Extracranial Artery Dissection Research Articles

Cervical Artery Dissection

Cervical artery dissection is a common cause of stroke in young adults. This article reviews the pathophysiology, etiology and risk factors, evaluation, management, and outcomes of spontaneous cervical artery dissection. Cervical artery dissection is believed to be a multifactorial disease, with environmental factors serving as possible triggers in patients who have a genetic predisposition to dissection formation. Cervical artery dissection can cause local symptoms or ischemic events, such as ischemic stroke or transient ischemic attack. Neuroimaging is used to confirm the diagnosis; classic findings include a long tapered arterial stenosis or occlusion, dissecting aneurysm, intimal flap, double lumen, or intramural hematoma. Patients with cervical artery dissection who present with an acute ischemic stroke should be evaluated for IV thrombolysis, endovascular therapy eligibility, or both. Antithrombotic therapy with either anticoagulation or antiplatelet treatment is used to prevent stroke from cervical artery dissection. The risk of recurrent ischemia appears low and is mostly limited to the first two weeks after symptom onset. Cervical artery dissection is a known cause of ischemic strokes. Current data show no difference between the benefits and risks of anticoagulation versus antiplatelet therapy in the acute phase of symptomatic extracranial cervical artery dissection, thereby supporting the recommendation that clinicians can prescribe either treatment. Further research is warranted to better understand the pathophysiology and long-term outcomes of cervical artery dissection.

Long-term outcome of cervical artery dissection

ObjectiveThe 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. MethodsA retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022. ResultsThirty-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. ConclusionsThe majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.

Dissection of the main arteries of the brain: etiology, clinic, diagnosis and treatment

Dissection of the internal carotid and vertebral arteries is the leading cause of ischemic stroke at a young age. It is a rupture of the intima of the artery with the formation of an intrahepatic (intramural) hematoma, leading to stenosis or occlusion of its lumen. The article describes the epidemiology, etiology, pathogenesis, and clinical picture of extracranial artery dissection. The paper presents modern principles of treatment of this pathology.

The role of smoking in the development of strokes at a young age

Stroke in young patients is a disease based on a number of known specific non-modifiable factors (extracranial artery dissection, thrombophilia, open oval hole, etc.) and modifiable factors (alcohol abuse, drug use, smoking, etc.), in combination leading to the development of pathology. Smoking is a generally recognized modifiable risk factor for stroke, which is directly proportional to the number of tobacco-containing products smoked. Quitting smoking is the basis of prevention, an integral part of the treatment and rehabilitation of stroke patients. If it is impossible to completely give up smoking combustible cigarettes, it is advisable to switch to alternative smokeless products. This article presents the results of current studies on the comparative assessment of the risk of stroke in young people when using combustible cigarettes and smokeless analogues.

Abstract TP199: Genome Wide Association Study Of Intracranial Artery Dissection Reveals Potential Novel Loci

Introduction: Cervico-cephalic dissections (extracranial artery dissection [EAD] and intracranial artery dissection [IAD]) are defined by a mural hematoma in the wall of a cervical or intracranial artery and represent an important cause of stroke in young adults. It is relatively uncommon in the general population and likely to represent the ethnic difference with higher frequency of IAD in Asian than European populations. A few studies examining the genetic contributions for these phenotypes were reported. In EAD, the PHACTR1 genes which had previously been identified as common genetic risk variants of hypertension and migraine was associated with EAD using genome-wide association study (GWAS) approaches. RNF213 , an important susceptibility gene for Moyamoya disease was associated with IAD in one small study (n=24) using a candidate-SNP analysis but no GWAS of IAD have been reported so far. We performed GWAS to identify common variants associated with IAD. Methods: A total of 100 Japanese patients with IAD based on imaging diagnostic criteria from multidisciplinary expert consensus were prospectively enrolled in National Cerebral and Cardiovascular Center from March 2011 to August 2018. Results: We performed GWAS in 100 IAD cases (61 men, 50 years of median age[IQR, 45-61]) and 8380 controls from the Tohoku Medical Megabank Project which is a publicly available healthy cohort. No variant reached to genome-wide significant but 14 variants (7 regions) showed nominal significant association with IAD (p < 10 -5 ). Among 14 variants, rs73828631 on RBMS3 gene showed highest association with IAD (odds ratio = 2.16, 95% confidence interval = 1.59-2.92; P = 3.08 х 10 -7 ). RBMS3 was previously identified as genetic loci associated with brain aneurysm. According to the Genotype-Tissue Expression (GTEx) project database, RBMS3 is highly expressed in artery. Conclusions: We identified potential 14 variants associated with IAD. We need to increase the number of IAD cases for further confirmation.

