Anterior Cerebral Artery Dissection Research Articles

Successful Intra-Arterial Thrombolysis and Stenting in an Acute Ischemic Stroke Patient Caused by Anterior Cerebral Artery (ACA) Dissection with Occlusion

Successful Intra-Arterial Thrombolysis and Stenting in an Acute Ischemic Stroke Patient Caused by Anterior Cerebral Artery (ACA) Dissection with Occlusion

A case of azygos anterior cerebral artery dissection with subarachnoid hemorrhage and hemorrhagic infarct during treatment for cerebral infarction

A case of azygos anterior cerebral artery dissection with subarachnoid hemorrhage and hemorrhagic infarct during treatment for cerebral infarction

Importance of Chronological Changes on High-Resolution Vessel Wall Imaging for Diagnosis of Isolated Anterior Cerebral Artery Dissection

IntroductionThe accurate diagnosis of isolated anterior cerebral artery dissection (iACA-D) is made difficult by the spatial resolution on conventional magnetic resonance imaging (MRI) techniques including time-of-flight magnetic resonance angiography that is too limited to detect minute arterial wall abnormalities. Recent advances in high-resolution vessel wall imaging (HRVWI), which can detect intramural hematomas (IMH), have improved the noninvasive diagnostic accuracy of iACA-D. However, despite the risk of overlooking minute IMH and aneurysmal dilations especially at the early disease stage, the utility of T1-weighted and T2-weighted HRVWI at each disease stage (i.e., acute, early subacute, late subacute and chronic) has not been evaluated thoroughly enough. This prompted us to undertake the present study to determine the diagnostic value of chronological changes of IMHs on T1-weighted HRVWI and arterial dilations on T2-weighted HRVWI to achieve the earliest possible and most accurate diagnosis of iACA-D. MethodsIn addition to six patients with iACA-D, five previously reported iACA-D patients from three institutions for whom reliable information on HRVWI and its examination date was available were enrolled in this study. IMHs on T1-weighted HRVWI and aneurysmal dilations on T2-weighted HRVWI and their chronological changes were visually evaluated. ResultsEither or both of IMHs on T1-weighted HRVWI and aneurysmal dilations on T2-weighted HRVWI were detected in all our six patients and the five previously reported ones. The disease stage showed a notable influence on the degree of their visualization. In contrast to IMHs which are regarded as the gold standard for the diagnosis of intracranial dissections, aneurysmal dilations were identified in 80% of cases even at the acute stage, reaching 100% at the early subacute stage. Despite the excellent detection rate of IMHs at the late subacute stage (100%), their detectability is poor at the acute and early subacute stages (0 and 40%, respectively). ConclusionThe results of this study highlighted the importance of aneurysmal dilations on T2-weighted HRVWI as a diagnostic marker to raise suspicion of iACA-D at the acute and early subacute stages, and similarly IMHs on T1-weighted HRVWI to confirm the diagnosis of iACA-D at the late subacute stage. These stage-dependent detectability changes in IMHs and aneurysmal dilations make an understanding of the chronological changes of these abnormal imaging findings mandatory to achieve an early and accurate diagnosis of iACA-D.

Low-Profile Visualized Intraluminal Support Stent-Only Technique for Intracranial Aneurysms—A Report of 12 Cases with Midterm Follow-Up

To evaluate the safety and efficacy of stent-only technique with Low-profile Visualized Intraluminal Support (LVIS) for uncoilable intracranial aneurysms. Twelve uncoilable aneurysms in 12 patients were treated with the stent-only technique in our department from January 1, 2016, to December 31, 2017. The characteristics of the aneurysms and the patients were analyzed. The midterm follow-up results of these patients also were analyzed. Twelve patients (7 male and 5 female) were enrolled in the series. The 12 aneurysms included 6 vertebral-basilar artery aneurysms, 3 internal carotid artery aneurysms (2 blood blister-like aneurysms and 1 posterior communicating artery aneurysm), 1 posterior cerebral artery dissecting, 1 anterior cerebral artery dissecting of the third segment, and 1 pseudoaneurysm at the first segment of the anterior cerebral artery. Seven aneurysms were? ruptured, whereas 5 remained unruptured. A total of 24 LVIS stents were deployed. Three aneurysms were covered by 3 overlapped stents, 6 aneurysms were covered by 2 stents, and the other 3 aneurysms were covered by 1 stent. All procedures were successful without any perioperative complications. Imaging follow-up between 3 and 10 months after operation was available in all 12 patients, with complete obliteration in 10 aneurysms, improvement in 1, and parent artery occlusion in1. LVIS stent-only technique is safe and efficacious for uncoilable aneurysms, even for ruptured ones.

