Spontaneous Intracranial Artery Dissection Research Articles

Sequential detection rates of intramural hematoma for diagnosing spontaneous intracranial artery dissection.

Spontaneous intracranial artery dissection (IAD) can be definitively diagnosed by detecting intramural hematoma (IMH) on arterial wall imaging. However, evidence of a time-dependent natural history for the development of radiological findings is lacking. Therefore, this study aimed to determine when imaging detects IAD. We obtained data from our cohort databases between March 2011 and August 2018 on consecutive patients who had definite, probable, or possible IAD based on the multidisciplinary expert consensus criteria. We assessed IMH on initial and follow-up high-resolution three-dimensional T1-weighted imaging (HR-3D-T1WI). We retrospectively investigated the association between IMH detection and days from symptom onset to initial HR-3D-T1WI and compared the IMH detection rate with other definitive diagnostic arterial dissection findings. We analyzed 106 patients (mean age=51 ± 13 years, 31 women) with at least initial HR-3D-T1WI data. The final diagnoses were definite, probable, and possible IAD in 83, 18, and5 patients, respectively. IMHs were observed in 63 patients (59%, 95% confidence interval [CI] = 49%-69%). Overall IMH detection rate was 55% (95% CI=45%-64%), 20% (95% CI=3%-60%), 40% (95% CI=21%-64%), and 50% (95% CI=37%-63%) on the initial HR-3D-T1WI and Days 3, 7, and 13, respectively. Among 68 patients evaluated with digital subtraction angiography and HR-3D-T1WI, IMH was confirmed more frequently than other definitive diagnostic arterial dissection findings. The overall IMH detection rate on HR-3D-T1WI was >50% and peaked in 1-2 weeks. IMH was a frequently detectable finding for the diagnosis of IAD compared to other radiological findings.

Abstract WMP71: Sequential Detection Rates Of Intramural Hematoma For Diagnosing Spontaneous Intracranial Artery Dissection

Introduction: Spontaneous intracranial artery dissection (IAD) can be diagnosed with the detection of intramural hematoma (IMH). We previously reported that high-resolution 3-dimensional T1-weighted magnetic resonance imaging (HR-3D-T1WI) is useful to detect IMH. Limited evidence is available regarding sequential detection rates of IMH and appropriate timing of the detection. Methods: We retrieved data on consecutive patients from our prospective cohort databases from March 2011 to August 2018 who had definite, probable, or possible IAD based on the multidisciplinary expert consensus criteria. We detected IMH on initial and follow-up HR-3D-T1WI. We explored the association between detection of IMH and days from symptom onset to initial or follow-up HR-3D-T1WI. Results: A total of 104 patients (mean age 51 ± 13; 30 female; 68 patients, definite IAD; 31 patients; probable IAD, 5 patients; possible IAD) with at least initial HR-3D-T1WI data were included in the analysis. Clinical diagnoses included ischemic stroke (46%), subarachnoid hemorrhage (6%), transient ischemic attack (2%), and head or neck pain alone (46%). Age, Sex, vascular risk factors and modified Rankin Scale at 3 months were comparable between patients with IMH and without. Among them, follow-up HR-3D-T1WI was performed in 54 patients (52%). IMH was observed in 61 patients, 59% of all and 90% of definite IAD. The median days from symptom onset to initial or follow-up HR-3D-T1WI were 11 (interquartile range[IQR] 8–15) and 29 (IQR 19–57) days, respectively. The median days from symptom onset to first IMH detection were 12 (IQR range 8–17). The detection rate of IMH on initial HR-3D-T1WI was 55% overall, reaching 20% on day 3, 40% on day 7, and 50% on day 8–12 ( Figure ). Of the 23 patients who did not have an IMH on the initial HR-3D-T1WI, 4 (17%) had an IMH detected on the follow-up imaging. Conclusion: The detection rate of IMH on HR-3D-T1WI was approximately 60%, which reached the maximum in 1-2 weeks.

