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PubMedDate not supplied

Carotid and vertebral artery dissection: Magnetic Resonance findings in 15 cases.

PURPOSE: Spontaneous dissection of the carotid and vertebral arteries represents a rare pathology. Its pathogenesis, probably multi-factorial, can be related to neck trauma and to a genetic basis, extensively demonstrated in the cases of association with type IV fibromuscular dysplasia, Ehlers-Danlos syndrome, Marfan's syndrome, pseudoxanthoma elasticum and osteogenesis imperfecta. Onset symptoms include neck, facial pain and diffuse headache. Cranial nerve palsy has been also described. The aim of this study was to evaluate MR angiography and MR findings in a population of patients with carotid and vertebral artery dissections. MATERIALS AND METHODS: We reviewed the MR angiography and MR exams of 15 patients (10 males, 5 females, average age 42.0, age range 30-55) with carotid and/or vertebral artery dissection; the serial MR follow-up studies were also examined. RESULTS: Twelve internal carotid arteries (ICA) showed the presence of an irregular stenosis; three of these showed complete occlusion. In two patients both ICA were involved. Six vertebral arteries (VA) showed irregular stenosis (only one patient suffered from both CI and VA dissection); in one case there was also a pseudoaneurysm of the VA. Follow-up studies showed vessel lumen re-opening in 5/11 ICA (one patient underwent vascular stent positioning) and in 3/6 VA. CONCLUSIONS: The present study confirms the usefulness of MR angiography and MR in the diagnosis and follow-up of patients with carotid and vertebral artery dissection.

Adult↗

PubMed2003

Endovascular management of vertebrobasilar dissecting aneurysms.

BACKGROUND AND PURPOSE: Several approaches to the treatment of dissecting aneurysms of the vertebrobasilar system have been used. We evaluated our endovascular experience, which includes trapping and proximal occlusion. METHODS: Thirty-five patients with intradural vertebrobasilar dissecting aneurysms presented to our institution between 1992 and 2002. Twenty-six were treated by endovascular means and two with surgery. In the endovascular group, 14 were in a supra-posterior inferior cerebellar artery (PICA) location, and three of these extended to the vertebrobasilar junction on the initial angiogram. Ten were located in an infra-PICA location, or no antegrade flow was seen in the PICA or anterior spinal artery. Two were located at the PICA with antegrade flow preserved in the branch. Twelve lesions were treated with trapping; another 14 were initially treated with proximal occlusion techniques, two of which eventually required trapping procedures. Follow-up images were obtained within 1 year of initial treatment in 24 patients. Mean follow-up for these patients was 3.5 years. RESULTS: Initial treatments were technically successful and without complication in all 26 patients. Follow-up examinations showed complete cure in 19 of 24 patients. One patient died of global ischemia after presenting as Hunt and Hess grade 5 with subarachanoid hemorrhage. Two recurrent hemorrhages occurred in patients in the proximal occlusion group; one died, and the other underwent a trapping procedure. One patient developed contralateral vertebral dissection 24 hours after occlusion of a dissecting aneurysm of the dominant vertebral artery and died of a brain stem infarct. Another died of probable vasospasm, and the last died of an unknown cause 1 month after treatment. Two patients had recanalization despite an initial trapping procedure, both underwent further treatment. Mortality rate was 20% in the treated group (including the two patients treated surgically), with four of five deaths occurring during the initial hospital course. Mortality rate was 50% in the six patients in the untreated group who were available for follow-up. CONCLUSION: Dissecting aneurysms of the vertebrobasilar system remain high-risk lesions because of their natural history. They can be managed by endovascular methods according to aneurysm location, configuration, collateral circulation, and time of presentation. Trapping results in better prevention of rehemorrhage. Proximal occlusion can achieve occlusion without manipulation of the affected segment when more direct endovascular occlusion or stent placement cannot be performed.

Adolescent↗

PubMed2005

[Cerebral arterial dissection].

