Traumatic Dissection of Arterial Cervical Vessels: Report of Two Cases and Literature Review

Even though traumatic dissection of cervical arterial vessels is themajor cause of stroke among adults, it is still an underdiagnosed disease in neurosurgical emergencies, since most patients do not have or present subtle clinical signs in the acute phase. The authors report two interesting cases of cervical artery dissection with different traumatic mechanisms and present a broad literature review about this subject.

Caracterización clínica e imagenológica de una serie de pacientes con disección de arterias cervicales e intracraneales / Cervicocranial arterial dissection: experience in 57 patients

Background: Cervicocranial arterial dissection (CIAD) is an important cause of stroke. Aim: To describe the clinical and imaging characteristics of patients with CIAD. Material and Methods: An anonymous registry was made including all patients admitted to a private hospital with a diagnosis of CIAD. Patients were subdivided as having an anterior or posterior circulation dissection (ACD or PCD, respectively). Results: Fifty-seven patients aged 40 ± 8 years (60% women) were included in the study, 39 with PCD and 18 with ACD. Cervical pain was the most common symptom. CIAD was diagnosed with no clinical or imaging signs of stroke in 49% of patients. Fifty one percent of patients had focal neurological deficits and 72% had a NIH stroke score below five. No significant differences between patients with ACD or PCD were found. Fifty patients received antiplatelet therapy (simple or dual), seven patients were anticoagulated and 13 were subjected to stenting due to progression of stenosis with hemodynamic involvement or bilateral dissection with scarce collaterals. The lesion was located in V3 segment in 27 patients and cervical segment of the internal carotid in 16 cases. A favorable Modified Rankin Scale (0-2) was achieved in 85.9%, with a trend towards achieving better functional prognosis in PCD. Conclusions: Due to the greater availability of non-invasive imaging methods, 50% of these patients with CIAD did not have a stroke. Thus, an earlier and more timely management is feasible.

Cerebellar infarction after sneezing

SUMMARY Vertebral Artery Dissection (VAD) is a rare condition that can be caused by a wide amplitude of neck movement, which injures the vessel wall and can cause ischemia in the cerebellum. We present a 37-year-old man with herniated lumbar disc and allergic rhinosinusitis, which caused sneezing spells. After one of these bouts with a ricochet of the head, he presented C3 misalignment with local pain. Twenty-one days later, affected by a new crisis, he presented left temporal headache, nystagmus, and vertigo. After 3 days, Magnetic Resonance Imaging (MRI) identified 2 regions of cerebellar ischemia and filling failure of the right vertebral artery. After 2 days, Computed Angiotomography (CT Angiography) was performed and showed right VAD with a local thrombus, without aneurysmal signs. Transcranial Doppler did not indicate an increase in blood flow from this artery. The suggested treatment involved administration of anticoagulant Apixabana 5mg, 12/12h, for 3 months, until the condition was reevaluated with new Angio CT and MRI. It was recommended that the patient was released from work for 1 month and forbidden from doing intense physical exercises for 3 months; however, due to setbacks, these deadlines were extended until a new appointment, 4 months after the first visit. The new tests showed no changes, indicating that the condition was stable. This case aims to indicate the possible investigations of the diagnosis and therapeutic options of the rare association between VAD with cerebellar infarction in a well-documented case.

