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PubMed2004

Endovascular stent-graft repair of aortic dissection.

Between October 2000 and January 2002, 9 consecutive male patients with subacute or chronic aortic dissection underwent stent-graft placement. The indication for surgery was continuous pain or aneurysm development. One patient had a type A dissecting aortic aneurysm with a primary tear in the ascending thoracic aorta; the other 8 had type B dissection. Placement of an endovascular stent-graft was technically successful in 8 patients, and one underwent an open procedure for abdominal aortic fenestration. The entry site was sealed and the false lumen disappeared in 8 cases, and thrombosis of the false lumen was obtained. Rupture of an iliac artery dissecting aneurysm occurred in one patient 2 days after stent-graft placement; abdominal aortic fenestration with prosthetic replacement of the distal abdominal aorta was performed. One patient died of myocardial infarction 3 days after the stent-graft procedure. During a mean follow-up period of 7 months (1-16 months), one patient died of acute myocardial infarction at 11 months. It was concluded on the basis of these short-term results that endovascular repair of aortic dissection is a promising treatment, and abdominal aortic fenestration is a useful adjuvant procedure.

Adult↗

PubMed2000

Vertebral artery dissection and migraine headaches in children.

Strokes of the posterior circulation are uncommon in childhood. In vertebrobasilar insults, vertebral artery dissection remains a rare diagnosis. We report the case of an 8-year-old boy with a history of migraine headaches who presented with acute cerebellar signs and agitation following multiple infarctions of bilateral cerebellar hemispheres. Vertebral angiography demonstrated dissection of the left vertebral artery with occlusion of the basilar artery just distal to its origin. Risk factors for vertebral artery dissection are reviewed, with emphasis on association with migraine headaches. A review of imaging studies for the diagnosis of dissection is also presented. This case demonstrates the importance of considering arterial wall dissection in pediatric patients with a history of atypical migraines associated with new neurologic findings.

Cerebral Angiography↗

PubMed2002

Endovascular repair of a type B aortic dissection with transposition of a coexistent aberrant subclavian (lusorian) artery.

PURPOSE: To report the endovascular treatment of a relatively uncommon entity: an aortic type B dissection combined with an aberrant subclavian artery (SA). CASE REPORT: A 59-year-old patient was admitted with chest pain and interscapular back pain. A transesophageal ultrasound and magnetic resonance angiography revealed a type B aortic dissection originating at the level of an aberrant SA orifice. After failure of medical therapy, the dissection was treated by transluminal implantation of an Excluder stent-graft covering the entry site of the dissection at the aberrant SA orifice. Prior to the endovascular procedure, a transposition of the aberrant SA to the right carotid artery was performed through a supraclavicular approach. The patient remains asymptomatic at 19 months after the endovascular repair. CONCLUSIONS: Endovascular repair of a type B aortic dissection in the presence of a lusorian artery appears to be a feasible, safe, and less invasive alternative to conventional surgery. The need for concurrent transposition of the SA remains to be determined.

Aortic Dissection↗

PubMed2002

Complications after endovascular repair of type B aortic dissection.

PURPOSE: To outline the complications encountered after endoluminal treatment in patients with type B aortic dissection. METHODS: Between 1999 and 2001, 14 patients (12 men; mean age 60.3 years, range 39-79) with isolated type B aortic dissection (13 chronic, 1 acute) underwent aortic stent-grafting. Three patients with chronic dissection presented an acute clinical picture and were managed emergently. The left subclavian artery was intentionally covered by the prosthesis in 9 patients. Follow-up studies were performed at 6-month intervals. RESULTS: Stent-graft implantation was technically successful in all patients, but incomplete sealing (endoleak) of the entry site required additional proximal stent-graft implantation in 4. The left subclavian artery remained patent in 5 patients. Secondary conversion was required in 3 patients: 2 for acute type A dissection resulting from injury to the aortic arch by Talent endografts and a sustained hemorrhage (left hemothorax). In another patient, a secondary intramural hematoma subsided spontaneously. Anterior spinal artery syndrome in 1 patient persisted at 1 month. No bypass was necessary for the 9 patients with the covered left subclavian arteries. Mean follow-up was 14 months (range 1-23). CONCLUSIONS: Stent-grafting is feasible in patients with type B aortic dissection, although it is associated with a considerable rate of complications. Frank reporting of these sequelae for a variety of stent-grafts is of paramount importance to clarifying the limitations of the method.

