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PubMed2000

[Vertebral arterial dissection with subarachnoid hemorrhage after ischemic onset].

A case is reported of the vertebral arterial dissection presenting initially with cerebellar infarction, and which subsequently occurred with subarachnoid hemorrhage 14 days later. A 75-year old male was admitted because of vertigo and ataxia. MR T2-weighted imaging showed a hyperintensity areas on the left cerebellar hemisphere and MR angiography showed multiple stenotic lesions in the left vertebral artery. We diagnosed his illness as dissection of the left vertebral artery and antiplatelet therapy and the blood pressure control were carried out. Fourteen days after the onset, the patient complained of sudden onset of headache and subarachnoid hemorrhage was confirmed on CT scan. Proximal clip occlusion of the left vertebral artery and OA-PICA anastomosis was carried out immediately. The patient was discharged with slight truncal ataxia. We evaluated the features of this vertebral arterial dissection presenting with subarachnoid hemorrhage after ischemic stroke with reference to another reported cases.

Aged↗
PubMed2005

Ruptured vertebral artery dissecting aneurysm followed by spontaneous acute occlusion and early recanalization: case report.

A 47-year-old man presented with a ruptured vertebral artery dissecting aneurysm manifesting as subarachnoid hemorrhage followed by acute occlusion and early recanalization of the affected artery. Cerebral angiography 2 hours after the onset of the symptom showed pearl-and-string sign in the right vertebral artery. Serial angiography showed that the affected artery was occluded at 12 hours but was recanalized on the 4th day. The dissecting aneurysm was resected with side-to-side anastomosis between the bilateral posterior inferior cerebellar arteries. Postoperative cerebral angiography demonstrated disappearance of the lesion and patency of the right posterior inferior cerebellar artery via the anastomosis. Histological examination of the lesion showed hematoma between the media and adventitia, disrupting the internal elastica and intima. Acute occlusion and early recanalization of the affected artery may occur in ruptured vertebral artery dissecting aneurysms. Serial neurological and neuroradiological examinations are essential to decide the timing and method of treatment.

Acute Disease↗
PubMed1998

Surgical treatment for ruptured vertebral artery dissecting aneurysms.

We analyze 20 cases of ruptured vertebral artery dissecting aneurysms and discuss the best choices for the surgical procedure. The preoperative Hunt and Kosnik grade was I in nine cases, Ia in four cases, II in three cases, III in three cases, and IV in one case. Rebleeding occurred in six cases, in four cases within 24 hours after the initial bleeding, and in every case within 6 days. In two cases surgery was performed within 3 days after the initial bleeding, in two cases within 4 to 7 days, in 16 cases after more than 7 days. A total of 22 operations were performed in the 20 patients (coating in 12, trapping in 6, proximal clipping of the vertebral artery in 2, clipping of the bleeding point in 2). A case of proximal clipping rebled 32 days after the operation and subsequently died. Both cases of clipping of the bleeding point were reoperated because of rebleeding and a slipped clip, respectively. All cases in which trapping or coating was performed resulted in a good outcome. Trapping is the most reliable method of preventing rebleeding. Coating or proximal clipping is an optional procedure, but cannot always prevent rebleeding because of the continuing circulation.

Adult↗
PubMed1997

Magnetic resonance angiography demonstrates vascular healing of carotid and vertebral artery dissections.