RESUMO A Dissecção da Artéria Vertebral (DAV) é quadro raro que pode ser causado por movimentação de grande amplitude do pescoço, que lesiona a parede desse vaso, podendo provocar isquemia no cerebelo. Apresentamos um homem de 37 anos, com hérnia de disco e rinossinusite alérgica que lhe causava crises de espirros em salva (CE). Após uma dessas crises com ricocheteamento da cabeça, apresentou desalinhamento de C3 com dor local. Vinte e um dias depois, acometido por nova crise, apresentou cefaleia temporal esquerda, nistagmo e vertigem. Decorridos 3 dias, o paciente foi submetido a Ressoânncia Magnética (RM), que identificou 2 regiões de isquemia cerebelar e enchimento comprometido da artéria vertebral direita. Após 2 dias, foram feitos Angiotomografia Computadorizada (Angio TC), que constatou DAV direita com trombo local, sem sinais aneurismáticos, e Doppler Transcraniano, que não indicou aumento do fluxo sanguíneo dessa artéria. O tratamento sugerido envolvia administração de anticoagulante Apixabana 5mg, 12/12h, por 3 meses, até que o quadro fosse reavaliado com novas Angio TC e RM. Foi recomendado que o paciente ficasse afastado do trabalho por 1 mês e de exercícios físicos intensos por 3 meses, porém devido a contratempos, esses prazos foram prorrogados até nova consulta, 4 meses após a primeira. Os novos exames não apresentaram alterações, indicando que o quadro estava estável. Esse caso tem como objetivo indicar as possíveis investigações do diagnóstico e opções terapêuticas da rara associação entre DAV com infarto cerebelar em caso bem documentado.

Multi-mode images to assess posterior circulation ischemic stroke caused by bilateral vertebral artery dissection based on vascular ultrasound: A case report / 中国脑血管病杂志

The etiology of posterior circulation ischemic stroke caused by bilateral vertebral artery dissection ( VAD) is often difficult to detect. In this study, the authors report a case of posterior circulation ischemic stroke with a history of excessive back elevation of the neck. The dissection of bilateral vertebral arteries was detected by carotid Doppler ultrasonography and further confirmed by magnetic resonance imaging and high-resolution magnetic resonance imaging. After 6 months of standard administration of dual antiplatelet therapy, recanalization of the bilateral vertebral artery was achieved. It proves that the early diagnosis and standardized medical treatment of VAD can significantly improve patients' prognosis.

Spectrum of Magnetic Resonance Imaging Findings in Vertebral Artery Dissection

Introduction: Vertebral artery dissection (VAD) is animportant cause of posterior circulation stroke in youngpatients and presents with a host of clinically varied symptomsdepending upon the type and site of dissection. Currentresearch aimed to study the spectrum of magnetic resonanceimaging findings in vertebral artery dissection.Material and methods: This was an observational studywhere a cohort of 193 patients of posterior circulation strokewere evaluated with magnetic resonance imaging and amongthem 17 patients having vertebral artery dissection wereselected and magnetic resonance imaging findings werestudied using spin echo, diffusion weighted imaging and 3Dtime of flight MR angiography sequences.Results: Of the total 17 patients imaged with age range of23-59 years (mean age 38 years), 11 were males and 6 werefemales. V3 was the commonest site of dissection (n=10)followed by V4 (n=4) and V2 (n=3). The most commonpattern of dissection was steno-occlusive (n=15), whereas2 patients had aneurysmal type of dissection. T1W imagesrevealed intra-arterial thrombus in all the 17 patients. T2Wrevealed absent flow in vertebral artery in 5 patients. 3D TOFMRA revealed narrowed lumen in 10 patients and completeocclusion in 5 patients. One patient revealed intimal flap on3D TOF MRA.Conclusion: MRI is an excellent non-invasive modality forevaluation of posterior circulation stroke. MRI in conjunctionwith MR angiography helps clinch the diagnosis of VAD andthus helps in planning management and subsequent follow upof these patients.

Vertebral Artery Dissection Presenting with Acute Infarction in Cervical Spinal Cord and Cerebellum

We describe a case of vertebral artery dissection (VAD) presenting with acute infarctions in cervical spinal cord and cerebellum in a 78-year-old man. Diffusion-weighted magnetic resonance (MR) imaging of the brain demonstrated diffusion-restricted lesions in the right cerebellum and sagittal T2-weighted MR imaging of spinal cord showed a hyperintense lesion of the cervical spinal cord at C2-C4 level. Right VAD was identified by transfemoral cerebral angiography and computed tomography angiography which showed segmental occlusion in the right vertebral artery.