Dissection of anterior cerebral artery presenting with cerebral infarction in contralateral frontal lobe

AbstractAlthough diagnosis of dissection in the anterior cerebral artery (ACA) has increased, cerebral infarction in frontal lobe due to contralateral ACA dissection is rare. A 52‐year‐old woman developed headache and motor weakness in the left hemibody. Magnetic resonance images demonstrated a fresh cerebral infarction in the right frontal lobe and thin right ACA. The initial diagnosis was a cerebral infarction in the right frontal lobe due to right ACA stenosis. Angiography performed nine days after onset showed dilatation and stenosis of the left ACA, and a small diameter of the right ACA. An intramural thrombus in the left ACA was demonstrated on MRI. The diagnosis was a cerebral infarction in the right frontal lobe due to dissection of the contralateral left A2 and A3 of ACA. There is a possibility that cerebral infarction in frontal lobe is induced by the contralateral ACA abnormality in a case with bihemispheric ACA.

A case of left anterior cerebral artery dissection causing both infarction and subarachnoid hemorrhage accompanied with reversible cerebral vasoconstriction syndrome

症例は 48歳女性．突然発症の運動性失語と下肢優位の右片麻痺のため緊急入院した．頭部 CTAで左前大脳動脈（anterior cerebral artery: ACA）の描出が不良で，両側主幹動脈の多発狭窄を認めた．MRIで左前頭葉内側面の新規梗塞巣とその外側の脳溝に限局する皮質性くも膜下出血を認めた．来院時に著明な高血圧と軽度の嘔気嘔吐を認め，左 ACA解離を疑って降圧薬と脳保護薬の投与を開始した．第 5病日のフォローアップ頭部 CTAで主幹動脈の多発狭窄は改善しており，第 12病日に施行した脳血管撮影で左 A2以遠の pearl and string signを認め，動脈解離に矛盾しない所見であった．しかし動脈解離のみでは説明できない可逆的でびまん性の脳動脈狭窄の存在が示唆され，典型的な雷鳴頭痛はなかったが可逆性脳血管攣縮症候群（reversible cerebral vasoconstriction syndrome: RCVS）の合併と診断した．頭蓋内 ACA解離と RCVSの合併は既報がなく，貴重な症例と考えられた．

Reversible Cerebral Vasoconstriction Syndrome with Concurrent Anterior Cerebral Artery Dissection

The pathophysiology of reversible cerebral vasoconstriction syndrome (RCVS) is not known but coexisting vascular lesion, such as carotid artery and vertebral artery dissection, has been reported. However, RCVS concurrent with anterior cerebral artery dissection has never been reported. We describe a 28-year old patient presenting with anterior cerebral artery dissection with RCVS associated with coughing. This case could support the causality between RCVS and arterial dissection. Key Words: Anterior cerebral artery, Dissection, Vasoconstriction, Thunderclap headache

Good recovery of subarachnoid hemorrhage concomitant with ischemia due to anterior cerebral artery dissection by conservative treatment: A case report.

The present report describes the case of a 57-year-old woman presenting with subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) due to anterior cerebral artery (ACA) dissection, which exhibited severe stenosis at the origin with distal dilatation of the A2 segment and occlusion of the A3 segment. In this case, computed tomography (CT) revealed SAH in right superior frontal sulcus and the interhemispheric fissure. Magnetic resonance imaging demonstrated acute infarct in the territory of the right ACA. Brain digital subtraction angiography showed severe stenosis at the origin of the A2 segment with distal dilatation and occlusion at the origin of the A3 segment of the right ACA, suggesting a diagnosis of dissection. Only treatment with atorvastatin, her clinical condition subsequently improved. The stenosis and dilatation of A2 segment were ameliorated as demonstrated by a follow-up CT angiography 5 months after onset. SAH concomitant with ischemia caused by ACA dissection is rare. Conservative treatment may be a safe and effective choice for patients with SAH concomitant with AIS due to ACA dissection.

