MATERIAL AND METHOD

All SCAD patients admitted to King Chulalongkorn Memorial Hospital between January 1997 and October 2011 were enrolled. All of the patients fulfilled vascular imaging diagnostic criteria for SCAD. Clinical profiles, associated risk factors, vascular neuroimaging patterns, treatments, and outcomes were analyzed by SPSS program version 17.

RESULTS

Fifty patients with SCAD were identified (0.5% of total hospitalized ischemic cerebrovascular disease and subarachnoid hemorrhage (SAH) patients). SCAD was found in 1.6% of patients under the age of 45 years. Eighty-six percent of the patients were diagnosed during the last five years of this present study period. Internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD) were detected in 42% and 58% respectively. The mean age was 48.3 +/- 15.3 years. Atherosclerotic risk factors included hypertension (16%), diabetes mellitus (24%), and dyslipidemia (28%). History of previous minor head injury and migraine were encountered in 8% and 4% respectively. Headache was detected in 80% of the cases. Localized headache was observed in 64% of the cases. Diffuse headache due to SAH was detected in 14% of the cases. Neurological syndromes at presentation were ischemic stroke (72%), transient ischemic attack (TIA) (80%), and SAH (16%). Pathognomonic vascular neuroimaging patterns of dissection included wall hematoma (36%), flame-shaped appearance (28%), dissecting pseudoaneurysm (24%), and intimal flap (8%). Other vascular imaging features included dissecting vessel stenosis (58%) and dissecting vessel occlusion (18%). Treatment consisted of anticoagulants (60%), antiplatelets (10%), surgical intervention (22%), and conservative management (8%). Neurological outcomes at discharge with MRS 0-3 were 72%. No recurrent dissection or recurrent cerebrovascular events were observed during the six-month follow-up period In this present study, significant differences between ICAD and VAD in terms of percentage of SAH, severity, and outcomes were observed

CONCLUSION

SCAD results in diverse cerebrovascular events such as ischemic stroke, TIA, and SAH in the young and middle-aged population. Advances in vascular neuroimaging play a crucial role in the diagnosis of SCAD. Prompt management is essential for SCAD with a rather favorable outcome.

[Cervical and intracranial artery dissections]

Cervical and intracranial artery dissections result from the occurrence of an intramural hematoma. Arterial dissection is one of the main causes of ischemic stroke in young adults. Pathophysiology remains misunderstood but probably results from the association of a triggering environmental factor with an underlying arteriopathy. Usually, headache or neck pain, sometimes associated with local signs (e.g., Horner's sign) occurs after a trivial trauma, followed some hours or days later by cerebral infarct. Diagnosis may be confirmed by CT-scan or MRI with angiogram. In the absence of randomized studies, acute treatment of cervical artery dissection is based on antithrombotics. IV thrombolysis is recommended in acute stroke. Outcome is favorable in most cases, related to infarct severity. Recurrences are very rare.

Carotid and vertebral artery sacrifice with a combination of Onyx and coils: technical note and case series

INTRODUCTION

Permanent vessel sacrifice has become a routine for the management of aneurysms, pseudoaneurysms, tumors, and carotid blowouts. The purpose of this study is to describe a new technique for carotid and vertebral artery sacrifice using a combination of Onyx and coils and to assess its feasibility, safety, and efficacy.

METHODS

The technique consists of deploying a few coils in the parent vessel under proximal flow arrest followed by Onyx embolization directly into the coil mass. A total of 41 patients underwent carotid/vertebral artery sacrifice using this technique in our institution.

RESULTS

A total of 26 internal carotid arteries and 15 vertebral arteries were treated. In all but one patient, a balloon test occlusion was performed prior to permanent arterial sacrifice. The mean number of coils used was 6.8 (range, 2-19). The total volume of Onyx used was 1.3 ml on average (range, 0.2-5.2 ml). All 41 (100%) parent arteries were successfully occluded. No distal migration of Onyx or coils was noted. Periprocedural complications occurred in 14.6% (6/41) of cases causing permanent morbidity in 7.3% (3/41). No patient developed a recurrence during the follow-up period (mean, 14 months).

CONCLUSION

Parent vessel sacrifice with a combination of Onyx and coils appears to be feasible, safe, and effective and may be an alternative to the traditional deconstruction technique with coils alone. The risk of thromboembolism exists with this technique, but there were no instances of Onyx migration.