MALE PATIENT WITH DISSECTION OF THE POSTERIOR CEREBRAL ARTERY AND OCULOMOTOR NERVE PALSY: A CASE REPORT AND A REVIEW FROM THE LITERATURE

Spontaneous intracranial artery dissection is an uncommon and probably under diagnosed cause of stroke and subarachnoid hemorrhage that is defined by the occurrence of a hematoma in the wall of an intracranial artery. We introduce a case of dissection of the P2 segment of the posterior cerebral artery (PCA) presented with new onset headache and unilateral, left oculomotor nerve palsy. The patient had a diagnosed thrombophilia and previous deep vein thrombosis. Digital subtraction angiography (DSA) revealed dissection of the P1-P2 segment of the PCA with occlusion of the distal branches P3-P4. CT excluded acute stroke. The patient was put on anticoagulant therapy, with clinical improving after 2 weeks. The left third nerve had been distorted because of vascular compression.  Conclusion: Isolated dissection of the PCA is rare. Multicenter prospective studies with standardized protocols for diagnosis, imaging, and follow-up of intracranial artery dissection are needed. Keywords: dissection, PCA

Propensity Score-Matched Analysis of Lesion Patterns in Stroke Patients With Patent Foramen Ovale and Patients With Spontaneous Intracranial Artery Dissection.

Aims: To investigate the relationship between clinical and imaging features of stroke patients with patent foramen ovale (PFO) and those with spontaneous intracranial artery dissection (SIAD).Materials and methods: We retrospectively examined both clinical and imaging results of 40 stroke patients with PFO and 29 with SIAD. To reduce selection bias, we conducted a propensity score-matching analysis. The patients' propensity scores were estimated using a logistic regression model based on the following variables: age, sex, hypertension, diabetes mellitus, hypercholesterolemia, cigarette smoking, stroke histories, and their NIHSS scores. We compared the pattern of cerebral DWI lesions between patients with PFO and those with SIAD.Results: After propensity score matching, 21 pairs of patients were selected. Clinical characteristics of the 2 groups were well matched. The distribution of DWI lesion patterns differed between the 2 groups. Single lesions (cortical or subcortical) were more frequently observed in the PFO group than in the SIAD group (P = 0.026). Multiple lesions in one vascular territory occurred more frequently in the SIAD group than in the PFO group (P = 0.035).Conclusion: The present study suggests that lesion patterns observed from DWI of patients with PFO and SIAD might provide clues to the etiology of infarcts. Single lesions (cortical or subcortical) might be a typical feature of PFO associated strokes, while multiple lesions in one vascular territory might be a specific feature of SIAD associated strokes.

A unique case of Turner syndrome with spontaneous intracranial artery dissection (P2.3-065)

A unique case of Turner syndrome with spontaneous intracranial artery dissection (P2.3-065)

Abstract TP243: Relationship of Neutrophil-to-Lymphocyte Ratio to Stroke Subtype and Functional Outcome in Intracranial Artery Dissection

Background and Purpose: Spontaneous intracranial artery dissection (IAD) might be an underdiagnosed cause of stroke that is defined by the occurrence of a hematoma in the wall of an intracranial artery and develop either ischemic or hemorrhagic stroke, but it is not known about parameters to distinguish ischemic stroke from hemorrhagic stroke. Several studies demonstrated that the neutrophil-to-lymphocyte ratio (NLR) is associated with adverse outcomes in patients with stroke at the time of occurrence. We investigated (i) the association between NLR and stroke subtype, and (ii) the clinical impact of NLR on functional outcome at 3 months after IAD. Methods: We retrieved data on consecutive patients with IAD within one month from onset from prospective cohort databases from February 2011 to November 2016. All patients who were clinically diagnosed with IAD accompanying ischemic or hemorrhagic stroke, or headache alone were principally admitted. We measured WBCs subtype at admission, and examined the relationship between NLR, stroke subtype, and 3-months functional outcome (mRS 0-2 vs 3-6) using logistic regression analysis. Results: Of the total 105 patients with IAD (mean age, 52±2; 30% men), 6 with recurrent IAD and 6 with both hemorrhagic and ischemic stroke were excluded. One patient was also excluded because of missing blood data. Of the remaining 92 patients with IAD analyzed, 33 patients (36%) had ischemic stroke, 34 patients (37%) had hemorrhagic stroke, and 25 patients (27%) had headache alone. In univariate analyses, higher median admission NLR values were documented in patients with hemorrhagic stroke (4.76; IQR, 2.11-13.34) versus patients with headache alone (3.00; IQR, 1.67-4.95); P=0.015), and versus patients with ischemic stroke (3.02; IQR, 1.67-4.95; P=0.02). In multivariate analysis adjusting for age, sex and current smoking, NLR was associated with hemorrhagic stroke [odds ratio (OR) 2.29, 95% CI 1.32-4.00]. After adjustment for age and sex, NLR was independently associated with unfavorable functional outcome (mRS 3-6). Conclusions: NLR appears to be a potential predictor of stroke subtype, especially subsequent hemorrhagic stroke, in patients with IAD.