Adult↗

PubMed2004

Complicated acute aortic dissection type B caused by femoral cannulation for endoscopic coronary artery bypass surgery.

PURPOSE: To report endovascular treatment of a patient with complicated acute aortic type B dissection caused by cannulation of the femoral artery for endoscopic coronary artery bypass (CAB) surgery. CASE REPORT: A 63-year-old man underwent single-vessel CAB surgery facilitated by the Da Vinci surgical system. After the procedure, acute lower limb ischemia led to the discovery of a type B dissection from the left subclavian artery to the iliac arteries. The subclavian artery was also dissected, with only minimal flow in the left mammary artery. The visceral and renal vessels originated from the false lumen and were not perfused. Emergent stent-graft placement was undertaken to close the entry tear and re-establish perfusion of the lower extremity as well as visceral and renal organs. Additional stent-grafts were placed in the dissected left subclavian artery to perfuse the left internal mammary bypass and in the inferior mesenteric artery, which arose from the false lumen. Six months after operation, the patient is well. CONCLUSIONS: Acute iatrogenic aortic dissection secondary to endoscopic CAB surgery can be treated emergently to restore distal perfusion to vital organs.

Aneurysm↗

PubMed2002

Vertebrobasilar dissection: a possible role of whiplash injury in its pathogenesis.

We reviewed 29 patients with vertebrobasilar dissections (VBD) to investigate the correlation between minor trauma and VBD and the clinical features of this trauma-related condition. Mean age was 43 years, with a male predominance (male/female ratio was 25/4). Seventeen patients presented with subarachnoid hemorrhage (SAH), and 12 with ischemic symptoms. Two patients presenting with ischemia had extracranial VBD (V3 segment). Angiographically, aneurysmal dilatation was observed in most SAH patients (13 patients) in contrast to narrowing or occlusion in most ischemic patients (10 patients). Among the 12 SAH patients treated with coil embolization or conservatively, five died, whereas all ischemic patients recovered well with anticoagulation and/or antiplatelet therapy. Seven patients had received minor or trivial head/cervical trauma, due to whiplash injury, minor fall, or during exercise, which were identified to precede with the lapse of some time (a few minutes or days) the onset of symptoms. All of these patients presented with ischemic symptoms, and they were younger than the other ischemic or SAH patients. The site of vertebral artery dissection was intracranial in four cases, extracranial in one case, and combined in two cases at the level of the V3 segment and the origin of the posterior inferior cerebellar artery. However, no SAH occurred. These clinicopathological findings, i.e. ischemia and angiographic narrowing/occlusion, suggest that dissections were subintimal. Therefore, it is believed that this minor or trivial trauma may primarily cause subintimal dissection with luminal compromise, leading to ischemic symptoms, rather than subadventitial or transmural dissection with aneurysmal dilatation, leading to SAH. This lesion may also occur in younger patients with a favorable outcome. Careful note should be made of patient for the early recognition of this disorder.

Adolescent↗

PubMed2005

Is there a relationship between weather conditions and aortic dissection?

BACKGROUND: Bleeding and rupture of blood vessels has been correlated with weather conditions in the past. This is the first study in the world literature with the aim of investigating the relationship between atmospheric pressure and temperature with the presentation of aortic dissection. METHODS: The dates of all emergency aortic dissection repairs from 1996-2002 in a regional cardiothoracic unit at Blackpool Victoria Hospital were obtained. Hourly temperature and pressure data from a regional weather station for this time period was supplied by the Meteorological Office. The mean and standard deviation of hourly temperature and pressure data for that month were compared to the mean and standard deviation of the data 24 and 48 hours prior to the aortic dissection. RESULTS: 26 patients were found to have been operated on during the time period studied. There was no statistically significant correlation between temperature or atmospheric pressure readings, and the incidence of aortic dissection, using a Bonferonni-corrected significance p-value of 0.005 CONCLUSION: This study is the first to examine the relationship between atmospheric pressure, temperature and dissecting thoracic aorta. No statistically significant relationship was demonstrable.