Structural Changes of Intra and Extracranial Artery Dissection: a Study of High-Resolution Magnetic Resonance Imaging

ObjectivesThe prognosis of a cerebral artery dissection is known to be benign, but the structural changes of vessel wall at follow-up are not well known. The natural course of an intracranial and extracranial artery dissection may differ due to structural differences. We aimed to figure out how stenosis and other wall features change, according to the dissection location. Materials and MethodsWe retrospectively enrolled patients who suffered an ischemic stroke or transient ischemic attack due to a dissection and who had undergone both initial and follow-up high-resolution magnetic resonance imaging (HRMRI). Patients were dichotomized to intracranial or extracranial dissection group. The clinical and HRMRI characteristics of two groups were compared. Factors associated with stenosis changes were also investigated. ResultsA total of 57 patients (intracranial, n = 43; and extracranial, n = 14) were enrolled. The mean age (45.6 vs. 32.2, p < 0.001) was higher and hypertension (37.2% vs. 7.1%, p = 0.04) was more frequent in the intracranial dissection group. In HRMRI analysis, stenosis improvement (27.9% vs. 85.7%, p < 0.001) were more frequent whereas residual wall enhancement (86.0% vs. 46.2%, p = 0.006) and intramural hematoma (62.8% vs. 21.4%, p = 0.007) were less frequent in the extracranial dissection group. Multivariate analysis indicated that extracranial location was the only independent factor (odds ratio 8.98, 95 % confidence interval 1.45-55.65; p = 0.02) associated with stenosis improvement. ConclusionsYounger age, stenosis improvement, disappearance of wall enhancement and intramural hematoma were more frequent in an extracranial dissection compared with an intracranial dissection. An extracranial location is independently associated with stenosis improvement in dissection patients.

ESO guideline for the management of extracranial and intracranial artery dissection.

The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.

Surgical and radiological interventions for treating symptomatic extracranial cervical artery dissection.

Cervical artery dissection (CeAD) is a pathological bleed or tear, or both, in the wall of the carotid or vertebral arteries as they course through the neck, and is a leading cause of stroke in young people. To assess the effectiveness of surgical and radiological interventions versus best medical treatment alone for treating symptomatic cervical artery dissection. We performed comprehensive searches of the Cochrane Stroke Group Trials Register (last searched March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL), 2020, Issue 4, in the Cochrane Library (searched March 2020), MEDLINE (1946 to March 2020) and Embase (1974 to March 2020). We searched relevant ongoing trials and research registers (searched March 2020), checked references in all relevant papers for additional eligible studies, and contacted authors and researchers in the field. Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of either surgical or endovascular intervention for the management of symptomatic CeAD were eligible for inclusion. Only studies with anticoagulants or antiplatelet treatment as the control group were included. Two review authors planned to independently extract data. Primary outcomes were ipsilateral stroke and disability. Secondary outcomes were death, any stroke, or transient ischaemic attack, residual stenosis (> 50%), recurrence of cervical dissection, expanding pseudoaneurysm, or major bleeding. We analysed the studies according to the first choice of treatment. We planned to assess for risk of bias and apply GRADE criteria for any included studies. We did not find any completed RCTs or CCTs undertaken in this area of research. No RCTs or CCTs compared either surgery or endovascular therapy with control. Thus, there is no available evidence to support their use for the treatment of extracranial cervical artery dissection in addition to antithrombotic therapy in people who continue to have neurological symptoms when treated with antithrombotic therapy alone.