We investigated a total of 98 cases with stroke caused by cerebral arterial dissection recruited in Strategies against Stroke Study for Young Adults in Japan (SASSY-Japan). The most frequent site of dissection was the intracranial vertebrobasilar artery. The stroke subtype was divided into ischemic (TIA and cerebral infarction) and hemorrhagic types (subarachnoid hemorrhage). The ischemic type was predominant (69%) and patients with the ischemic type were younger than those with the hemorrhagic type (P < 0.01). In the intracranial arterial dissection, nearly all cases were of the ischemic type. In contrast, in the extracranial arterial dissection, 60% of cases were ischemic and 40% were hemorrhagic. Cerebral angiography was the most important diagnostic procedure in the hemorrhagic type. In the ischemic type, MRI and MRA were more frequently used to show the findings specific to the dissection such as an intimal flap or double lumen and intramural hematoma. The outcome at discharge is generally good such that the modified Rankin Score was among 0-II in 69% of cases. However, in the hemorrhagic type, recurrence during an acute stage was frequent, and the outcome was poor with a mortalit rate of 19%. The establishment of an effective intervention to prevent the recurrence of subarachnoid hemorrhage is urgently required.

Adult↗

PubMed1998

Ischemic optic neuropathy associated with internal carotid artery dissection.

BACKGROUND: Ischemic optic neuropathy (ION) is an infarction of the anterior or, less frequently, posterior part of the optic nerve, usually due to a disease of small arteries supplying the optic nerve. Carotid stenosis or occlusions are rare causes, and among them, carotid dissections have been so far reported in only 5 cases. METHODS: We describe 4 patients with ION (2 anterior and 2 posterior) due to internal carotid artery dissection of a consecutive series of 110 patients with internal carotid artery dissection (3.6%). RESULTS: None of the patients had signs of central retinal artery occlusion or ischemic ocular syndrome. Ischemic optic neuropathy occurred after a mean of 5.3 days (range, 3-8 days) following the first symptom, which was headache in 1 patient, transient monocular blindness in 2, and hemispheric transient ischemic attack in 1. One patient had associated Homer syndrome, and 2 had severe ipsilateral headache and orbital pain. None of the patients developed a cerebral infarction. These features differ from those observed in "classic" nonarteritic anterior ION and might therefore point to carotid dissection. CONCLUSION: Ischemic optic neuropathy may occur as an early sign of carotid dissection: young age, previous transient monocular blindness, an association with pain, Horner syndrome, or hemispheric transient ischemic attacks are suggestive of this cause and should prompt confirmatory investigations.

Adult↗

PubMed2005

Diffusion-weighted magnetic resonance imaging in symptomatic vertebrobasilar atherosclerosis and dissection.

BACKGROUND: Acute multiple brain infarction (AMBI) pattern on diffusion-weighted imaging (DWI) is associated with arterial and cardiac sources of embolism. The DWI characteristics of patients with stroke due to vertebrobasilar arterial dissection and atherosclerotic disease have not been reported in detail. OBJECTIVE: To describe the DWI stroke patterns in patients with posterior circulation occlusive disease to determine mechanisms of ischemia. DESIGN: Retrospective analysis of infarct patterns in patients with symptomatic vertebrobasilar disease. SETTING: Large community-based teaching hospital. PATIENTS: Patients admitted with stroke due to vertebrobasilar disease were identified retrospectively. Patients were included if DWI was obtained within 7 days of symptom onset. MAIN OUTCOME MEASURE: Infarct patterns were analyzed according to established templates of vascular territories. RESULTS: Eleven patients with vertebral dissection and 39 patients with atherothrombosis were identified. An AMBI pattern was present in 8 (72%) of 11 patients with arterial dissections and 25 (64%) of 39 patients with atherosclerotic disease (P = .48). Distal embolism to the terminal branches of the basilar artery occurred with equal frequency in both groups and was found in half of all cases. Isolated thalamic infarction did not occur. Pontine infarction was noted in 2 (18%) of 11 patients with dissections and 18 (46%) of 39 patients with atherosclerosis (P = .09). Cerebellar border zone involvement was found in 14 (36%) of 39 patients with atherosclerosis and 4 (37%) of 11 patients with dissections (P = .6). CONCLUSIONS: Large arterial disease is frequently associated with AMBI in the posterior circulation. The incidence of AMBI was comparable to that reported in the anterior circulation. This DWI study supports the importance of embolism as the main mechanism of infarction in patients with vertebrobasilar occlusive disease. On the basis of our experience, large-vessel vertebrobasilar disease rarely causes isolated small-vessel thalamic infarction.