Spontaneous Intracranial Vertebral Artery Dissection in a 2-Year-Old Child Diagnosed with High-Resolution MRI: a Case Report

Although many imaging modalities can play some roles in the diagnosis of vertebral artery dissection (VAD), digital subtraction angiography (DSA) remains the gold standard method, with the highest detection rate and ability to assist in planning for endovascular treatment. However, this tool is often avoided in children because its invasive nature and it exposes them to radiation. High resolution magnetic resonance imaging (HR-MRI) have been suggested to be a reliable and non-invasive alternative, but it has never been discussed in children in whom vertebral artery dissection is a rare condition. In this report, we evaluate a case of a 2-year-old child who initially presented with cerebellar symptoms, and was early diagnosed with vertebral artery dissection using HR-MRI and was successfully treated.

Vascular ultrasound assessment of internal carotid artery dissection and vertebral artery dissection and the difference analysis of lumen recanalization / 中国脑血管病杂志

Objectives To diagnose and test cervical artery dissection (CAD) during the follow-up by color Doppler flow imaging (CDFI) and to analyze and compare the differences of internal carotid artery dissection ( ICAD) and stenosis degree of vertebral artery dissection ( VAD) , and lumen recanalization. Methods From January 2016 to December 2018 , a total of 136 consecutive patients (160 dissecting vessels) with CAD of intramural hematoma type diagnosed by CDFI and confirmed by high-resolution MRI and/or CT angiography in Xuanwu Hospital .Capital Medical University were enrolled retrospectively. They were divided into ICAD group (n =66, with 75 ICADs) and VAD group (n =70,with 85 VADs).The gender, age,risk factors,cerebral ischemic symptoms, and CDFI manifestations were compared in the patients between the two groups. They were followed up at 3,6, and 12 months after onset. The patients with CAD were reexamined, and the difference of recanalization rate between the two groups was compared. Results There was a statistically significant difference in the mean age and proportion of hypertension between the ICAD group and the VAD group (both P 0. 05); there was significant difference in the degree of vascular stenosis (P 0. 05) between the VAG group and the ICAD group. Conclusions ICAD was different from VAD in the degree of lumen stenosis and the rate of lumen recanalization at different follow-up time. CDFI had good test and follow-up re-examination values for CAD.

Bilateral Vertebral Artery Dissection after a Chiropractic Therapy Session

Vertebral artery dissection (VAD) is a rare and sometimes unrecognized cause of stroke in patients younger than 45 years. Herein, we describe a very rare case of bilateral vertebral artery dissection after a session of cervical therapy manipulation (chiropractic).

Vertebral artery dissection (VAD) is a rare and sometimes unrecognized cause of stroke in patients younger than 45 years. Herein, we describe a very rare case of bilateral vertebral artery dissection after a session of cervical therapy manipulation (chiropractic).

Endovascular treatment of ruptured intracranial vertebral artery dissecting aneurysm:correlation between location and outcome / 国际脑血管病杂志

Objective To investigate the correlation between the location of ruptured intracranial vertebral artery dissecting aneurysm (VADA)and the outcome after endovascular treatment. Methods Thirty-six patients with ruptured intracranial VADA undergoing endovascular treatment were enrolled retrospectively. According to the relationship between VADA and the location of the opening of posterior inferior cerebellar artery(PICA),they were divided into 3 groups:proximal to PICA group (n=13), distal to PICA group (n=13),and PICA involvement group (n=10). The demographic data, vascular risk factors, clinical features, imaging features, endovascular treatment mode, postoperative complications, and differece of the good outcome rate(defined as the modified Rankin scale 0-2)after 6 months of treatment were compared.Results Seven patients in the proximal to PICA group received reconstructive endovascular treatment (RET), and 6 received endovascular internal trapping(EIT);the good outcome rate was 100%(13/13).Seven patients in the distal to PICA group received RET,6 were treated with EIT;the good outcome rate was 84.6%(11/13).Four patients in the PICA involvement group received RET,and 6 received EIT,and 2 of them received contralateral vertebral artery retrograde PICA stenting combined with VADA segment and proximal vertebral artery coil embolization;the good outcome rate was 60.0%(6/10). There were significant differences in the overall outcome good rate among the 3 groups (P<0.05). The good outcome rate in the PICA involvement group was significant lower than that in the proximal to PICA group,and significantly lower than that in the proximal to PICA combined with distal to PICA group(P<0.05).Multivariate logistic regression analysis showed that only Fisher grade 3-4 was the independent risk factor for poor outcome (odds ratio 28.0, 95% confidence interval 1.71-458.82; P=0.020). Conclusions The surgical options of endovascular treatment for ruptured intracranial VADA needs to evaluate the relationship between the location of dissecting aneurysms and the PICA origin. The risk of endovascular treatment in patients with intracranial VADA involving the origin of PICA is higher and it may affect the outcome.