Carotid and vertebral arterial dissections in the emergency department

Although carotid and vertebral (cervical) arterial dissections are not common presentations to the emergency department, timely and appropriate diagnostic strategies will allow early initiation of effective treatment therapies. Cervical arterial dissection occurs when the intimal wall of an artery is damaged as a result of trauma or defect. As blood fills the layers of the arterial wall, thrombi form, which can lead to stroke, pseudoaneurysm, vessel occlusion, and stroke. Intracranial dissections may result in subarachnoid hemorrhage. Because cervical arterial dissections may present with common signs and symptoms such as headache, neck pain, neurological deficits, and stroke, it is essential that dissection be considered early and ruled out quickly. Computed tomographic angiography, magnetic resonance angiography, and digital subtraction angiography may be used for diagnosis. Anticoagulation or antiplatelet therapy is the mainstay of treatment for spontaneous or traumatic dissections and will reduce the risk of stroke. Endovascular therapy or surgery may be indicated. Recurrence or rebleeding is a significant risk and must be managed.

Reconstructive stent-buttressed coil embolization of a traumatic pseudoaneurysm of the supraclinoid internal carotid artery

It is critical that traumatic intracranial pseudoaneurysms should be removed completely from the parent artery because there is a possibility of significant morbidity and mortality from the high risk of rebleeding from any remnants of the pseudoaneurysm. However, the deconstruction of the parent artery has the risk of ischemic damage to the distal to the trapped artery. We describe a case of a successful reconstructive stent-buttressed coil embolization in a patient with a traumatic pseudoaneurysm of the intracranial internal carotid artery. A 30-year-old man with a stuporous mentality was admitted to our institution after a traffic accident. The initial computed tomography scan showed a diffuse subarachnoid hemorrhage and a pseudoaneurysm of the left supraclinoid internal carotid artery. A reconstructive endovascular treatment using stent-assisted coil embolization with a stent-within-a-stent technique was conducted in order to save carotid blood flow. The pseudoaneurysm was completely obliterated and the patient recovered without any neurological deficit. We suggest that multiple stent placements with coiling may be considered as a treatment option for intracranial traumatic pseudoaneurysms as a reconstructive treatment.

Pediatric traumatic carotid, vertebral and cerebral artery dissections: a review

Traumatic cerebral dissections are rare but potentially dangerous conditions that through improved diagnostics have recently gained increased interest. However, there is still a significant lack of knowledge on the natural history, as well as on the best treatment options. Most of the literature on this topic consists of case reports and retrospective studies with no prospective randomized controlled studies. In our review, we highlight the fact that there is no level 1 evidence for the natural history of cerebral dissections or for the best treatment. We present 26 case studies derived from 70 pediatric patients affected by dissections, occlusions, and pseudoaneurysms.

[Horner syndrome as a manifestation of carotid artery dissection]

CLINICAL CASE

A 42-year-old man presented with ptosis and miosis in his left eye and a history of headache over the last 20 days. An angioresonance showed dissection of internal carotid artery.

DISCUSSION

"Painful Horner's Syndrome" is considered to be a medical emergency due possible onset of an internal carotid artery dissection. We consider that awareness of neuro-ophthalmologic emergencies is very important in the clinical praxis of an ophthalmologist. Multidisciplinary treatment and follow-up of these patients is required.

Emergent self-expanding stent placement for acute intracranial or extracranial internal carotid artery dissection with significant hemodynamic insufficiency

BACKGROUND AND PURPOSE

ICAD with hemodynamic insufficiency may present with either fulminant infarct or with progressive neurologic deterioration. The purpose of this study was to evaluate the safety and efficacy of emergent self-expanding stent placement for acute intracranial or extracranial ICAD with significant hemodynamic insufficiency.

MATERIALS AND METHODS

Eight patients (7 men and 1 woman; age range, 20-55 years; NIHSS score, 5-21) underwent emergent self-expanding stent placement for treatment of significant hemodynamic insufficiency due to acute ICAD. The safety and efficacy of emergent self-expanding stent placement were retrospectively evaluated.

RESULTS

All patients presented with progressive (n = 6) or fluctuating (n = 2) neurologic deficits and revealed markedly decreased perfusion on CT or MR perfusion studies. Conventional angiography revealed acute occlusion (n = 2) or critical stenosis (n = 6) in intracranial (n = 3) or extracranial (n = 5) carotid arteries with a lack of sufficient collaterals. Stent placement was successful in all patients without any procedure-related complications. In all patients, hemodynamic insufficiency was corrected immediately after stent placement, and neurologic symptoms were completely resolved during several days. Mean improvement of the NIHSS score between baseline and discharge was 11.6 (range, 5-21). All patients remained neurologically intact (mRS, 0) during clinical follow-up for a mean of 21 months (range, 8-50 months). Angiographic follow-up was available for 6 patients at 3-12 months. None of the 6 patients revealed residual or in-stent restenosis.