Clinical characteristics and risk factors analysis of intracranial and extracranial arterial dissection

Objective: To compare and analyze the clinical features and potential risk factors of intracranial and extracranial arterial dissection. Methods: A total of 241 consecutive patients with cervicocerebral artery dissection (CAD) in the First Affiliated Hospital of Zhengzhou University from 2010 to 2019 were observed. The 241 CAD patients were divided into extracranial artery dissection group (EAD) (n=81) and intracranial artery dissection group (IAD) (n=160), clinical characteristics and risk factors were compared between the two groups. Results: Compared with EAD, the National Institute of Health Stroke Scale (NIHSS) score was higher in patients with ischemic stroke in the IAD group (P=0.015). Patients with IAD were more likely to present with headache (58.8% vs 37.0%, P<0.001), and dissection Aneurysms (76.3% vs 38.3%, P<0.001). Patients with EAD more likely to have a history of mild head and neck injuries (11.1% vs 4.4%, P=0.047) and often involved the anterior circulation (77.8% vs 20.0%, P<0.001). Multivariate Logistic regression analysis showed differences in a history of minor head and neck trauma (OR=3.53, 95%CI 1.04-11.97, P=0.042), anterior circulation involvement (OR=0.09, 95%CI 0.05-0.19, P<0.001), dissection aneurysms (OR=4.98, 95%CI 2.80-8.84, P<0.001), headache (OR=2.42, 95%CI 1.39-4.20, P=0.002) remained significant, and the NHISS score lost its significance. Conclusions: EAD often involves the anterior circulation and a history of mild injury to the head and neck. IAD is more prone to exhibit headache symptoms, and it is more likely to form a dissection aneurysm, and the symptoms of ischemic stroke are more severe.

Treatment of Extracranial Arterial Dissection: the Roles of Antiplatelet Agents, Anticoagulants, and Stenting.

Cervicocephalic arterial dissection (CeAD) is the most commonly identified cause of stroke in young healthy individuals. The management of acute ischemic stroke due to the diagnosed or suspected CeAD is well established and is appropriate for thrombolysis. There is a substantial risk of stroke recurrence in the early post-stroke period. The optimum method of stroke prevention in the subacute period remains debatable. In our review, we focused on the management of recurrent stroke in CeAD, the choice of various antithrombotic agents for stroke risk reduction with regard to specific pathogenetic mechanisms of dissections, and the utility of endovascular therapy. Recent studies suggest that various pathogenetic types of CeAD based on radiologic characteristics may be associated with greater risk of thrombogenicity, especially in the early post-stroke period. The use of anticoagulants has been shown to be effective in the eliminating microembolic signals (MES) detected by transcranial Doppler (TCD). The only randomized trial that compared combinations of antiplatelet agents and vitamin K-agonist anticoagulation did not find significant difference in risk of stroke, major bleeding, or mortality. The benefit of dual antiplatelet therapy cannot be excluded. Limited data on the use of direct oral anticoagulant agents (DOAC) is currently available. Endovascular therapy with stenting, while potentially effective, may pose significant risk of complications. Therefore, it needs to be carefully considered on a case-to-case basis. The recurrence of ischemic stroke in patients with CeAD is overall rare. No significant difference in treatment with various antiplatelet and anticoagulant agents has been shown in randomized trials. Only a few studies were based on radiological characteristics of dissections. An ongoing randomized trial is investigating the role of MES and the efficacy of antiplatelet versus anticoagulation agents. The role of DOAC agents has yet to be determined in clinical trials. Stenting in CeAD is an effective revascularization technique and may be considered in selected patients. However, current data is only based on low evidence level findings from small studies, lacking longitudinal outcomes and prognosis.

Cervical artery dissection - retrospective analysis of 19 cases

Cervical artery dissection is a common cause of stroke in young adults. It might occur shortly after a forceful neck trauma or a minor injury. However, spontaneous dissection is also common, which is associated with genetic, anatomical or environmental risk factors. Cervical artery dissection can produce a broad spectrum of clinical presentation varying from local symptoms to focal neurological deficits determined by the arterial territory involved. Early recognition is important since immediate initiation of treatment can significantly improve patient outcomes. While clinical features may raise suspicion for dissection, the diagnosis has to be confirmed by neuroimaging findings. The purpose of this paper is to give an overview on cervical (carotid and vertebral) artery dissections while presenting 19 cases. During three years, we evaluated the clinical features, risk factors, diagnostic and therapeutic procedures of these patients admitted with extracranial artery dissection. The prognosis of the disease can vary, 42% of our patients became asymptomatic. Orv Hetil. 2019; 160(22): 861-868.