Good outcome case of anterior cerebral artery dissection that was treated with recombinant tissue plasminogen activator and trapping with A3‐A3 anastomosis surgery

AbstractA 41‐year‐old Japanese man was diagnosed with acute ischemic stroke in the emergency room. He was given recombinant tissue plasminogen activator within a suitable time frame and symptoms were improved. However, follow‐up magnetic resonance imaging showed asymptomatic expansion of the ischemic infarction, and 3‐D computed tomography angiography showed the pearl and string sign of the left anterior cerebral artery. Then, trapping with A3‐A3 anastomosis surgery was successfully carried out. This is a very rare case of a patient who was treated with recombinant tissue plasminogen activator and had a good outcome, and also had trapping with A3‐A3 anastomosis surgery for an anterior cerebral artery dissecting aneurysm. However, because the pathology was determined to be dissection to the outer membrane, there was a risk of subarachnoid hemorrhage during the recombinant tissue plasminogen activator treatment. Cerebral arterial dissection is a disease that should not be forgotten, and that treatment is very difficult.

Dynamic Nature of Postpartal Carotid Artery Dissection

Abstract Craniocervical carotid artery dissection (CCAD) is an important cause of stroke in young adults, but it has rarely been reported as a cause of stroke in puerperium. We report the case of a 27-year-old female with a history of migraine who presented with unilateral left headache, transient episodes of dysphasia and right hemiparesis 30 days after vaginal delivery. The first symptoms started six days after the prolonged childbirth. The first magnetic resonance angiography revealed dissection in the supraclinoid and a cavernous segment of the left Internal carotid artery (ICA). We followed up the patient for two years and she had an unstable course. During this time, she had occlusion of the supraclinoid segment of the left ICA, with caudal extension on the extracranial segment and recanalisation one month later. Two months later, she had intracranial extension with dissection of the left anterior cerebral artery. During this time, she suffered from two strokes with minimal neurological impairment and good clinical recovery. The pathophysiology of CCAD appears to be multifactorial. Vessel wall injury related to the Valsalva manoeuvre during labour, as well as hemodynamic and hormonal changes of the vessel wall related to pregnancy in a patient with a history of migraine, may be causes of postpartum spontaneous craniocervical artery dissection in healthy women.

Fusiform Dilatation of the Outer Contour of a Dissected Anterior Cerebral Artery Revealed by Magnetic Resonance Cisternography in a Patient with Simultaneous Cerebral Infarction and Subarachnoid Hemorrhage

A 46-year-old man presented with right hemiparesis. Cranial magnetic resonance (MR) imaging revealed both an acute cerebral infarction in the territory of the left anterior cerebral artery (ACA) and a thin subarachnoid hemorrhage in the left superior frontal sulcus. MR angiography revealed stenosis at the A2 segment of the left ACA. MR cisternography was, therefore, performed on day 12 after admission using sagittal, 3-dimensional, heavily T2-weighted images. Fusiform dilatation of the outer contour was confirmed by MR cisternography at the region of narrowing identified by MR angiography. This case indicates that the combination of MR cisternography and angiography can be useful for detecting ACA dissection.

くも膜下出血と脳梗塞を同時にきたした前大脳動脈解離の1例

A 49-year-old woman presented with a sudden onset of right hemiparesis and motor aphasia. Computed tomography (CT) and magnetic resonance imaging (MRI) showed subarachnoid hemorrhage (SAH) localized in the interhemispheric fissure and cerebral infarction in the territory of the left anterior cerebral artery (ACA). Digital subtraction angiography (DSA) demonstrated segmental narrowing and dilatation at the left A2 segment, leading to a diagnosis of ACA dissection. The day after the onset, we planed trapping of the dissecting portion and A3–A3 side-to-side anastomosis. As a result, we performed only the wrapping of the dissection portion, because the dissection was longer than we expected. Neither aneurysmal dilatation nor narrowing progressed almost six months after the operation. This case indicates wrapping is also effective as a treatment of dissecting aneurysms, and it is important to consider longer-than-expected ACA dissections.

