Cervicocranial arterial dissection: experience of 73 patients in a single center

doi:10.1016/j.surneu.2008.10.002

Surgical Neurology

Volume 72, Supplement 2, December 2009, Pages S20-S27

https://doi.org/10.1016/j.surneu.2008.10.002 Get rights and content

Abstract

Background

Arterial dissection involving cervicocranial arteries usually results in ischemia or SAH. This study correlated the clinical manifestations, image characteristics, and outcome of arterial dissection and compared the differences between arterial dissection of anterior and posterior circulation at our institute.

Methods

Clinical symptoms and neuroradiologic findings were retrospectively analyzed in 73 patients (6-75 years old) who had a spontaneous arterial dissection of cervicocranial vessels verified by angiography or MRI. Twenty-four cases of ACAD and 49 cases of PCAD were included in this study.

Results

The leading presentation of arterial dissection of ACAD group was ischemic stroke (79.2%), and that of posterior circulation was SAH (44.9%), followed by ischemic stroke (42.8%). In the ACAD group, the extracranial ICA was more commonly involved (62.5%), with long segmental narrowing the most common angiographic finding. In the PCAD group, the intracranial VA was more commonly involved (81.6%), with alternating narrowing and dilatation the leading angiographic picture.

All the cases presenting with ischemic stroke or headache were conservatively treated with anticoagulants or antiplatelets, except for one treated with intra-arterial thrombolysis for thromboembolism in basilar artery at an early stage. One of them died of progressed brainstem infarct in spite of anticoagulation therapy. All the others reached improved or stable clinical condition. Eighteen cases were treated by surgical or endovascular intervention. None of them had rebleeding. Of the 5 patients with SAH due to dissecting lumens without treatment, 2 died of rebleeding.

Conclusions

Ischemia is the predominant presentation of ACAD; and PCAD has similar occurrence of SAH and ischemia. Intracranial arterial dissection is not uncommon; and it should be kept in the list of differential diagnosis of young stroke. Aggressive treatment of arterial dissection presenting with SAH should be considered; otherwise, rebleeding may occur.

Introduction

Arterial dissection of cervical and intracranial vessels could result in ischemic stroke or SAH. The overall incidence of cervicocranial arterial dissection remains unknown, but is likely higher than reported because the presenting symptoms may be nonspecific and some individuals could be asymptomatic [16].

Arterial dissection is the most important cause among non-atherosclerotic vasculopathies that result in young stroke [14]. It is increasingly diagnosed in recent years because of increasing familiarity with the clinical entity and progress in investigative methods. Early diagnosis of cervicocranial arterial dissection seems mandatory because young patients are mainly affected and because there is much evidence that cerebral infarct may be prevented by instant anticoagulation.

Subarachnoid hemorrhage could be caused by intracranial arterial dissection, mostly vertebrobasilar artery system. Early angiographic diagnosis is necessary because the recurrent hemorrhage rate is high and the treatment method of dissecting lumens is different from that of saccular lumens.

We reviewed the cases of arterial dissection involving cervical and intracranial vessels diagnosed at our department and compared the clinical and radiologic differences between anterior circulation and PCAD.

Section snippets

Materials and methods

In this retrospective study, 73 cases of cervicocranial arterial dissection diagnosed in a 5-year period from January 1998 through December 2003 at our institution were included for analysis. The diagnosis was based on the DSA, or MRI with MRA. The inclusion criteria on angiography were pearl and string sign (alternating narrowing and dilatation), fusiform dilatation with presence of false lumen or intimal flap, and long segmental narrowing (string sign or tapered occlusion). Cases of arterial

Results

The demographic profile of our subjects is listed in Table 1. The 73 patients included 42 males and 31 females, with a mean age of 45.3 years (6-75 years; SD, 11.9). In our study, male patients were slightly predominant (42/73 = 57.5%), and 66.7% were in the ACAD group and 53.1% were in the PCAD group. Of these patients, 40 presented with ischemic stroke (54.8%), 22 with SAH (30.1%), 3 with combined ischemia and SAH, 1 with brainstem hemorrhage, and 1 with blindness. Four patients presented

Discussion

Spontaneous dissections of the cervicocranial artery affect all age groups, but there is a distinct peak in the fifth decade of life [12]. The data revealed 72.6% of our patients were 40 years or older. Thirteen of 24 (54.2%) and 40 of 49 (81.6%) were 40 years or older in the ACAD and PCAD groups, respectively. In the PCAD group, about 34.7% of patients were older than 50 years. It is evident that spontaneous dissections of carotid or vertebral arteries are an important cause of stroke in young

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IschemiaCervicocranial arterial dissection: experience of 73 patients in a single center

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

J Vasc Surg

Vertebral artery dissection presenting findings and predictors of outcome

Stroke

Endovascular treatment of vertebral artery dissections and pseudolumens

J Neurosurg

Clinical and neuroradiological features of intracranial vertebraobasilar artery dissection

Stroke

Coil embolization for the treatment of ruptured dissecting vertebral aneusysms

Am J Neuroradiol

Stroke patterns of internal carotid artery dissection in 40 patients

Stroke

Treatment of a vertebral dissecting lumen with stents and coils: technical case report

Neurosurgery

Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysm

Neurosurgery

Treatment of dissecting pseudolumen of the cervical internal carotid artery using a wall stent and detachable coils: case report

Neurosurgery

Ischemia
Cervicocranial arterial dissection: experience of 73 patients in a single center