Extracranial and intracranial artery dissections: Experiences from a tertiary referral center

Background:&#x0D; Craniocervical artery dissection is an important cause of ischemic stroke&#x0D; especially in young and middle aged adults. In this study, we evaluated&#x0D; extracrainal and intracranial artery dissections in terms of etiologies, risk&#x0D; factors, stroke severity and functional outcomes. &#x0D; &#x0D; Methods: A&#x0D; total of 29 patients who were diagnosed with ischemic stroke due to&#x0D; extracranial or intracranial artery dissections were enrolled to this study.&#x0D; The ischemic stroke diagnosis was confirmed with diffusion weighted magnetic&#x0D; resonance imaging in all patients. Computed tomography angiography, magnetic&#x0D; resonance angiography and digital subtraction angiography were used to&#x0D; demonstrate the dissection. Demographic findings, risk factors and presence of&#x0D; trauma were evaluated. National Institute of Health Score Scale (NIHSS) was&#x0D; used for stroke severity assessment at disease onset. Functional outcomes were&#x0D; measured with Modified Rankin Scale (mRS) at the 3rd month. &#x0D; &#x0D; Results:&#x0D; Fifteen patients (51.72%) had carotid artery dissections while 12 patients&#x0D; (41.37%) had vertebral artery dissection (VAD), 1 (3.4%) had basilar artery&#x0D; dissection (BAD) and both VAD and BAD were seen in 1 patient (3.4%).&#x0D; Coagulopathy was detected in 12 patients (41.37%). Connective tissue disease&#x0D; was suspected in 3 patients (10.3%). In 6 patients, dissections occured after&#x0D; trauma. Nineteen patients (65.51%) presented with somatosensory deficits. The&#x0D; 3rd month mRS scores were in the range of 0-2 and no significant correlation&#x0D; was found in terms of risk factors, etiology and trauma history.&#x0D; &#x0D; Conclusion:&#x0D; Arterial dissection should be kept in mind for the clinical presentation of&#x0D; ischemic stroke in young adults. We think that better understanding of the risk&#x0D; factors, etiologies and clinical presentation of the dissections and early&#x0D; diagnosis-proper treatments might yield improved clinical outcomes.

Surgical and radiological interventions for treating symptomatic extracranial cervical artery dissection

Surgical and radiological interventions for treating symptomatic extracranial cervical artery dissection

Pathogenesis Concept Of Extracranial Dissections In Iran

Background: Dissection of Extracranial Internal Carotid Artery (EICA) and Extracranial Vertebral Artery (EVA) is an amportant cause of brain infarction with miscellaneous etiologies around the world.Methods: A prospective observational clinical study was conducted in Ghaem Hospital, Mashhad, Iran between 2008-2016. Diagnosis of brain infarction and TIA was made by stroke neurologist. Detection of EICA and EVA dissections were made by performing CT angiography and MR angiography or DSA in the suspected patients. Demographic features, clinical manifestations, territorial involvement, pathophysiology and pathogenesis of dissections were assessed in all of the patients. Pathogenesis of dissections was classified as Idiopathic, Trumatic, Postural and Genetic categories.Results: Twenty eight patients (21 males, 7 females) were admitted with extracranial arterial dissection. Mean age of males and females with dissection was 39.81± 4.2 and 35.71±6.1 years respectively. Influence of gender on age of the patients was not significant, p&gt;0.05. Among patients with extracranial dissection only 3.6% had atherosclerosis risk factors and 96.4% had no other cause for brain infarction. 100% of extracranial dissections in males occured in carotid territory, while 28.6% of females had dissection in the EVA. The influence of gender in territory of dissection was significant, p&lt;0.05. Idiopathic dissections and genetic susceptibility was found in 10.7% and 3.6% of extracranial dissections respectively. 53.5% of the patienrs had trumatic pathogenesis for extracranial dissections and 32.1% developed dissection due to special neck postures. Important details in pathophysiology and pathogenesis of extracranial dissections will be presented in the lecture.Conclusion: Stroke patients with extracranial dissections have characteristic demographic and territorial involvement. Trumatic pathogenesis is the most frequent cause of dissection in Iran followed by neck postural injry. Dissection, Etiology, Pathogenesis