BACKGROUND AND PURPOSE: Dissection of the carotid and vertebral arteries is most accurately diagnosed with conventional angiography. MR techniques are sensitive for detecting the abnormalities associated with dissection but may lack specificity. We hypothesized that MR may be useful for serial monitoring of dissection and may therefore guide therapy. METHODS: All patients with angiographically proven carotid and/or vertebral artery dissection from July 1994 to June 1996 were followed for a median duration of 10.5 months. Of these 29 patients (44 vessels), 18 were concurrently evaluated with MR, and a target group of 9 patients (17 vessels) was prospectively followed with MR at 3-month intervals. RESULTS: In the 18 patients with both imaging studies at baseline, angiography revealed 30 dissected vessels while MR detected 27 (90%). In the target group of 9 patients, initial MR identified 15 of the 17 dissections diagnosed with angiography. Serial MR revealed complete healing in 5 vessels, improvement in 6 vessels, no change in 4 vessels, and worsening in 2 vessels. The radiographic features most likely to resolve were stenosis and mural hematoma, while occlusion and luminal irregularity tended to persist. Late ischemic events occurred in 2 patients, both with persistent MR evidence of dissection, one while subtherapeutic on warfarin therapy and the other occurring 1 week after warfarin was discontinued. CONCLUSIONS: MR is a reliable noninvasive method for following the vascular response to treatment and may guide the course of a clinical trial comparing medical therapies for carotid and vertebral artery dissection.

Adolescent↗
PubMed2006

[A case of vertebral artery dissection with recurrent brain embolism].

We report a 63-year-old case of the vertebral artery dissection with recurrent brain embolisms. She was admitted to the hospital because she suffered a visual symptom. She was examined by magnetic resonance imaging (MRI) and diagnosed a left vertebral artery (VA) dissection. Digital subtraction angiography (DSA) revealed the string sign on the left VA supporting the evidence of dissection. However, after DSA, multiple brain embolic stroke was occurred. She was treated with anti-platelet drug (sodium ozagrel), then, recanalization of the pseudo-lumen at the dissecting lesion was observed by MRI examination. Anti-platelet medicine (cilostazol) was taken for preventing reattack although the dissecting lesion was not closed. Following 4 weeks, brain embolisms were observed in the posterior circulation system. MRI revealed a dilated pseudo-lumen at the dissecting lesion with recurrent VA. This time, she was treated only with free radical scavenger (edarabone). After the occlusion of the dissected VA was observed, she started to take anti-platelet medicine again. It is generally accepted to use anti-platelet drug or anti-coagulant drug as a treatment of VA dissection causing brain ischemia. However, it should be assessed more carefully in cases showing recanalization of the pseudo-lumen as observed in this case. Surgical treatments should be taken into consideration at the early stage, especially for the cases presenting fragile dissecting lesions. Further study need to decide the effective treatment of the vertebral artery dissection.

Angiography, Digital Subtraction↗
PubMed1993

Endovascular treatment of vertebral artery dissections and pseudoaneurysms.

Sixteen patients with dissecting aneurysms or pseudoaneurysms of the vertebral artery, 12 involving the intradural vertebral artery and four occurring in the extradural segment, were treated by endovascular occlusion of the dissection site. Patients with vertebral fistulas were excluded from this study. The dissection was caused by trauma in three patients (two iatrogenic) and in the remaining 13 no obvious etiology was disclosed. Nine patients presented with subarachnoid hemorrhage (SAH), two of whom had severe cardiac disturbances secondary to the bleed. The nontraumatic dissections occurred in seven women and six men, with a mean age on discovery of 48 years. Fifteen patients were treated with endovascular occlusion of the parent artery at or just proximal to the dissection site. One patient had occlusion of a traumatic pseudoaneurysm with preservation of the parent artery. Four patients required transluminal angioplasty because of severe vasospasm produced by the presenting hemorrhage, and all benefited from this procedure with improved arterial flow documented by transcranial Doppler ultrasonography and arteriography. In 15 patients angiography disclosed complete cure of the dissection. One patient with a long dissection of extracranial origin extending intracranially had proximal occlusion of the dissection site. Follow-up angiography demonstrated healing of the vertebral artery dissection but persistent filling of the artery above the balloons, which underscores the need for embolic occlusion near the dissection site. No hemorrhages recurred. One patient had a second SAH at the time of therapy which was immediately controlled with balloons and coils. This patient and one other had minor neurological worsening resulting from the procedure (mild Wallenberg syndrome in one and minor ataxia in the second). Symptomatic vertebral artery dissections involving the intradural and extradural segments can be effectively managed by endovascular techniques. Balloon test occlusion and transluminal angioplasty can be useful adjuncts in the management of this disease.