Aortic Dissection↗

PubMed1985

Dissecting aneurysms of head and neck.

We analyzed four personal cases and 51 reported cases of dissecting aneurysms of the arteries of the head and neck. Subintimal dissection more commonly affects the intracranial vessels before age 40. In contrast, medial dissection tends to affect extracranial vessels after age 30. Vertebrobasilar dissection more variably affects either arterial plane. The reasons for these differing patterns of dissection are still not clear. In young subjects, the subintimal layer appears to be more susceptible; in contrast, the media becomes increasingly vulnerable with age, particularly in the presence of acquired medial disease.

Adolescent↗

PubMed1988

Spontaneous dissections of the vertebral arteries.

Clinical and angiographic features and outcome in 25 patients with spontaneous dissections of the vertebral arteries are described. Most patients were in their fourth or fifth decade of life, and women predominated. Forty-eight percent of the patients were hypertensive. Angiographic evidence of fibromuscular dysplasia was noted in one only. Brainstem ischemic symptoms (usually a lateral medullary syndrome) and ipsilateral occipital headache and neck pain (often preceding but sometimes associated with or following the brainstem ischemic event) were the most common clinical findings. The angiographic features in decreasing order of frequency were luminal stenosis (often irregular and tapered), aneurysm, occlusion, and intimal flap. On follow-up, most of the patients (88%) made complete or very good recoveries. Angiographic abnormalities either subsided or improved in 76%. Multivessel dissection (involvement of both vertebral arteries or one or both vertebral arteries and one or both internal carotid arteries) was noted in about two-thirds of the patients. This tendency of vertebral artery dissections to involve multiple cervicocephalic vessels concurrently, if not simultaneously, implies that four-vessel angiography should be attempted if a vertebral artery dissection is visualized. It also raises the possibility of an underlying arteriopathy that predisposes the vessel to dissection.

Adult↗

PubMed1989

Dissecting aneurysm of the vertebral artery and cervical manipulation: a case report with autopsy.

A 35-year-old woman with 3 weeks of cervical pain developed ischemia in the basilar artery territory following cervical manipulation. At autopsy, there was a dissecting aneurysm within the third segment of the right vertebral artery. The pathologic changes in the lower and the upper part of the dissecting aneurysm were different, indicating recurring bleeding. Cervical manipulation could have accounted for one recent dissection, but not for another, which was a few weeks old. This suggests that cervical pain, which prompted the manipulation, may have been the first symptom of the dissection, and manipulation of the neck precipitated the stroke by inducing bleeding within the dissecting aneurysm.

Adult↗

PubMed1995

Headache and neck pain in spontaneous internal carotid and vertebral artery dissections.

We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For patients with internal carotid artery dissection (ICAD), the mean age was 47 years and for those with vertebral artery dissection (VAD), 40.7 years. A history of migraine was present in 18% of the ICAD group and in 23% of the VAD group. Headache was reported by 68% of the patients with ICAD and by 69% of those with VAD, and, when present, it was the initial manifestation in 47% of those with ICAD and in 33% of those with VAD. Ten percent of patients with ICAD had eye, facial, or ear pain without headache. The median interval from onset of headache to development of other neurologic manifestations was 4 days for the ICAD group and 14.5 hours for the VAD group. For all dissections, headaches typically were ipsilateral to the side of dissection. In the ICAD group, headaches were limited to the anterior head in 60% of patients and were steady in 73% and pulsating in 25%. In the VAD group, headaches were distributed posteriorly in 83% of patients and were steady in 56% and pulsating in 44%. Neck pain was present in 26% of patients with ICAD (anterolateral) and in 46% of those with VAD (posterior). The median duration of the headache in patients with VAD and ICAD was 72 hours, but headaches became prolonged, persisting for months to years, in four patients with ICAD.