Adult↗

PubMed1998

The effects of more conservative neck dissections and radiotherapy on nodal yields from the neck.

OBJECTIVE: To determine the effects of conservative neck dissections (NDs) and preoperative radiotherapy on the quantitative recovery of lymph nodes from the neck. DESIGN: Retrospective review of case series. Data were obtained for age, preoperative TNM staging, type of ND, preoperative radiotherapy, total nodal yield (tNY), and positive nodal yield (pNY). The tNY and pNY were analyzed with factorial analysis of variance (ANOVA) to determine differences among types of ND and the effect of radiotherapy. SETTING: Tertiary care center for head and neck cancer. PATIENTS: Consecutive sample of 135 NDs in 110 patients with cancer of the head and neck. RESULTS: A significant difference in tNY was found among dissections (P<.001, ANOVA). Supraomohyoid ND had a significantly lower mean tNY (9.9 nodes) than both radical ND and modified radical ND (21.8 and 26.3 nodes, respectively; P<.05). Functional ND also had a significantly lower tNY (16.1 nodes) than modified radical ND (P<.05); the differences between radical ND and both functional ND and modified radical ND were not statistically significant. Positive nodal yield was not different among the types of dissections (P=.62). Preoperative radiotherapy significantly decreased mean tNY from 22.0 to 17.1 nodes (P=.02) over all types of dissections. Differences in tNY among dissection types were independent of the effect of radiotherapy. The presence or absence of preoperative radiotherapy had no significant effect on pNY (P=.18). CONCLUSIONS: Conservative modifications of the classic radical ND differ with respect to the quantity of cervical lymph nodes excised, but survival may not be altered since the pNY is not significantly different. When compared with the radical ND, the modified radical ND and functional ND do not compromise the quantity of cervical nodes excised. Radiotherapy significantly reduces the quantity of cervical nodes, but a significant number of nodes will still remain.

Adult↗

PubMed1999

Efficacy of targeted chemoradiation and planned selective neck dissection to control bulky nodal disease in advanced head and neck cancer.

PURPOSE: To determine the efficacy of targeted chemoradiation with the radiation plus platinum (RADPLAT) protocol and planned selective neck dissection in patients with N2 to N3 nodal disease associated with upper aerodigestive tract carcinoma. METHODS: Analysis of 52 patients with N2a, N2b, or N3 disease involving 60 heminecks treated with intraarterial cisplatin, 150 mg/m2, and intravenous sodium thiosulfate, 9 g/m2, on days 1, 8, 15, and 22; radiation therapy, 180 to 200 cGy per fraction for 35 fractions (total dose, 68-74 Gy); and planned neck dissection (33 of 35 procedures were selective). RESULTS: Of the 56 evaluable heminecks, a clinical complete response was achieved in 33 (59%). Within this group, 16 neck dissections were performed, none of which yielded disease on pathological examination. A clinical partial response was obtained in 21 heminecks, of which 18 subsequently had a neck dissection, yielding disease on pathological examination in 14. In all cases, it was possible to completely excise all adenopathy with clear margins on pathological examination. The rate of regional disease control among the 56 evaluable heminecks was 91% (51/56) (median follow-up, 36 months). Four failures were associated with uncontrolled disease at other sites, and 1 was an isolated neck recurrence. CONCLUSION: Selective neck dissection appears to be an effective adjunct to targeted chemoradiation in controlling N2 to N3 neck disease.

Adult↗

PubMed1993

Impact of bilateral neck dissection on recovery following supraglottic laryngectomy.