Middle cerebral artery dissection causing subarachnoid hemorrhage and cerebral infarction: Trapping with high-flow bypass preserving the lenticulostriate artery

Background:Spontaneous intracranial arterial dissection (IAD) is an increasingly important cause of stroke, such as subarachnoid hemorrhage (SAH) and hemodynamic or thromboembolic cerebral ischemia. IAD usually occurs in the posterior circulation, and is relatively rare in the anterior circulation including the middle cerebral artery (MCA). Various surgical and endovascular methods to reduce blood flow in the dissected lesion have been proposed, but no optimum treatment has been established.Case Description:An 80-year-old woman with dissection in the M1 portion of the MCA manifesting as SAH presented with repeated hemorrhage and cerebral infarction in the area of the inferior trunk of the MCA. High-flow bypass to the MCA was performed and the dissecting lesion was trapped. Prevention of repeated hemorrhage was achieved, and blood flow was preserved to the lenticulostriate artery as well as the MCA area distal to the lesion.Conclusions:Treatment strategy for IAD of the MCA should be planned for each patient and condition, and surgery should be performed promptly to prevent critical rebleeding given the high recurrence rate. In addition, preventing re-rupture of the IAD, and preserving important perforators around the lesion and blood flow distal to the dissection should be targeted by the treatment strategy.

左中大脳動脈閉塞を伴った左内頸動脈解離による脳梗塞に対し，rt-PA 静注療法を施行した13 歳女児の1 例

要旨：症例は13 歳の女児．中学校の体力テストで1 km 走り切った後の休憩中に意識障害を発症し，当院救急外来へ搬送された．発症後40 分で病着し，意識障害と失語，右片麻痺を認めた．頭部MRI 拡散強調画像で左基底核と左中大脳動脈の皮質を含んだ領域に淡い高信号域を認め，MRA では左中大脳動脈水平部起始部の途絶像を認めた．失語症状を中心とした高度の神経脱落徴候を認めたことから，家族にリスクを説明し同意を得た上で血栓溶解療法を発症後3 時間弱で施行した．入院後脳梗塞の原因検索を行い，頭部造影CT angiography では明らかではなかったが，脳血管造影検査では左内頸動脈から中大脳動脈にかけての動脈解離の所見を認め，動脈解離に伴う脳梗塞と診断した．小児例でかつ，頭蓋内動脈解離による脳梗塞に対して，症候性の有害事象は無く血栓溶解療法を施行し得た症例であり報告する．

De Novo Vertebral Artery Dissection after Endovascular Trapping for Ruptured Dissecting Internal Carotid Artery Aneurysm: Case Report

The authors present an extremely rare case of a 54-year-old female patient with subarachnoid hemorrhage due to a rupture of a dissecting internal carotid artery (ICA) aneurysm, who developed de novo vertebral artery dissection in the spasm period after endovascular trapping of the ICA. Interestingly, postoperative cardiopulmonary monitoring showed high global end-diastolic volume index and mean arterial pressure, which could contribute to this de novo dissection via hemodynamic stress in the cerebral circulation. Spontaneous intracranial artery dissection of more than two arteries is rare, and we believe this is the first case of de novo dissection occurring on a circulating vessel different from that of the initial dissection. The clinical implications are discussed in relation to postoperative hemodynamic stress with a review of the literature.