CONCLUSIONS

Self-expanding stent placement is a safe and effective option for selected patients with significant hemodynamic insufficiency due to acute intracranial or extracranial ICAD.

[Cerebral infarction suspected due to dissection of intracranial carotid artery in 2 children]

Intracranial cerebral artery dissection in children is very rare. We report 2 children who were diagnosed as having cerebral infarction which was suspected to be due to dissection of intracranial cerebral artery. Case 1: An 11-year-old girl presented with conscious disturbance and hemiparesis after seizure. Computed tomography (CT) showed cerebral infarction in the right frontal lobe. Her symptoms did not change, but angiography demonstrated reversible change. She received conservative therapy. Case 2: A 10-year-old boy complained of headache, and presented nausea and monoparesis of the left upper extremity. CT showed cerebral infarction in the right frontal lobe. He received superficial temporal artery-middle cerebral artery anastomosis because his symptoms fluctuated. In both cases, cerebral angiography showed string sign from the supraclinoid portion of the internal carotid artery to the middle and the anterior cerebral artery. Follow-up angiography showed improvement of stenosis. In pediatric cases of cerebral artery dissection, improvement with conservative therapy is frequently reported. It is necessary to follow-up such patients closely using magnetic resonance angiography or conventional angiography to determine whether or not surgery is indicated.

Symptomatic enlargement of an occluded giant carotido-ophthalmic aneurysm after endovascular treatment: the vasa vasorum theory

We describe a patient with a symptomatic left giant carotido-ophthalmic aneurysm who initially underwent coil embolization with subtotal obliteration. The patient's symptoms were initially stable, but 1 year later, she presented with a rapidly progressive contralateral visual deficit. Although angiogram showed a stable neck remnant, MR confirmed aneurysm growth and showed a new peripheral hematoma in the wall of the thrombosed aneurysm. Surgical exploration was undertaken, and even after trapping and intra-aneurysmal thrombectomy, constant bleeding was observed from the wall of the thrombosed aneurysm consistent with the vasa vasorum. Bleeding stopped after cauterization and partial resection of the aneurysm dome, and the aneurysm was clipped. The patient's recent visual deficit markedly improved, and the angiogram did not reveal any residue. Giant aneurysms may continue to grow due to a hypertrophic vasa vasorum and subadventitial hemorrhages. Surgery should be considered if complete thrombosis of the aneurysm does not alleviate patient's symptoms.

[Cervicocephalic arterial dissection]

The authors review the clinical and neuroradiological features of cervicocephalic arterial dissection, which is occasionally seen in young adults, with special reference to the differences in the region of occurrence of these lesions between patients in Western countries and Japan. In Western countries, the cervical internal carotid artery is the most common site of occurrence of these lesions; however, in Japan, these lesions have been frequently reported to occure in the intracranial vertebral artery. Most clinical manifestations of cervical arterial dissection are non-hemorrhagic events such as headaches associated with arterial dissection or cerebral ischemia caused by a distal embolism following thrombus formation in the cervical lesion. On the other hand, a subarachnoid hemorrhage and cerebral infarction are frequently observed in intracranial arterial dissections. Non-invasive procedures, including MR imaging, are useful for demonstrating characteristic features of this condition such as the presence of an intimal flap or a double lumen, and for monitoring the chronological changes in the lesions, which may regress spontaneously. Since the pathological mechanisms underlying the progression and / or the regression of this condition are still unknown, the clinical evidence indicating the optimal therapeutic strategies has not yet been reported. Nevertheless, conservative therapy, including antithrombotic treatment, is widely used for the treatment of non-hemorrhagic lesions, which generally results in good clinical outcomes. Further, surgical intervention is essential for the treatment of lesions with a subarachnoid hemorrhage to prevent fatal rebleeding, and it is also required for the treatment of certain non-hemorrhagic lesions. Recent advancements in surgical procedures, especially endovascular treatments, may therefore be helpful in the management of similar complicated vascular conditions.