Previously reported data from our institution has led us to perform bilateral neck dissections for therapeutic as well as staging advantages for horizontal supraglottic laryngectomies. Concern over the possibility of increased morbidity associated with simultaneous bilateral neck dissection prompted this retrospective review of patients with supraglottic laryngectomy who were treated with either unilateral (46 patients) or bilateral (23 patients) neck dissection. No significant differences were found in morbidity when patients were evaluated for transfusion rate, cervical wound drainage, need for tracheotomy, oral diet, or duration of hospitalization. Significant differences were noted in surgical operating time, eg, it took 100 minutes longer to perform bilateral dissections, and slight increases were noted in estimated blood loss and fluids given intravenously. No significant differences were noted in the percentage or type of postoperative complications. It seems that bilateral neck dissection in conjunction with supraglottic laryngectomy does not increase postoperative surgical morbidity and may actually avoid complications associated with postoperative radiation therapy in patients with supraglottic laryngectomy.

Carcinoma, Squamous Cell↗

PubMed1994

The impact of bilateral neck dissection on pattern of recurrence and survival in supraglottic carcinoma.

OBJECTIVE: The findings of an initial evaluation of 202 patients treated for squamous cell carcinoma of the supraglottic larynx have been previously reported. Recurrent disease was observed at the primary site in four patients (2%), in the regional lymphatics in 39 patients (20%), and at distant sites in 24 patients (12%). Critical analysis of patients who demonstrated recurrent disease in the cervical lymphatics indicated that 38 of 39 recurrences developed in nonsurgically treated necks irrespective of the use of postoperative radiation therapy. Accordingly, all patients with supraglottic carcinoma have been treated with routine bilateral neck dissection since that time. We have reviewed our data to determine if bilateral neck dissections deter recurrence and improves survival. DESIGN: A retrospective review of the clinical course of 76 patients undergoing excision of supraglottic squamous carcinoma combined with bilateral neck dissection between 1980 and 1990 was performed to determine survival and recurrence rates. Surgery alone was used to treat 32 patients, while 44 patients were treated with surgery plus adjunctive therapy. SETTING: Department of Otolaryngology--Head and Neck Surgery, The Eye and Ear Institute, University of Pittsburgh (Pa) School of Medicine. RESULTS: Distant metastatic spread was the most frequent site of failure, occurring in nine (11.8%) of 76 patients. Local recurrence was experienced by two patients (1%). The incidence of cervical recurrence (seven patients, 9.2%) following treatment for squamous cell carcinoma of the supraglottic larynx has been reduced from 20% to 9% through the use of bilateral neck dissection. The 2-year survival rate increased from 72% to 76%. CONCLUSION: Routine bilateral neck dissection is beneficial in the surgical management of squamous cell carcinoma of the supraglottic larynx.

Adult↗

PubMed1997

Treatment of spontaneous coronary artery dissection: report of three cases.

Spontaneous coronary artery dissection is an extremely rare cause of myocardial infarction. It has been reported mainly in young women during or after pregnancy. The prognosis and treatment of coronary dissection are not clear. We report three cases of spontaneous coronary artery dissection in young women. One of them was pregnant and one was 2 weeks after delivery. The dissection involved the left anterior descending artery (LAD) in two cases and the left main coronary artery in one case. There was no evidence of atherosclerosis on angiography or intracoronary ultrasound in any of the patients. Two of the women were treated by stent implantation with excellent results. This is the first known report of successful coronary stenting of spontaneous coronary artery dissection. The pregnant woman was not a candidate for stent implantation and underwent implantation of the left internal mammary to the LAD without cardiopulmonary bypass. She completed her pregnancy uneventfully.

Adult↗

PubMedDate not supplied

Systematic approach to the treatment of chylous leakage after neck dissection.

BACKGROUND: Chylous leakage is an uncommon complication after neck dissection for which several treatment modalities have been described in literature. It occurs in 1% to 2.5% of radical neck dissections, with the majority (75% to 92%) being on the left side. In a consecutive series of patients, we investigated the effect of a systematic approach to the complication. METHODS: Over a period of 5 years, the drain production of 221 patients who underwent a neck dissection was analyzed. One hundred thirty-two right-sided and 139 left-sided neck dissections were performed. In 11 patients a chyle fistula occurred, 1 right-sided and 10 lift-sided. In all cases closed vacuum suction drainage was continued and dietary modifications (medium-chain triglycerides [MCT]/Peptison nasogastric tube feeding [PNTF]) were made. RESULTS: In 5 patients dietary modifications were sufficient to stop the leak. In the other 6 patients total parenteral nutrition via the subclavian vein (TPN) was started. In 2 cases with a severe intractable hypoalbuminemia, surgical intervention was necessary. The leak was closed by a pectoralis major muscle flap transfer, after local application of fibrin sealant (Tissucol). CONCLUSIONS: Chylous leakage is a controllable complication after neck dissection for which is most cases a stepwise conservative approach consisting of dietary modifications, maintaining closed vacuum suction drainage, seems to be sufficient. Hematologic and serum values should be monitored very carefully and corrected appropriately. To initiate planned postoperative radiotherapy in a timely fashion, the conservative treatment should be limited to about 30 days.