Adult↗

PubMed2003

Arterial reconstruction by direct surgical clipping of a basilar artery dissecting aneurysm after failed vertebral artery occlusion: technical case report and literature review.

OBJECTIVE AND IMPORTANCE: Dissecting aneurysms of the basilar artery are rare lesions with significant morbidity and mortality. Their management is controversial and often difficult. Although the rebleeding rate is high, clip reconstruction carries prohibitive risk because of the damage to the parent vessel induced by the dissection and the lack of tissue to gather. An enlarging pseudoaneurysm in the chronic phase, however, may have sufficient tissue for clip reconstruction. We present a case in which this strategy was used successfully. CLINICAL PRESENTATION: A 45-year-old woman presented 3 months after an initial presentation with a subarachnoid hemorrhage from a dissecting aneurysm of the basilar trunk at an outside institution. The aneurysm had grown compared with previous angiograms. INTERVENTION: The dominant vertebral artery was sacrificed. Despite this, the aneurysm continued to enlarge. Given the progressive enlargement of the aneurysm, the decision was made to proceed with arterial reconstruction by direct surgical clipping of the saccular component of the dissecting aneurysm. The patient made an excellent recovery with a durable result. CONCLUSION: Although clipping an intracranial pseudoaneurysm in the acute phase may carry a prohibitive risk, clipping such an aneurysm in the chronic phase may occasionally be warranted. To our knowledge, this is the first case reported in the literature in which direct surgical clipping was used as the primary mode of treatment for a basilar artery dissecting aneurysm that enlarged despite occlusion of the dominant vertebral artery. We review the literature on this rare pathological entity and discuss our management strategy.

Aortic Dissection↗

PubMed2006

Multilayer image grid reconstruction technology: four-dimensional interactive image reconstruction of microsurgical neuroanatomic dissections.

OBJECTIVE: Cadaveric dissection is the gold standard for training physicians in various surgical specialties. However, limitations in acquiring and storing sufficient cadaveric material, recent pressures in training opportunities, and progress in digital image technology have led to advances in virtual or artificial visual means to augment surgical training. For training neurosurgeons, the appearance of reality is still crucial for learning anatomic structures and procedures. We developed a four-dimensional (including time) multilayer digital image reconstruction technology (MIGRT) that allows users to manipulate a "volumetric" set of photographic image data from exquisite cadaveric intracranial dissections and to navigate through stages of neurosurgical procedures as the dissection progresses. METHODS: A robotic microscope with two digital cameras was used to capture dissection images, usually in stereoscopic mode. A grid space was created to define positions at which images are captured. Images were acquired from identical angles at the same grid coordinates but at different stages of various dissections. RESULTS: Image data are reconstructed according to the sequence of acquisition into a multilayer image grid system by the MIGRT software. The single interactive, four-dimensional montage is viewable a on common computer platform. CONCLUSION: MIGRT uniquely focuses on capturing anatomic content that preserves natural appearances, including procedure, texture, and color, which is far superior and preferable to images and a reconstructed image environment based on artificial or animated concepts. MIGRT shows time-dependent changes in procedures, provides depth perception by stereoscopy or unique sequential motion, and allows simultaneous interactivity at each step of the procedure.

Brain↗

PubMed1991

Acute aortic dissection. A comparison between the results of medical and surgical treatments.

Over the last ten years 96 patients with aortic dissection were encountered in our Institute, of whom 51 had type A dissection, and 45 had type B dissection. In the patients with type A dissection the long-term survival rate was poor if they were not operated upon without delay, and the cause of death was usually rupture of the aneurysms. In the patients with acute type B dissection the surgical indication was limited and, generally speaking the long-term survival rate of the medically treated patients was more favorable.

Acute Disease↗

PubMed2005

The laryngeal dissection laboratory.