[Dissection of the carotid artery following blunt trauma: still a pitfall]

Two young patients, an 18-year-old woman and a 25-year-old man, were admitted to hospital after accidents with a car. They developed very severe complications as a consequence of blunt carotid artery dissection. This diagnosis was delayed in both patients until serious cerebral ischaemia had occurred. Despite current awareness of carotid dissection as a possible result of blunt trauma, this injury is often overlooked. Early diagnosis by means of Doppler ultrasonography and CT-angiography is important in adequate management of this injury and may reduce morbidity and mortality. The treatment of carotid dissection consists of antithrombotic, endovascular or surgical therapy and needs to be individualized.

Dural arteriovenous fistula of the anterior cranial fossa associated with a ruptured ophthalmic aneurysm: case report and review of the literature

BACKGROUND

Dural arteriovenous fistula (DAVF) accompanied by intracranial aneurysms is an extremely rare situation.

CASE DESCRIPTION

A 65-year-old man presented with sudden loss of consciousness for about half an hour. Computed tomographic scan of the brain showed subarachnoid hemorrhage. Angiogram revealed an ophthalmic aneurysm. In addition, a DAVF located in the anterior cranial fossa was also found. The ruptured aneurysm was completely occluded by coil embolization and the DAVF of the anterior cranial fossa was treated with gamma knife radiosurgery after an uneventful postoperative course. The patient was managed nonoperatively and discharged with close follow-up.

CONCLUSION

An unusual case of anterior cranial fossa DAVF associated with a ruptured ophthalmic aneurysm is reported. We feel special consideration may be required in deciding the priority of treatment in such cases.

Stroke prevention and treatment in patients with spontaneous carotid dissection

This review on spontaneous dissection of the internal carotid artery (sICAD) will discuss in the first part stroke prevention and focus on vascular risk factors, antithrombotic therapy, and treatment of severe stenosis or occlusion, and dissecting aneurysm. The second part of the review will summarize the treatment of acute ischemic stroke due to sICAD.

Urgent Endovascular Covered-Stent Treatment of Internal Carotid Artery Injury Caused by a Gunshot

Penetrating non-lethal injuries to the distal extra-cranial internal carotid artery are often a surgical challenge, because of the difficulty of direct exposure and repair of the internal carotid artery at the skull base. We describe a case of a successful emergency treatment, with an endovascular procedure using a PTFE covered-stent, of an internal carotid artery haemorrhagic pseudoaneurysm following penetrating trauma to the neck by single gunshot.

Multiple carotid stenting for extended thoracic aorta dissection after initial aortic surgical repair

Acute aortic dissection is one of the most common catastrophes affecting the aorta. Aortic branch occlusion occurs in up to one third of patients with aortic dissection and is associated with increased risk for early death and serious complications. A 67-year-old man without history of cardiovascular disease was referred to our center for acute aortic type A dissection and was treated with a 28-mm Vasculteck prosthesis. During the early postoperative period, he felt left hemiparesis, and an angio-computed tomography showed a progression of the dissection to the right common carotid artery and left brachiocephalic trunk: the abdominal aorta with the celiac trunk. We felt that the patient should receive conservative management, except for the carotid involvement, for which an endovascular approach was planned. After carefully engaging the carotid ostia with a modified no-touch technique, a self-expandable stent and a balloon-expandable stent were deployed to seal the left common and internal carotid artery dissection, whereas two self-expandable stents were implanted within the right internal carotid artery. Angiographic control demonstrated complete sealing of the carotid dissections. The patient recovered quickly after the intervention and was discharged after 2 days without any neurologic or vascular complication. The patient did extremely well at two 3-month follow-ups, and coverage of the descending thoracic aorta dissection was scheduled to be performed in the next 2 months. This case suggests that endovascular techniques may offer a reliable and effective answer to extended dissections, helping decrease the risk for neurologic or visceral complications and reducing the operative risk for further complete surgical or endovascular aortic repair.

Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion

BACKGROUND AND PURPOSE

Tandem internal carotid and middle cerebral artery occlusion independently predicts poor outcome after intravenous thrombolysis. Recanalization of internal carotid artery dissection by stent-assisted angioplasty has recently been proposed when anticoagulation fails to prevent a new ischemic event. We recently reported a case of tandem internal carotid and middle cerebral artery occlusion with dissection of the internal carotid artery successfully treated with endovascular stent-assisted thrombolysis.

METHODS

We compared clinical outcomes in consecutive patients presenting with tandem internal carotid and middle cerebral artery occlusion with internal carotid artery dissection within 3 hours of symptom onset who were eligible for intravenous thrombolysis, treated by either endovascular stent-assisted thrombolysis or intravenous recombinant tissue-type plasminogen activator (rtPA) when an endovascular therapist was unavailable. National Institutes of Health Stroke Scale scores were obtained at baseline and after 24 hours. The modified Rankin Scale score was used to assess outcomes at 3 months. Arterial recanalization was assessed by magnetic resonance imaging.