Intracranial and extracranial arterial dissection presenting with ischemic stroke: Lesion location and stroke mechanism

Background and purposeAlthough cervicocranial artery dissections (CADs) are common causes of ischemic stroke in young individuals, anatomical locations and mechanisms of ischemic strokes are still unclear.We evaluate the prevalence, location, and pathogenic mechanisms of ischemic stroke caused by CADs. MethodsWe reviewed CAD patients who presented with acute (<7days) ischemic events and who had undergone diffusion weighted magnetic resonance imaging (MRI) and appropriate vascular imagings (MR angiography, computed tomography angiography, digital subtraction angiography, and high-resolution MRI). Stroke mechanisms were categorized as artery-to-artery (AA) embolism, local branch occlusion, in situ thrombotic occlusion and hemodynamic impairment. ResultsOne hundred and thirty-five patients with cerebral infarcts (n=125) or transient ischemic attacks (n=10) were included. The locations of 159 dissected vessels were: 77 vertebral, 29 internal carotid, 24 middle cerebral, 12 basilar, eight posterior inferior cerebellar, five anterior cerebral, and four posterior cerebral arteries. Among stroke mechanisms, A–A embolism (n=70, 55.5%) was the most common followed by local branch occlusions (n=40, 31.7%) and in situ thrombotic occlusions (n=8, 6.3%). Intracranial CADs were more common (89 vs. 44), less often associated with trauma (21.3% vs. 40.9%, p=0.018) and A–A embolism (32.9% vs. 97.6%, p<0.001), and more often treated with intravenous thrombolysis (15.7% vs. 2.3%. p=0.021) than extracranial CADs. ConclusionsIn our cohort, intracranial CADs are more common than extracranial CADs, and the vertebral artery is the most frequently involved site. Although A–A embolism is the main stroke mechanism, local branch occlusion is another important stroke mechanism.

Intracranial versus Extracranial Artery Dissection Cases Presenting with Ischemic Stroke

To compare the clinical and radiologic characteristics, possible stroke mechanisms, and prognosis of intracranial artery dissections (IADs) with those of extracranial artery dissections (EADs) presenting with cerebral infarction. Among 3250 adult patients with acute ischemic stroke (cerebral infarction), we prospectively recruited and categorized patients with cerebral infarction secondary to spontaneous cerebral artery dissection into IAD or EAD groups. The clinical and radiologic characteristics, possible stroke mechanisms according to the distributions of the infarctions based on diffusion-weighted imaging, and prognosis were analyzed for both groups. There were 48 and 50 patients experiencing IAD and EAD, accounting for 1.5% and 1.5% of all ischemic stroke patients, respectively. Compression of the perforating artery was the most common possible stroke mechanism (33.3%) in IADs; thromboembolism was more common in EADs than that in IADs (36 of 50 versus 12 of 48; P<.001). Magnetic resonance imaging and angiography were used to investigate the arterial dissections in all IAD patients and 46 EAD patients. Based on magnetic resonance imaging and angiography, the IADs more frequently displayed dissecting aneurysm (6 of 48 versus 0 of 46; P=.027) and intimal flap or double lumen (21 of 48 versus 4 of 46; P<.001) than EADs. For the clinical characteristics and prognosis, there was no significant difference between the 2 groups. These results indicate that IAD is an important cause of ischemic stroke, and it displays unique radiologic characteristics andspecific stroke mechanisms compared with EAD.