The comparative study of CT angiography with DSA in vertebral artery dissection / 中华放射学杂志

Objective To explore the diagnostic value of CT angiography (CTA) of vertebral artery dissection (VAD) value. Methods We retrospectively analysed vertebral artery dissection in 30 patients (32 branches) according to the results of DSA. Tow radiologists independently analyzed the CTA images, and the sensitivity, specificity and accuracy of CTA in VAD patients were determined. The consistency of DSA and CTA results were evaluated by Kappa test. Results Thirty two branches of 60 vertebral arteries were diagnosed as VAD by DSA, 31 branches were diagnosed as VAD by CTA, 1 branch was misdiagnosis. Eight branches with dissection aneurysm were all displayed by CTA and DSA. Eleven branches of 12 branches withstring of beads signwere diagnosed by CTA. Five branches of 6 branches withstring and pearl signwere diagnosed by CTA;CTA and DSA of 1 branch withdouble-lumen signwere all displayed. Six branches of 5 branch withlinear signwere diagnosed by CTA. One branch showedlinear sign, but was diagnosed thrombosis by CTA. Two branches were showedlinear sign, but were diagnosedstring of beads signandstring and pearl sign. The sensitivity, specificity, accuracy of CT angiography in diagnosing VA dissection were 96.8％(31/32), 100％(28/28), 98.3％(59/60), respectively. The results made good agreement with DSA(Kappa=0.967,P<0.01). Conclusion Dual source CTA was a sensitive and accurate technique for the diagnosis of VAD.

Characteristics for Ischemic Stroke in 18–30 Years Old Patients, Multicenter Stroke Registry Study / 이화의대지

OBJECTIVES: Although there have been several reports that described characteristics for young age stroke, information regarding very young age (18–30 years old) has been limited. We aimed to analyze demographic factors, stroke subtype, and 3-month outcome in acute ischemic stroke patient who have relatively very young age in multicenter stroke registry. METHODS: We evaluated all 122 (7.1%) consecutive acute ischemic stroke (within 7 days after symptom onset) patients aged 18 to 30 from 17,144 patients who registered in multicenter prospective stroke registry, 1997 to 2012. Etiology was classified by Trial of Org 10172 in Acute Stroke Treatment criteria. Stroke severity was defined as National Institutes of Health Stroke Scale (NIHSS) and stroke outcome was defined by modified Rankin scale (mRS) at 3 months after index stroke. RESULTS: The mean age of all included patients was 25.1±3.7 years and 76 patients (62.2%) were male. The median NIHSS at admission was 4. Considering stroke subtype, 37 patients (30.3%) had stroke of other determined etiology (SOD), 37 (30.3%) had undetermined negative evaluation (UN) and 31 (25.4%) had cardioembolism (CE) were frequently noted. After adjusting age, sex and variables which had P<0.1 in univariable analysis (NIHSS and stroke subtype), CE stroke subtype (odds ratio, 4.68; 95% confidence interval, 1.42–15.48; P=0.011) were significantly associated with poor functional outcome (mRS≥3). CONCLUSION: In very young age ischemic stroke patients, SOD and UN stroke subtype were most common and CE stroke subtype was independently associated with poor discharge outcome.