RESULTS

Of 10 patients screened, 6 were treated with endovascular therapy and 4 with intravenous rtPA. Before treatment, mean National Institutes of Health Stroke Scale scores were high and comparable in the 2 groups (17 and 16, respectively). In the endovascular group, all patients achieved middle cerebral artery recanalization with subsequent dramatic improvement versus only 1 patient with middle cerebral artery recanalization in the intravenous rtPA group. At 3 months, 4 patients in the endovascular group had a favorable outcome (modified Rankin Scale score=0). In the intravenous rtPA group, 3 patients had a poor outcome (modified Rankin Scale score> or =3).

CONCLUSIONS

Endovascular stent-assisted thrombolysis is a promising treatment in tandem internal carotid and middle cerebral artery occlusion due to internal carotid artery dissection and compares favorably with intravenous rtPA.

Percutaneous Interventions in Patients with Acute Ischemic Stroke Related to Obstructive Atherosclerotic Disease or Dissection of the Extracranial Carotid Artery

PURPOSE

To determine the safety, feasibility, and efficacy of carotid artery stenting (CAS) in patients with acute stroke who underwent angioplasty of the extracranial internal carotid artery (ICA).

METHODS

Patients were eligible for CAS if they presented within 6 hours of symptom onset and had a National Institutes of Health Stroke Scale (NIHSS) score >4. The records of all 18 acute stroke patients (11 men; mean age 68.3+/-14.3 years) who underwent endovascular intervention in the stroke-related extracranial ICA between May 2003 and February 2006 were reviewed. Fourteen (77.8%) had atheromatous obstructions and 4 (22.2%) had dissection of the extracranial ICA. Major adverse cerebral and cardiac events (MACCEs) and neurological status, including NIHSS and the modified Rankin Scale (mRS) scores, were recorded for all patients.

RESULTS

Successful revascularization was achieved in 83.3% (15/18) of the patients. Cerebral protection devices were applied successfully in 13 (72.2%). At discharge, a neurological improvement (NIHSS reduction > or =4) was observed in 77.8% (14/18) of patients. The clinical success rate was 72.2% (13/18). The median NIHSS was 8.5 on admission versus 4.5 at discharge (p<0.01). The 30-day death and stroke rate was 11.1%. During the 14.6+/-9.3-month follow-up, the MACCE and the death/stroke rates were 33.3% and 27.8%, respectively. The median mRS scores at 30 days and at midterm follow-up were 1 and 2.5, respectively (p = NS).

CONCLUSION

Endovascular revascularization of the extracranial ICA in patients with acute ischemic stroke is associated with high procedural success rates and favorable midterm outcome.

Dissection of the carotid artery as a cause of fatal airway obstruction

Carotid artery dissection is a rare entity, and most cases are attributable to causative factors, which include trauma and local malignancy. The vast majority of dissections present with cerebral infarct; those few that present with local mass effect and respiratory compromise may deteriorate rapidly, requiring urgent resuscitation and consideration of endotracheal intubation, which is often dangerous and/or impossible. The case of a spontaneous internal carotid artery dissection in an otherwise healthy young man, leading to gross mass effect and eventual fatal airway obstruction, is presented here. The need for a high index of suspicion for cervical vascular injury in cases of neck injury (even trivial), known head and neck malignancy/irradiation, or coagulopathy is highlighted. Patients presenting with unilateral neck swelling and symptoms related to mass effect must be assumed to have progressive airway obstruction, and difficult intubation should be anticipated.

Incidence and outcome of cervical artery dissection: a population-based study

BACKGROUND

Incidence rates for internal carotid artery dissection (ICAD) have been reported to be 2.6 to 2.9 per 100,000, but reliable epidemiologic data for vertebral artery dissection (VAD) are not available.

OBJECTIVE

To determine the incidence rate of cervical artery dissection (CAD) in a defined population.

METHODS

With IRB approval, we used the medical record linkage system of the Rochester Epidemiology Project to identify all patients diagnosed with spontaneous ICAD and VAD for the period of 1987-2003 in Olmsted County, MN.