Spontaneous Anterior Cerebral Artery Dissection Presenting with Simultaneous Subarachnoid Hemorrhage and Cerebral Infarction in a Patient with Multiple Extracranial Arterial Dissections

Simultaneous subarachnoid hemorrhage and infarction is a quite rare presentation in a patient with a spontaneous dissecting aneurysm of the anterior cerebral artery. Identifying relevant radiographic features and serial angiographic surveillance as well as mode of clinical manifestation, either hemorrhage or infarction, could sufficiently determine appropriate treatment. Enlargement of ruptured aneurysm and progressing arterial stenosis around the aneurysm indicates impending risk of subsequent stroke. In this setting, prompt treatment with stent-assisted endovascular embolization can be a reliable alternative to direct surgery. When multiple arterial dissections are coexistent, management strategy often became complicated. However, satisfactory clinical results can be obtained by acknowledging responsible arterial site with careful radiographic inspection and antiplatelet medication.

Anterior Cerebral Artery Dissection Presenting Subarachnoid Hemorrhage and Cerebral Infarction

A 35-year-old man presented with simultaneous occurrence of subarachnoid hemorrhage (SAH) and cerebral infarction (CI) caused by anterior cerebral artery (ACA) dissection. He complained of sudden onset of left frontal headache and his symptoms progressed to consciousness disturbance and right hemiparesis. Computed tomography and magnetic resonance imaging demonstrated SAH localized in the left interhemispheric fissure and CI in the territory of the left ACA. Right carotid angiography demonstrated a long double lumen sign at the left A2 to A4 segment of the left ACA, leading to a diagnosis of the combined type of CI and SAH caused by ACA dissection. Although many surgeons have previously tried to perform endovascular treatment, we selected only medication in this case, and his neurological findings gradually improved. Only 9 cases including the present case presented with simultaneous occurrence of SAH and CI caused by ACA dissection. Many of these patients showed stenosis with dilatation of ACA on carotid angiography. The prognoses of these patients were good. However, many SAH patients with dissecting aneurysm had poor prognoses. To improve the strategy for managing ACA dissection, we need to accumulate a greater number of such cases in the future. We also recommend that angiography should be performed in the patients with ACA dissection.

Dilated Outer Diameter of the Dissected Artery: Acute Bilateral Anterior Cerebral Artery Dissection Evaluated by Repeat Magnetic Resonance Cisternography -Case Report-

A 42-year-old male patient presented with an anterior cerebral artery (ACA) dissection manifesting as sudden onset of severe headache. Initial computed tomography revealed faint subarachnoid hemorrhage in the frontal region. Initial angiography showed tapering stenosis at the A(2) segment of right ACA. The patient was admitted to our hospital and treated conservatively. Magnetic resonance (MR) imaging and angiography did not detect intramural hematoma, intimal flap, or double lumen at the stenotic right A(2) segment. The ACA dissection was difficult to confirm based on the findings on day 0. ACA dissection was confirmed by improvement of the right ACA stenosis on follow-up angiography on day 14. On the other hand, MR cisternography revealed a fusiform dilatation of the vascular outer contour at the right A(2) on day 0, which had resolved on day 14. Cerebral angiography and MR cisternography similarly suggested asymptomatic contralateral (left) A(2) dissection on day 14. Fusiform dilatation of the vascular outer contour at the affected segment on MR cisternography may be indicative of arterial dissection in the acute phase.

Revascularization for Anterior Cerebral Artery Dissecting Aneurysms -Three Case Reports-

We describe three rare cases of dissecting aneurysms in the anterior cerebral artery (ACA) treated by surgical reconstruction, and reviewed 79 previously reported cases with the ACA dissecting aneurysm. We found that 35 (77.8%) of 45 patients with ischemic event and 15 (40.5%) of 37 patients with hemorrhagic event were treated conservatively, with 11.4% (4/35 cases) and 13.3% (2/15) risk of bleeding and rebleeding, respectively. Furthermore, half of these patients died. The other 32 patients were treated surgically, and their outcome was favorable, especially after surgical reconstruction. Simultaneous treatment of both hemorrhagic and ischemic events is essential. We recommend early treatment with revascularization for patients with ACA dissection that has hemorrhaged and for patients presenting with signs of clinical deterioration with ischemic event.