Symptomatic Recurrence of Intracranial Arterial Dissections

The frequency and pattern of symptomatic recurrence of spontaneous intracranial arterial dissection (IAD) are unknown. A follow-up study of 143 patients (85 men, 58 women; mean age, 50.7 [7-83] years) with spontaneous IADs at The University of Tokyo and affiliated hospitals from 1980 to 2000 was conducted. Tissue samples of IAD vessels obtained from 13 patients at various intervals from onset were also examined histologically. With a mean follow-up of 8.2 years, symptomatic recurrence occurred in 47 patients (33%). Of 37 cases initially presenting with hemorrhage, 35 developed hemorrhagic recurrence with a mean interval of 4.8 days, and 2 developed nonhemorrhagic recurrences after 21 and 85 months, respectively. Of 10 patients initially presenting with nonhemorrhagic symptoms, 1 developed hemorrhagic recurrence 4 days later, and 9 developed nonhemorrhagic recurrences with a mean interval of 8.6 months. Histopathologically, the affected vessels in the acute stage of hemorrhage (days 0-6) demonstrated insufficient granulation formation within the pseudolumen, followed by marked intimal thickening around the pseudolumen and recanalizing vessel formation in the late stage (>day 30). In the late stage of brain ischemia, subintimal and subadventitial hemorrhage accompanied with intimal thickening was observed. These data indicate that IAD is a disease carrying a relatively high risk of symptomatic recurrence, apparently occurring in 3 phases and patterns: early hemorrhagic recurrence, late nonhemorrhagic recurrence, and chronic fusiform aneurysm transformation. Knowledge of this triphasic recurrence and corresponding histopathological characteristics help determine the treatment and follow-up strategy for IAD patients.

Direct thrombus aspiration using the Penumbra system for the treatment of pediatric intracranial dissection

We describe a case of a 15-year-old girl who developed a spontaneous intracranial arterial dissection with distal middle cerebral artery (MCA) occlusions. From the digital subtraction angiography provided, the dissection...

Spontaneous intra-cranial arterial dissection frequently causes anterior cerebral artery infarction

Background and purpose Spontaneous intra-cranial arterial dissection (SICAD) without history of head and neck injury is now recognized as an important cause of stroke. However, the frequency of SICAD involving the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) territories remains unclear. This study therefore investigated the distribution of SICAD. Methods Subjects comprised 194 patients (126 men, 68 women; median age, 68.0 years) with infarct isolated to the ACA, MCA or PCA territories who underwent conventional angiography. Diagnosis of SICAD was based on clinical and neuroradiological findings. Frequency of SICAD was compared among ACA, MCA, and PCA infarcts. All patients were divided into SICAD and non-SICAD groups, and clinical characteristics were compared between groups. Results Infarcts involved the ACA in 14 cases (7.2%), MCA in 165 cases (85.1%), and PCA in 15 cases (7.7%). SICAD was diagnosed in 17 of 194 cases (8.8%), with cerebral angiography showing main findings of the string sign in 11 patients (64.7%), the pearl and string sign in 6 patients (35.3%), and pseudoaneurysm formation in 2 patients (11.7%). SICAD most frequently involved the ACA (ACA, 64.3%; MCA, 4.2%; PCA, 6.7%; P < 0.001). Conclusion SICAD was seen in 64.3% of patients with ACA infarct. The mechanisms of ACA infarction may thus differ from those of MCA and PCA infarction.

MRI and MRA in spontaneous intracranial arterial dissection

MRI and MRA in spontaneous intracranial arterial dissection

Spontaneous intracranial arterial dissection in the young: diagnosis by CT angiography

BackgroundSpontaneous carotid artery dissections have been rarely reported in children. Diagnosis has traditionally been confirmed by catheter arteriography. More recently diagnosis has been made by magnetic resonance imaging and magnetic resonance angiography; however the sensitivity of these techniques has yet to be determined. The authors are unaware of reports of carotid dissection confirmed by dynamic computed tomography (computerized tomographic arteriography) in the young.Case presentationWe recently evaluated a fourteen year-old male following the development of transient neurologic symptoms. There was no antecedent illness or trauma. Dynamic computed tomography revealed an intracranial dissection involving the supraclinoid segment of the left internal carotid artery (confirmed by catheter arteriography). Studies for vasculitis, pro-thrombotic states, and defects of collagen were negative.ConclusionSpontaneous carotid artery dissection is a potential cause of transient neurological symptoms and ischemic stroke in the pediatric population. Dynamic computed tomography appears to be a reliable diagnostic tool which can lead to early diagnosis.

Spontaneous Intracranial Arterial Dissection and Subarachnoid Hemorrhage

Spontaneous intracranial arterial dissection may cause subarachnoid or rarely intraventricular hemorrhage. The clinical presentation may resemble aneurysmal rupture. Experience using magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in establishing the diagnosis of intracranial arterial dissection has been limited. We report three patients with intracranial arterial dissection and describe the correlation between findings on conventional angiography and MRI or MRA.