Adult↗
PubMed2000

Imaging in the diagnosis and follow-up evaluation of vertebral artery dissection.

The purpose of this report is to discuss the value of ultrasonographic examination in the diagnosis and follow-up evaluation of vertebral artery dissection. We collected data on 8 patients with 11 pathologic vessels: 9 were affected intracranially and 6 were affected extracranially. Four vessels were affected in both intracranial and extracranial segments. Extracranial color-flow duplex sonography could detect abnormalities in every extracranial vertebral artery dissection. Most abnormal findings were non-specific, including severely reduced flow, absence of flow, and absence of diastolic flow. A specific finding (intramural hematoma) was noted in one artery. Abnormal transcranial color-coded sonographic findings included absence of flow, reduced velocity and reversed flow direction. Three intracranial dissecting arteries showed normal findings on transcranial color-coded sonography. Ultrasonographic follow-up study revealed evidence of improvement; this was noted almost exclusively in the extracranial segments of the vertebral artery but infrequently in the intracranial segment. Extracranial color-flow duplex sonography is sensitive in the detection of extracranial vertebral artery dissection, both in initial diagnosis and in follow-up evaluation.

Adult↗
PubMed1997

Carotid and vertebral artery dissections.

Dissections of the carotid and vertebral arteries are a common cause of stroke in young adults. The diagnosis may be missed because the typical signs and symptoms are often delayed in onset, or easily confused with other more commonly encountered entities. Dissections of the carotid and vertebral arteries may occur spontaneously or may accompany mild to severe trauma. They present with a variety of findings including headache, neck and face pain, Horner's syndrome, or stroke.

Adolescent↗
PubMed1992

Rebleeding from vertebral artery dissection after proximal clipping. Case report.

The authors present the case of a patient with vertebral artery dissection that rebled after being treated by proximal clipping. This is the second report of such a case. The results indicated that proximal clipping is not free from the risk of rebleeding, and a better alternative surgical technique should always be sought when treating vertebral artery dissections.

Adult↗
PubMed2004

[Intracranial extension of extracranial vertebral artery dissections. A review of 16 cases].

INTRODUCTION: Vertebral artery (VA) dissections can involve both the extracranial and intracranial portions of the VA. Intradural extension explains the occurrence of subarachnoid hemorrage (SAH). We have studied the rate of this extension, the risk of associated SAH and the therapeutic repercussions at the acute stage. METHODS: From 1985 to 2001, 42 patients with a recent extracranial VA dissection were admitted to our department of neurology. When the diagnosis of extracranial VA dissection (involving the first, second or third segment of the VA) was established, we looked for an ipsilateral intracranial extension (involving the fourth segment of the VA and/or the basilar artery). VA dissections strictly located at the intracranial level were excluded. RESULTS: Among 42 patients with angiographically diagnosed extracranial VA dissections, 16 patients (38 percent) had an ipsilateral intradural extension. Two of them developed an inaugural and spontaneous SAH. After a mean follow-up of 4 Months under antithrombotic treatment, none of the patients has developed SAH or recurrent SAH. CONCLUSIONS: Because of the potential risk for spontaneous SAH at the acute stage, it seems important to exclude an intracranial extension. Lumbar puncture should be undertaken to exclude SAH before consideration of antithrombotic therapy.

Adult↗
PubMed2000

[Vertebral artery dissections: follow-up with magnetic resonance angiography and injection of gadolinium].