Locked-in Syndrome Performed Endovascular Treatment for Vertebral Artery Dissection and Basilar Artery Occlusion Caused by a Golf Swing

No abstract available.

Disección espontánea de la arteria vertebral / Spontaneous vertebral artery dissection

La disección arterial como causa de ataque cerebrovascular es infrecuente, presentándose más comúnmente en población joven asociado a un trauma menor que involucra la hiperextensión del cuello. Presentamos el reporte de un paciente hombre, joven, con un accidente cerebrovascular de fosa posterior y cuya etiología fue una disección espontánea de la arteria vertebral derecha.

Arterial dissection as a cause of stroke is uncommon, most commonly presenting in young people sometimes associated with trauma involving hyperextension of the neck as the only history which would suggest the traumatic origin. We present the case report of a young man with posterior stroke whose etiology was a spontaneous dissection of the right vertebral artery.

Aberrant Origin of Vertebral Artery and its Clinical Implications

Abstract Aberrant origin of vertebral artery is rare. The anatomical features and clinical significance of this lesion remain to be clarified. A comprehensive collection of the pertinent literature resulted in a cohort of 1286 cases involving 955 patients and 331 cadavers. There were more left than right and more unilateral than bilateral aberrant vertebral arteries. Patients with aberrant origin of vertebral artery were often asymptomatic and in only 5.5% of the patients their symptoms were probably related to the aberrant origin of vertebral artery. The acquired cardiovascular lesions were present in 9.5% of the patients, 20.9% of which were vertebral artery-associated lesions. Eight (0.8%) patients had a vertebral artery dissection. Logistic regression analysis showed significant regressions between bovine trunk and left vertebral artery (P=0.000), between the dual origins of vertebral artery and cerebral infarct/thrombus (P=0.041), between associated alternative congenital vascular variants and cervical/aortic dissection/atherosclerosis (P=0.008). Multiple logistic regression demonstrated that side of the aberrant origin of vertebral artery (left vertebral artery) (P=0.014), arch branch pattern (direct arch origin) (P=0.019), presence of the common trunk (P=0.019), associated acquired vascular disorder (P=0.034) and the patients who warranted management (P=0.000) were significant risk predictors for neurological sequelea. The patients with neurological symptoms and those for neck and chest operations/ interventions should be carefully screened for the possibility of an aberrant origin of vertebral artery. The results from the cadaver metrology study are very helpful in the design of the aortic stent. The arch branch pattern has to be taken into consideration before any maneuver in the local region so as to avoid unexpected events in relation to aberrant vertebral artery.

The value of high-resolution magnetic resonance imaging of arterial walls in the diagnosis of cerebral artery dissection / 国际脑血管病杂志

Objective To investigate the value of high-resolution magnetic resonance imaging (HR-MRI) of arterial walls in the diagnosis of cerebral artery dissection (CAD).Methods The patients diagnosed as CAD and completed computed tomography angiography (CTA),magnetic resonance angiography (MRA),digital subtraction angiography (DSA),and HR-MRI were enrolled retrospectively.The detection rate and diagnostic value of the 4 imaging techniques were compared and analyzed.Results A total of 15 patients were enrolled,5 had internal carotid artery dissection,7 had vertebral artery dissection,2 had middle cerebral artery dissection,and 1 had basilar artery dissection.HR-MRI revealed 11 intramural hematoma,9 intimal flap,3 double lumen sign,and 2 pseudoaneurysm.A total of 18 CADs were detected in 15 patients,17 (94.44％),14 (77.78％),5 (27.78％) and 6 (33.33％) were detected with HR-MRI,DSA,CTA and MRA,respectively.There were significant difference in CAD detection rates of HR-MRI,DSA,CTA and MRA (x2 =24.939,P ＜ 0.001).The CAD detection rate of HR-MRI and DSA were significantly higher than those of CTA and MRA (all P ＜ 0.01 for HR-MRI,all P ＜ 0.05 for DSA),but there was no significant difference in CAD detection rate between HR-MRI and DSA.Conclusion HR-MRI is a diagnostic method for CAD with higher sensitivity.