Simultaneous Occurrence of Subarachnoid Hemorrhage and Cerebral Infarction Caused by Anterior Cerebral Artery Dissection Treated by Endovascular Trapping -Case Report-

A 48-year-old man presented with a rare dissection of the anterior cerebral artery (ACA) causing simultaneous subarachnoid hemorrhage (SAH) and cerebral infarction manifesting as sudden onset of headache and left hemiparesis. Computed tomography and magnetic resonance imaging showed SAH localized in the interhemispheric fissure and cerebral infarction in the territory of the right ACA. Digital subtraction angiography (DSA) demonstrated segmental narrowing and dilatation at the right A(1) and A(2) portions of the ACA, leading to a diagnosis of ACA dissection. Fourteen days after the onset, DSA confirmed the enlarged fusiform dilatation of the right A(2) portion with distal narrowing, suggesting the risk of rerupture of the dissection. Endovascular obliteration of the aneurysm with parent artery occlusion was performed without anastomosis on day 16. The aneurysm was catheterized and obliterated with detachable coils. Postoperative DSA revealed complete obliteration of the dissection and parent artery. The patient was doing well without recurrence of the dissection 8 months after the intervention. The simultaneous occurrence of SAH and cerebral infarction in patients with ACA dissection is extremely rare, and the optimal treatment has not yet been established. Endovascular treatment is safe and effective for the treatment of ACA dissection.

Isolated Anterior Cerebral Artery Territory Infarction: Dissection as an Etiological Mechanism

Background: Intracranial arterial lesions are important causes of ischemic stroke, particularly in the Asian population. Of the intracranial lesions, the etiology of isolated anterior cerebral artery (ACA) territory infarction is not fully elucidated. The purpose of this study was to determine the etiological and clinical characteristics of patients with isolated ACA territory infarction, especially those with ACA dissection. Methods: Of 3,115 consecutive patients with acute ischemic stroke, 42 patients (1.3%, 30 men, 38–88 years old) having an isolated ACA territory infarction were studied. Infarcts were principally verified by diffusion-weighted MRI, and vascular lesions were identified by MRA, CTA, or digital subtraction angiography. Three-dimensional rotational angiography was performed if needed. Results: Eighteen patients (43%) were diagnosed as having ACA dissection. The stroke subtypes of the other 24 patients included cardioembolism for 6 patients and large-artery atherosclerosis for 8. Patients with dissection were younger (p < 0.001) and heavier (p = 0.026), less commonly had heart disease (p = 0.002) and previous stroke (p = 0.002), and had lower initial systolic blood pressure (p = 0.029) and lower levels of D-dimer (p = 0.041) than patients without dissection. Stroke onset more commonly followed physical exertion (p = 0.013) and headache (p = 0.041) in patients with dissection than in patients without dissection. At hospital discharge, the modified Rankin scale score was lower in patients with dissection than in patients without dissection (p = 0.005). Conclusions: Arterial dissection was the most common vascular lesion underlying an isolated ACA territory infarction in our Japanese cohort. Patients with ACA dissection had unique baseline characteristics and unique conditions at stroke onset.

Chronic Recanalization of Dissection of the Distal Anterior Cerebral Artery: Case Report and Review of the Literature

The natural history of atraumatic idiopathic dissection of the distal anterior cerebral artery is still unclear. We present a 38-year-old man who had dissection of the left A2 segment of this vessel associated with subintimal hematoma and infarction. Because of complete stroke in acute stage, he did not undergo surgery. About three months later, administration of aspirin (100 mg/day) was started. At nine months, magnetic resonance angiography revealed complete recanalization of the A2 dissection. To assess the outcome of dissection, we should observe the patient for at least one year.

Dissecting aneurysms involving both anterior cerebral artery and aorta

Non-traumatic intracranial dissecting aneurysm (IDA) has been recently reported with increasing frequency and is recognized as a possible cause of subarachnoid hemorrhage. However, the pathogenesis of this disease is still unclear. Cystic medial necrosis (CMN) is known to be a cause of aortic dissection, especially in Marfan's syndrome. Presented herein is the case of a 49-year-old man who had IDA of the right anterior cerebral artery and abdominal aortic dissection without Marfan's syndrome. Histological examination showed medial degenerative changes with the accumulation of acid mucopolysaccharides in various intra- and extracranial arteries. Coexistence of dissecting aneurysms in the anterior cerebral artery and aorta suggests the presence of underlying pathogenesis that is common to these two dissection processes.