Adult↗

PubMed1996

Learning gross anatomy: dissection and prosection.

The gross anatomy course at St. Louis University School of Medicine consists of 40 regions or units covering the entire body and utilizes peer teaching in which students do every fourth dissection. One-fourth of the students learn each unit by dissecting; three-fourths learn from predissected material. Four multiple choice tests were studied to determine whether students scored better on questions on units they dissected than those who learned from predissected material. Results were adjusted on the basis of students' scores on whole tests. There were four teams of students and four tests resulting in 16 sets of questions. Dissectors scored better than nondissectors in 13 sets, but the overall differences were small (67.80 vs. 66.70). It is concluded that there is a small advantage gained from dissecting and demonstrating to their peers, but that learning from dissected cadavers is a satisfactory method of study, since our students traditionally score above the national average on the anatomy portion of the National Board Examination.

Anatomy↗

PubMed2001

Double vessel extension of spontaneous left main coronary artery dissection in young women treated with thrombolytics.

Spontaneous coronary artery dissection is an extremely rare cause of myocardial infarction. The prognosis and treatment of coronary artery dissection have not yet been defined. We report on a 42-year-old woman who was admitted to the emergency unit of a regional hospital with central chest pain and electrocardiographic signs of extensive acute anterior myocardial infarction (MI). She was treated with thrombolytics, yet her condition deteriorated rapidly, resulting in cardiogenic shock. An angiogram revealed dissection of the left main coronary artery that extended into the anterior descending (LAD) and circumflex arteries (LCX). At autopsy a recent anterolateral MI of the left ventricle was found. Dissection of the left coronary artery system was confirmed. Extension of the dissection may have been due to thrombolytic treatment.

Adult↗

PubMed1998

The role of type III collagen in spontaneous cervical arterial dissections.

A case-control study was carried out to investigate whether type III collagen deficiency plays a role in the pathogenesis of spontaneous cervical arterial dissections. In 16 patients with spontaneous cervical arterial dissections and in 41 healthy controls, protein analysis of type III collagen (ratio of type III/type I collagen) was performed. Furthermore, single-stranded conformation polymorphism/heteroduplex analysis was used to investigate the type III collagen gene in the 16 patients with spontaneous cervical dissections to detect mutations. The ratios of type III/type I collagen in the controls ranged from 5.5 to 19.8% (median, 10%). The ratios of type III/type I collagen in the patients with spontaneous cervical arterial dissections ranged from 3.2 to 17.9% (median, 9.3%). Two patients had a low ratio of type III/type I collagen (<5.5%). No abnormalities suggesting a mutation in the gene of type III collagen were demonstrated in any of the 16 patients. Our findings are in keeping with the hypothesis that a reduced production of type III collagen may contribute to the formation of spontaneous cervical arterial dissections in some patients. The absence of a responsible mutation indicates that the coding sequence of the type III collagen gene is not involved.

Adult↗

PubMed2004

Dissection from the Spanish anatomist's perspective: aims, attitudes, and related aspects.

We present the results of a study conducted on participants of the 21st Congress of the Spanish Society of Anatomy, in which anatomists were asked their opinions about a range of issues related to anatomical dissection: its relative roles as the exclusive source of anatomy teaching, as a source for medical research, or to assist the future professional to acquire emotional control; the attitudes and behaviors they expect the student to have in the dissecting room; whether the student-cadaver relationship can convey knowledge and attitudes affecting the future doctor-patient relationship; and the anatomists' attitudes toward donation. Anatomists considered dissection to be mainly an instrument for professional training and to help develop professional skills. They gave little importance to the role it could play in helping students to control their emotions. However, this aspect was considered to be more important by anatomists who also valued a close doctor-patient relationship. On the other hand, a majority of anatomists felt that the student's attitude and behavior during dissection could be to some extent reflected in future relationships with patients. However, they did not feel that dissection-related attitudes would distinguish between future good or bad doctors. Finally, anatomy teachers are generally in favor of donation (86.5%), especially of organs alone (52.7%), and this aspect was not affected by their religious beliefs.