Cervical artery dissection / 国际脑血管病杂志

Cervical artery dissection (CeAD) is characterized by an intramural hematoma of the internal carotid artery or the vertebral artery.CeAD is the major cause of ischemic stroke in young adults.Carotid artery dissection is a major cause of stroke.Early recognition and treatment of CeAD is important for the prevention of ischemic stroke.

Multiple Cerebral Infarctions due to Unilateral Traumatic Vertebral Artery Dissection after Cervical Fractures / 대한신경손상학회지

We report a case of multiple symptomatic cerebral infarctions from a traumatic vertebral artery dissection (VAD) after cervical fractures. A 73-year-old man was admitted with stuporous mentality and left hemiparesis after a motor-vehicle accident. A brain computed tomography (CT) scan at admission showed a traumatic subarachnoid hemorrhage on the left parietal lobe. A cervical CT scan showed left lateral mass fractures on C2, C5, and C6, involving the transverse foramen. Cervical spine magnetic resonance imaging (MRI) revealed loss of signal void on the left vertebral artery. Neck CT angiography showed left VAD starting at the C5 level. Brain MRI revealed acute, multiple cerebral infarctions involving the pons, midbrain, thalamus, corpus callosum, and parietal and frontal lobes on diffusion weighted images. The patient was treated conservatively at the intensive care unit in the acute stage to prevent extent of stroke. Aspirin was started for antiplatelet therapy in the chronic stage. The possibility of symptomatic cerebral infarctions due to traumatic VAD following cervical fracture should be considered.

Treatment of cervical artery dissections / 国际脑血管病杂志

Cervical artery dissection (CeAD) is an important cause of ischemic stroke in young adults w ith ischemic stroke. The clinical manifestations are often local facial pain, Horner syndrome, and ischemic stroke. With the development of noninvasive imaging, many patients w ith CeAD have got early diagnosis. Thromboembolism is an important mechanism of its pathogenesis. Timely giving anticoagulation therapy is reasonable. How ever, anticoagulants may lead to intramural hematoma expansion; therefore, there are also people w ho support antiplatelet therapy. How ever, the effectiveness of the 2 regimens needs to be confirmed by randomized trials. The recently completed Cervical Artery Dissection in Stroke Study (CADISS) in patients w ith stroke is the first prospective study aiming at the problem. The results have show ed that there w as no significant difference in efficacy betw een the anticoagulants and the antiplatelet drugs. Thrombolysis in patients w ith acute CeAD can not increase the risks of hemorrhage, and the rate of good functional outcome is similar to that of the control group. Therefore, it can be used as a treatment method in acute phase. For patients w hose antithrombotic treatment is invalid or having contraindications and repeated recurrent stroke can conduct endovascular intervention or surgical treatment. Usualy, the prognosis of patients w ith CeAD is better. The stroke recurrence rate is low . The abnormal arterial w als in more than half of the patients w il disappear at 3 to 6 months.

Delayed Vertebral Artery Dissection after Posterior Cervical Fusion with Traumatic Cervical Instability: A Case Report

Vascular injury presented immediately after the penetration, but delayed onset of vascular symptom caused by an embolism or vessel dissection after cervical fusion or traumatic event is extremely rare. We present a case of a 56-year-old woman who underwent an operation for cervical fusion for type II Odontoid process fracture. She presented symptoms of seizure with hemiparesis in 6 days after the operation. Multifocal acute infarction due to an embolism from the left VA (V3 segment) dissection was observed without a definite screw breach the transverse foramen. We hereby reported the instructive case report of delayed onset of vertebral artery dissection after posterior cervical fusion with type II odontoid process fracture patient. When a cervical operation performed in the cervical trauma patient, even if no apparent VA injury occurs before and during the operation, the surgeon must take caution not to risk cerebral infarction because of the delayed VA dissection.