Vertebral artery dissection is a frequent cause of ischemic stroke in young adults but time course of VA dissections remains poorly documented. Angiography was considered as the gold standard for the diagnosis. Recently, non-invasive methods have been developed such as helical CT and magnetic resonance angiography. The purpose of the study was to assess the reliability of a gadolinium-enhanced fast three dimensional (3D) magnetic resonance (MR) angiographic sequence to image vertebral arteries and to assess the long-term follow-up of vertebral artery (VA) dissections. Sixteen consecutive patients with 18 angiographically documented VA dissections were followed-up by gadolinium-enhanced 3D MR angiography and cervical T1-weighted MR imaging at a median delay of 22 months. Ten patients had MR imaging scan at the acute stage as well and nine had early follow-up angiography at a median delay of 3 months. MR angiography was evaluated in a consensus manner including image quality, presence of residual stenosis, luminal irregularities and occlusion. All patients clinically improved. Ten of 11 stenotic dissections returned to normality whereas one stenotic dissection progressed to occlusion. Two pseudoaneurysms detected on the initial angiography resolved spontaneously, one appeared only on a delayed MR angiographic scan and one was detected on early MR angiograms and finally resolved on a late one. Of the seven initially occluded VAs, five reopened with a hairline residual lumen in three. Contrast MR angiography is an interesting tool to assess the late course of VA dissections. Most lesions resolved spontaneously but persisting occlusion or pseudoaneurysm may be found in long term follow-up.

Adult↗
PubMed2003

Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.

OBJECTIVE: To determine whether spinal manipulative therapy (SMT) is an independent risk factor for cervical artery dissection. METHODS: Using a nested case-control design, the authors reviewed all patients under age 60 with cervical arterial dissection (n = 151) and ischemic stroke or TIA from between 1995 and 2000 at two academic stroke centers. Controls (n = 306) were selected to match cases by sex and within age strata. Cases and controls were solicited by mail, and respondents were interviewed using a structured questionnaire. The medical records of interviewed patients were reviewed by two blinded neurologists to confirm that the patient had stroke or TIA and to determine whether there was evidence of arterial dissection. RESULTS: After interview and blinded chart review, 51 patients with dissection (mean age 41 +/- 10 years; 59% female) and 100 control patients (44 +/- 9 years; 58% female) were studied. In univariate analysis, patients with dissection were more likely to have had SMT within 30 days (14% vs 3%, p = 0.032), to have had neck or head pain preceding stroke or TIA (76% vs 40%, p < 0.001), and to be current consumers of alcohol (76% vs 57%, p = 0.021). In multivariate analysis, vertebral artery dissections were independently associated with SMT within 30 days (OR 6.62, 95% CI 1.4 to 30) and pain before stroke/TIA (OR 3.76, 95% CI 1.3 to 11). CONCLUSIONS: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.

Adult↗
PubMed1999

Dissecting vertebral artery aneurysm: diagnosis and coil embolization.

Dissecting aneurysm of the intradural vertebral artery, a rare cause of stroke and sub-arachnoid haemorrhage, is associated with a poor neurological outcome if the disease is unrecognized and remains untreated. Clinical manifestations may be delayed or overlooked and non-invasive radiological investigations demonstrate little or no abnormality. We describe the diagnosis and successful endovascular occlusion of a dissecting vertebral artery aneurysm using detachable microcoils; a novel technique that has advantages over conventional therapeutic procedures.

Adult↗
PubMed2003

[Spontaneous extra-cranial vertebral artery dissection accompanied with multiple cerebral infarctions due to re-canalization].

In this paper we report a case of vertebral artery occlusion caused by spontaneous extra-cranial vertebral artery dissection accompanied with cerebellar and thalamic infarctions due to recanalization. Furthermore, after a nine-week time lapse we performed PTA/stenting. A 62-year-old man with vertigo, dysarthria and nuchal pain without injury was admitted to our hospital. Emergent cerebral angiography revealed an occlusion of the right vertebral artery and the right PICA. The patient's symptoms gradually improved owing to local-fibrinolysis with urokinase for the right PICA via the left vertebral artery. Follow-up angiography (2 weeks later) showed re-canalization and dissection of the right vertebral artery. Treatment for spontaneous extra-cranial vertebral artery dissection is chosen, depending on whether there is co-lateral circulation or not. We obtained a good result using PTA/Stenting in this case of spontaneous extra-cranial vertebral artery dissection within nine weeks after onset.

Cerebellum↗
PubMedDate not supplied

Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias.