RESULTS

Of 48 patients with CAD, there were 32 patients with ICAD and 18 patients with VAD. In Olmsted County, the average annual incidence rate for ICAD was 1.72 per 100,000 population (95% CI, 1.13 to 2.32) and for VAD 0.97 per 100,000 population (95% CI, 0.52 to 1.4). The average annual incidence rate for CAD was 2.6 per 100,000 population (95% CI, 1.86 to 3.33). The most frequently encountered symptoms in CAD were head or neck pain (80%), cerebral ischemia (TIA or infarct) (56%), and Horner syndrome (25%). Good outcome (defined as modified Rankin score of 0 to 2) was seen in 92% of patients. No recurrence of dissection was observed during a mean 7.8 years of follow-up.

CONCLUSIONS

Internal carotid artery dissection was detected approximately twice as frequently as vertebral artery dissection in the overall study, but in the latter half of the study period, vertebral artery and internal carotid artery dissection incidence rates were equivalent. The majority of cervical artery dissection patients in the community have excellent outcome, and contrary to many tertiary referral series, re-dissection is rare.

Use of the Amplatzer vascular plug as an anchoring scaffold for coil-mediated parent vessel occlusion: technical case report

OBJECTIVE

Parent vessel sacrifice is a useful treatment strategy for fusiform intracranial aneurysms. Originally performed using the detachable silicone balloon, endovascular arterial occlusion is currently achieved using coils, a process which can be limited by coil mass migration.

METHODS

We demonstrate the use of the Amplatzer vascular plug as a fixed anchor within the target parent vessel to facilitate coil-mediated occlusion, especially in vascular segments not encased by a bony canal. The technique was used successfully in two patients: a 90-year-old woman presenting with IIIrd and VIth cranial nerve palsy from a fusiform left cavernous internal carotid aneurysm and a 44-year-old man with distal thromboemboli from a fusiform dissecting-type right vertebral artery involving the origin of the posterior inferior cerebellar artery.

RESULTS

Both patients were treated successfully with proximal parent vessel occlusion using coils after deployment of an Amplatzer vascular plug proximal to the target lesion. With the Amplatzer device acting as a fixed anchor in the parent vessel, coils were deployed proximally in a compact configuration. After deployment of the vascular plugs and coils, hermetic occlusion of the parent vessel was documented angiographically.

CONCLUSION

The Amplatzer vascular plug can facilitate coil occlusion of large cervical vessels by acting as a focal coil and embolic material immobilizer, which can prevent coil mass migration and lead to improved packing density.

Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment

Extracranial arterial dissections are a recognised cause of stroke, particularly in young adults. Clinical diagnosis may be difficult, and the classical triad of symptoms is uncommon. Imaging plays a pivotal role in the diagnosis of extracranial arterial dissections, and this review provides a detailed discussion of the relative merits and limitations of currently available imaging modalities. Conventional arteriography has been the reference standard for demonstrating an intimal flap and double lumen, which are the hallmarks of a dissection, and for detecting complications such as stenosis, occlusion or pseudoaneurysm. Noninvasive vascular imaging methods, such as ultrasound (US), magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are increasingly replacing conventional angiography for the diagnosis of carotid and vertebral dissections. Ultrasound provides dynamic and "real-time" information regarding blood flow. Source data of MRA and CTA and additional cross-sectional images can provide direct visualisation of the mural haematoma and information about the vessel lumen. Anticoagulation to prevent strokes is the mainstay of medical treatment, but randomised trials to define the optimal treatment regime are lacking. Surgery has a limited role in management of dissections, but endovascular procedures are gaining importance for treatment of complications and if medical management fails.

Pulsatile tinnitus as a symptom of cervicocephalic arterial dissection

The aim of this study was to investigate pulsatile tinnitus as a presenting symptom in cervicocephalic arterial dissection (CCAD). Of the 136 consecutive patients with confirmed CCAD, 16 presented with pulsatile tinnitus. On admission 10 patients presented with subjective tinnitus and five with objective tinnitus, tinnitus being the only presenting symptom in one case. In one further case with bilateral ICA dissection (ICAD) subjective tinnitus appeared three months after the initial symptoms of arterial dissection, despite a contralateral cervical bruit being evident on admission. Thirteen patients presented with headache or neck pain. Ischaemic symptoms were detected in six and Horner’s syndrome in four patients. Vertigo and dysgeusia were reported in two patients each. Arterial dissection involved unilateral ICA in 11, bilateral ICA in two, unilateral vertebral artery (VA) in two and bilateral ICA and bilateral VA in one patient. In angiography the most common finding was irregular stenosis, and the majority of these abnormalities normalized during follow-up. To avoid delay in diagnosis a high index of suspicion and early angiography (digital subtraction or magnetic resonance angiography) are warranted.