Anatomy↗

PubMed2005

Development of instructional, interactive, multimedia anatomy dissection software: a student-led initiative.

Although dissection provides an unparalleled means of teaching gross anatomy, it constitutes a significant logistical and financial investment for educational institutions. The increasing availability and waning cost of computer equipment has enabled many institutions to supplement their anatomy curriculum with Computer Aided Learning (CAL) software. At the Royal College of Surgeons in Ireland, two undergraduate medical students designed and produced instructional anatomy dissection software for use by first and second year medical students. The software consists of full-motion, narrated, QuickTime MPG movies presented in a Macromedia environment. Forty-four movies, between 1-11 min in duration, were produced. Each movie corresponds to a dissection class and precisely demonstrates the dissection and educational objectives for that class. The software is distributed to students free of charge and they are encouraged to install it on their Apple iBook computers. Results of a student evaluation indicated that the software was useful, easy to use, and improved the students' experience in the dissection classes. The evaluation also indicated that only a minority of students regularly used the software or had it installed on their laptop computers. Accordingly, effort should also be directed toward making the software more accessible and increasing students' comfort and familiarity with novel instructional media. The successful design and implementation of this software demonstrates that CAL software can be employed to augment, enhance and improve anatomy instruction. In addition, effective, high quality, instructional multimedia software can be tailored to an educational institution's requirements and produced by novice programmers at minimal cost.

Anatomy↗

PubMedDate not supplied

Retrograde aortic dissection during cardiopulmonary bypass.

Femoral artery perfusion for cardiopulmonary bypass is still employed for reoperation, procedures involving the thoracic aorta, and partial bypass in critical patients. Retrograde aortic dissection is the most significant complication of femoral perfusion. The reported incidence is from 0.6% to 14% with a mortality of 66%. Most of the deaths occurred in patients in whom the dissection was not recognized , or in whom the dissection was recognized but not treated appropriately. Our experience with retrograde dissection totals six patients of 640 (0.9%) in whom femoral inflow was used. Four of the six patients survived the dissection. Sudden increase in extracorporeal line pressure shortly after beginning cardiopulmonary bypass associated with decreased venous return, dampened radial arterial pressure, and the abrupt appearance of a bluish, bulging ascending aorta establishes the diagnosis. Survival is enhanced if cardiopulmonary bypass is promptly discontinued, aortic cannulation established, and bypass reinstituted with the induction of profound hypothermia. Circulatory arrest may then be employed to repair the false passage. In this series the proposed operation was completed in all six patients.

Adult↗

PubMed2002

Planned neck dissection after definitive radiotherapy for squamous cell carcinoma of the head and neck.

BACKGROUND: To define the role of planned neck dissection after definitive radiotherapy for patients with node-positive squamous cell carcinoma of the head and neck. METHODS: Review of the pertinent literature. RESULTS: Radiotherapy alone produces a relatively high likelihood of regional control for patients with early-stage neck disease. Patients with more advanced neck disease have a higher probability of regional control if a planned neck dissection follows radiotherapy. However, for patients who have a complete response to radiotherapy, the likelihood of an isolated recurrence in the neck is low. Radiographic evaluation of the response to radiotherapy may better define the subset of patients who are likely to benefit from a neck dissection. CONCLUSIONS: Neck dissection after definitive radiotherapy improves regional control for patients with advanced neck disease. Patients who have a complete clinical and radiographic regional response to radiotherapy have a low probability of an isolated recurrence in the neck. It is advisable to proceed with a neck dissection for patients who have an equivocal response to radiotherapy, because the likelihood of salvage of an isolated recurrence in the neck is remote.

Carcinoma, Squamous Cell↗