BACKGROUND CONTEXT: The growing recognition of cervical manipulation as a treatment of neck pain and cervicogenic headaches has lead to increased interest in potential complications that may result from this treatment approach. Recent surveys have reported that many neurologists will encounter cases of vertebral artery dissection that occur at various times after cervical manipulation, whereas most practitioners of spinal manipulation are of the opinion that these events are extremely rare. We asked the question whether these differences in perception could be explained in part by referral or selection bias. PURPOSE: To assess the effect of referral bias on the differences in perceived incidence of vertebral artery dissection after cervical manipulation between neurologists and chiropractors in Canada. STUDY DESIGN: This study was a retrospective review of cases where neurological symptoms consistent with cerebrovascular ischemia were reported by chiropractors in Canada. METHODS: An analysis of data from a chiropractic malpractice insurance carrier (Canadian Chiropractic Protective Association [CCPA]) and results of a survey of chiropractors was performed to determine the likelihood that a vertebral artery dissection after cervical manipulation would be reported to practicing chiropractors. This was compared with the likelihood that a neurologist would be made aware of such a complication. RESULTS: For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime. CONCLUSIONS: The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.

Bias↗
PubMedDate not supplied

[Rupture of the dissecting vertebral arterial aneurysm].

The paper describes a rare case of a patient with dissecting vertebral arterial aneurysmal rupture. The patient was operated on--the aneurysmal wall was reinforced with surgical gauze. The intraoperative signs of the dissecting aneurysm are described in detail. The angiographic signs of dissecting aneurysms are given.

Aneurysm, Ruptured↗
PubMed2003

Recurrence of a vertebral artery dissecting pseudoaneurysm after successful stent-supported coil embolization: case report.

OBJECTIVE AND IMPORTANCE: Dissecting aneurysms of the intracranial vertebral artery are increasingly recognized as a cause of subarachnoid hemorrhage. We present a case involving technical success of the stent-supported coil embolization but with recurrence of the dissecting pseudoaneurysm of the intracranial vertebral artery. The implications for the endovascular management of ruptured dissecting pseudoaneurysms of the intracranial vertebral artery are discussed. CLINICAL PRESENTATION: A 36-year-old man with a remote history of head injury had recovered functionally to the point of independent living. He experienced the spontaneous onset of severe head and neck pain, which progressed rapidly to obtundation. A computed tomographic scan of the head revealed subarachnoid hemorrhage centered in the posterior fossa. The patient underwent cerebral angiography, which revealed dilation of the distal left vertebral artery consistent with a dissecting pseudoaneurysm. INTERVENTION: Transfemoral access was achieved under general anesthesia, and two overlapping stents (3 mm in diameter and 14 mm long) were placed to cover the entire dissected segment. Follow-up angiography of the left vertebral artery showed the placement of the stents across the neck of the aneurysm; coil placement was satisfactory, with no residual aneurysm filling. Approximately 6 weeks after the patient's initial presentation, he developed the sudden onset of severe neck pain. A computed tomographic scan showed no subarachnoid hemorrhage, but computed tomographic angiography revealed that the previously treated left vertebral artery aneurysm had recurred. Angiography confirmed a recurrent pseudoaneurysm around the previously placed Guglielmi detachable coils. A test balloon occlusion was performed for 30 minutes. The patient's neurological examination was stable throughout the test occlusion period. Guglielmi detachable coil embolization of the left vertebral artery was then performed, sacrificing the artery at the level of the dissection. After the procedure was completed, no new neurological deficits occurred. On the second day after the procedure, the patient was discharged from the hospital. He was alert, oriented, and able to walk. CONCLUSION: We appreciate the value of preserving a parent vessel when a dissecting pseudoaneurysm of the intracranial vertebral artery ruptures in patients with inadequate collateral blood flow, in patients with disease involving the contralateral vertebral artery, or in patients with both. However, our case represents a cautionary note that patients treated in this fashion require close clinical follow-up. We suggest that parent vessel occlusion be considered the first option for treatment in patients who will tolerate sacrifice of the parent vessel along its diseased segment. In the future, covered stent technology may resolve this dilemma for many of these patients.

Adult↗