Superior cerebellar artery–posterior cerebral artery bypass: in situ bypass for posterior cerebral artery revascularization

Iatrogenic pseudoaneurysms are rare but serious complications of transsphenoidal surgery, and an iatrogenic pseudoaneurysm of the posterior cerebral artery (PCA) has been reported just once in the literature. The authors encountered such a case with a new P1 segment PCA pseudoaneurysm after endoscopic transsphenoidal resection of a pituitary adenoma. The aneurysm proved ideal for a novel intracranial-intracranial bypass in which the superior cerebellar artery (SCA) was used as an in situ donor artery to revascularize the recipient P2 segment. The bypass allowed aneurysm trapping without causing ischemic stroke or neurological morbidity. This case represents the first reported surgical treatment of an iatrogenic PCA pseudoaneurysm. Endovascular occlusion with coils was an option, but dolichoectatic morphology requires sacrifice of the P1 segment, with associated risks to the thalamoperforators and circumflex perforators. The SCA-PCA bypass was ideal because of low-flow demands. Like other in situ bypasses, it requires no dissection of extracranial arteries, no second incision for harvesting interposition grafts, and has a high likelihood of long-term patency. The SCA-PCA bypass is also applicable to fusiform SCA aneurysms requiring revascularization with trapping. This case demonstrates a dangerous complication that results from the limited view of the posterolateral surgical field through the endoscope and the imprecision of endoscopic instruments.

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.

Aspirin versus anticoagulation in intra‐ and extracranial vertebral artery dissection

To evaluate the incidence and predictors of ischaemic recurrent stroke and the adverse events of antithrombotic therapy in patients with first intra- or extracranial vertebral artery dissection (VAD) who were treated with aspirin or oral anticoagulation (OA). A 21-year database of consecutive patients with confirmed diagnoses of VAD (n=110, 63% men; mean age 37.9±8.5years) without intracerebral hemorrhage and who were treated with aspirin or OA were analyzed retrospectively. In all cases, the admission diagnosis was ischaemic stroke. Three groups were defined according to the site of the dissection: (i) extracranial, (ii) intracranial, and (iii) intra-/extracranial. Clinical follow-up was obtained by neurologic examination. Outcome measures were (i) recurrent ischaemic events (ischaemic stroke or transient ischaemic attack) and (ii) intra- and extracranial major bleeding. No difference in age, smoking, or hypertension was found between patients treated with OA (n=49) and those treated with aspirin (n=50). Extracranial artery dissection (49%) had preponderance over intracranial (27%) or intra-/extracranial (23%) location. During the follow-up, recurrent ischaemic events were rare (one case). There were no bleeding complications. The treatment that was used did not influence the functional outcome or recanalization. A good functional outcome (modified Rankin score≤2) was observed in 82 patients. Although this was a non-randomized study, our data suggest that the frequency of recurrent ischaemic stroke in patients with intra- or extracranial VAD is low and most likely independent of the type of antithrombotic treatment.

Internal Carotid Artery Dissection Heralded by an Oculomotor Nerve Palsy

Acute oculomotor nerve (CN III) palsies are commonly attributed to microvascular disease or compressive lesions and aneurysms, but may rarely be associated with ischemic large vessel disease. We report a case of an extracranial internal carotid artery (ICA) dissection heralded by CN III palsy with review of the relevant literature. A 24-year-old right-handed man presented with right-sided weakness preceded by vomiting 2 days earlier. The following day, the family noted his left eye to be deviated outward with enlarged pupil and droopy eyelid. On the day of admission, he had a fall owing to right-sided weakness. His neurological examination revealed significant aphasia, left third nerve palsy, right homonymous hemianopsia, and right-sided hemiplegia with hemisensory deficits. A brain magnetic resonance image showed an acute ischemic infarct in the left middle cerebral artery distribution without mass effect. Magnetic resonance angiogram showed a left extracranial internal cerebral artery (ICA) dissection with absence of flow within the distal cervical and intracranial ICA segments. He underwent a decompressive left hemicraniectomy with partial improvement in his deficits. Oculomotor nerve palsy as a result of ICA disease is a rare entity but has been reported in cases of stenosis, occlusion, and dissection. It is likely to be caused by hypoperfusion of CN III secondary to low flow or microembolism in the arteries feeding the nerve. The risk of CN III palsy in patients with ICA disease is higher in the presence of a fetal posterior cerebral artery. Acute oculomotor nerve palsies with pupillary involvement warrant thorough investigation. When routine work-up fails to elucidate an etiology, extracranial carotid pathology should be considered.