The purpose of this study was to dissect various animal larynges in support of a proposal for a laryngeal dissection laboratory. It was found that although the bovine larynx is larger than the human larynx, the anatomy is similar. Thirty-three bovine larynges were dissected by the author in various simulated phonosurgical and partial laryngectomy procedures. Following each procedure, the specimen was photographed for teaching purposes. The author concludes that dissecting bovine larynges offers a valuable aid to training in the field of laryngeal surgery. It is intended to apply these dissections in the form of a departmental surgical workshop.

Animals↗

PubMed1996

Fast CT for aortic dissection.

Results were evaluated in 81 patients with suspected acute aortic dissection who were examined on a fast CT system capable of a 1 s data acquisition time. 17 patients had Type A and nine had Type B dissections. Radiological assessment provided 78 confident reports and expressed some uncertainty about the diagnosis in three patients. Overall sensitivity for aortic dissection was 96.2% and specificity was 96.4%. When 78 confident reports alone were considered, both sensitivity and specificity reached 100%. Reconstruction of data at 100 ms intervals allowed discrimination between artefacts in the ascending aorta and Type A dissections. CT can often be used as the single investigation prior to surgery for acute Type A dissections.

Acute Disease↗

PubMed1997

Spontaneous dissections of the internal carotid artery: appearances on colour Doppler ultrasound.

Spontaneous dissection of the internal carotid artery (ICA) is an unusual finding. We present an analysis of five patients (aged 40-60 years) with ICA dissections, describing the various flow patterns detected on colour Doppler ultrasound. Particular attention was paid to the presence of a dual lumen, the direction of flow in the false lumen and the velocity/spectral broadening of the Doppler trace obtained from the true and false lumens. Four different patterns were observed. Narrowing of the true lumen by the false lumen thrombus was seen in two cases with a low velocity Doppler waveform; three cases had a patent false lumen ("double lumen" pattern); the direction of flow in the patent false lumen varied from being (i) forward, (ii) reversed and (iii) bidirectional. The flow dynamics in carotid dissections are complex and are primarily dependent upon the presence of thrombus within the false lumen, the entry and exit flaps if the false lumen is patent, the motion of the flap wall and the extent of the dissection. They illustrate the diverse nature of the disease and Doppler ultrasound plays an important role in the imaging of ICA dissections.

Adult↗

PubMed2005

Non-neoplastic process after neck dissection demonstrated on enhanced CT in patients with head and neck cancer.

OBJECTIVES: Head and neck radiologists should be familiar with typical post-therapeutic changes on enhanced CT after neck dissection because CT is widely used for the follow-up study in order to detect recurrent tumours at an early stage. The purpose of this study was to reveal post-therapeutic anatomical alterations and non-neoplastic processes demonstrated on enhanced CT. METHODS: Radical neck dissections were performed in 39 necks and modified radical neck dissections were performed in 8 necks. Post-operative radiotherapy was performed on 21 patients. Follow-up CT, studies were made within a period of 24 months. RESULTS: On enhanced CT, the densities of soft tissues replacing the resected structures were homogeneous in 44 necks and showed no contrast enhancement in 39 necks. During the 24 months after treatment, most of the soft tissues did not increase in size and the attenuation of the soft tissue remained unchanged. In 44 of 47 necks, lymphoedema (LE) was observed around the carotid artery at an early stage, and it converged into the space between internal carotid artery and external carotid artery gradually. In patients without post-operative radiotherapy, LE was observed around the carotid artery in 17 of 23 necks at 3 months after neck dissection and disappeared rapidly thereafter. In patients with post-operative radiotherapy, LE increased until 3 months after radiotherapy and decreased slowly thereafter. CONCLUSIONS: This is the first report of enhanced CT evaluation of LE around the carotid artery after neck dissection probably exacerbated by irradiation. Clinicians should be aware of LE around the carotid artery in patients with post-operative radiotherapy because of the possible risk of neck cellulitis at least 1 year after treatment.

Adult↗