Massive haemorrhagic transformation in cardioembolic stroke: the role of arterial wall trauma and dissection.

The pathogenesis of massive haemorrhagic transformation is not well established. Fatal haemorrhagic transformation associated with in situ dissection after acute middle cerebral artery (MCA) occlusion in a patient with atrial fibrillation is reported. An 80 year old woman with atrial fibrillation developed mild hemiparesis and aphasia. Brain CT and MRI at 4 and 5 hours, respectively, of symptom onset showed proximal MCA trunk occlusion with developing striatocapsular infarct and hypoperfusion in the superficial MCA territory. A few hours later, she developed massive bleeding into the ischaemic area and died. Pathological examination showed MCA trunk dissection, surrounded by a subarachnoid clot which communicated with the cerebral haematoma. It is suggested that direct arterial wall trauma as a result of cardioembolic MCA occlusion caused bleeding into the infarct. Secondary in situ dissection may be an overlooked mechanism of haemorrhagic transformation.

Recurrence of cervical artery dissection. A prospective study of 81 patients.

BACKGROUND AND PURPOSE: Spontaneous cervical artery dissection (SCAD) is a common cause of stroke in the young; however, its recurrence has been rarely studied. Recurrent SCAD at the level of the previously dissected vessel has been reported in only six patients. METHODS: We prospectively evaluated and followed a series of 81 patients seen in our center with carotid (n = 66) or vertebral (n = 15) artery dissection, in whom the diagnosis was confirmed by angiography, MRI, or both. Repeated clinical and ultrasound examinations were performed in all patients during a mean follow-up of 34 months (range, 12 to 57 months). RESULTS: Three patients died of the consequences of stroke, and four patients were unavailable for follow-up. Three of the remaining 74 patients (4%) had a recurrent carotid dissection while under prophylaxis with aspirin (n = 2) or anticoagulation (n = 1). None of the patients had a recurrent vertebral dissection. Recurrent carotid dissection occurred 16 months to 4 years after the first episode and presented with acute head and neck pain (n = 2) and hemispheric transient ischemic attack (n = 1). In one patient recurrence was documented by Doppler and MRI at the level of the first dissection. CONCLUSIONS: We confirm that recurrence of SCAD is uncommon and usually represents a benign condition. Delayed recurrence seems to be more common than previously suggested and can occur at the level of the previously dissected vessel.