Dissection vertebral artery

Infrequently, cervical artery dissection can lead to subarachnoid hemorrhage, usually when the dissection extends to the intracranial part of the vessel, with pseudoaneurysm formation and rupture (1% of cervical artery dissection cases in the large hospital-based series) [36, 37], Rupture of dissected vertebral arteries into the subarachnoid space is more common in children. Rupture of dissected carotid artery pseudoaneurysms into the neck or nasal sinuses is generally rare. Dissection can occur intracraiually and, on rare occasions, can spread intracraniaUy from a primary extracranial origin. 

Dissection of the internal carotid and vertebral arteries is a common cause of stroke, particularly in young patients. Although many occur due to trauma, it is estimated that over half occur spontaneously. The mechanism of stroke following arterial dissection is either by artery-to-artery embolism, by thrombosis in situ, or by dissection-induced lumenal stenosis with secondary cerebral hypoperfusion and low-flow watershed infarction. Occasionally, dissection may lead to the formation of a pseudoaneurysm as a source of thrombus formation. Vertebrobasilar dissections that extend intracranially have a higher risk of rupture leading to subarachnoid hemorrhage (SAH). ° ... 

Jacobs A, Lanfermann H, Neveling M, Szelies B, Schroder R, Heiss WD. MRI- and MRA-guided therapy of carotid and vertebral artery dissections. J Neurol Sci 1997 147 27-34. 

Schievink W. The treatment of spontaneous carotid and vertebral artery dissections. Curr Opin Cardiol 2000 15 316-321. 

Spontaneous dissection of the internal carotid or the vertebral artery is an important cause of ischemic stroke in young adults (Fig. 1.3). In the late 1970s Fisher et al. (1978) and Mokri et al. (1979) described dissections of carotid and vertebral arteries as detected by modern diagnostic techniques rather than by post-mortem examination. This may occur... 

Liu Y, Karonen JO, Vanninen RL et al. (2004) Acute ischemic stroke predictive value of 2D phase-contrast MR angiography-serial study with combined diffusion and perfusion MR imaging. Radiology 231 517-527 Lucas C, Leclerc X, Pruvo JP et al. (2000) [Vertebral artery dissections follow-up with magnetic resonance angiography and injection of gadolinium]. Rev Neurol (Paris) 156 1096-1105... 

Vertebral artery dissection has been described in a previously healthy man with a 3-year history of daily oral amfetamine abuse (26). 

Since this patient had no known risk factors for vertebral artery dissection and had abused amfetamine daily for 3 years with escalating amounts, an association between metamfetamine and vertebral artery dissection cannot be excluded. The local and systemic vascular impacts of amfetamine could have contributed to initial changes (along with smoking), resulting in dissection. 

Zaidat OO, Frank J. Vertebral artery dissection with amphetamine abuse. J Stroke Cerebrovasc Dis 2001 10 27-9. 

Penetrating and non-penetrating neck injuries are more likely to damage the carotid than the better protected vertebral artery. The vertebral artery appears to be more vulnerable to rotational and hyperextension injuries of the neck, particularly at the level of the atlas and axis. Laceration, dissection and intimal tears may be complicated by thrombosis and then embolism and, therefore, ischemic stroke at the time of the injury or some days or even weeks after the injury. Later stroke may be a consequence of the formation of a traumatic aneurysm, arteriovenous fistula or a fistula between the carotid and vertebral arteries (Davis and Zimmerman 1983). 

Schievink WI (2001). Spontaneous dissection of the carotid and vertebral arteries. New England Journal of Medicine 344 898-906 Schievink WI, Michels VV, Piepgras DG (1994). Neurovascular manifestations of heritable connective tissue disorders. A review. Stroke 25 889-903... 

Sturzenegger M, Matde HP, Rivoir A et al. (1993). Ultrasound findings in spontaneous extracranial vertebral artery dissection. Stroke 24 1910-1921... 

Headache is not uncommon around the time of stroke onset. It is more often severe in primary intracerebral hemorrhage than ischemic stroke, and more often severe with posterior than anterior circulation strokes. If the headache is localized at all, it tends to be over the site of the lesion. Headache is more common in cortical and posterior circulation than lacunar infarcts (Kumral et al. 1995). Severe unilateral neck, orbital or scalp pain suggests internal carotid artery dissection, particularly if there is an ipsilateral Horner s syndrome. Severe occipital headache can occur with vertebral artery dissection. Headache is also a particular feature of venous infarcts. Unusual headache in the days before stroke would suggest giant cell arteritis or perhaps a mass lesion rather than a stroke. 

Until recently, catheter angiography was the standard imaging modality to confirm or exclude carotid or vertebral artery dissection (Fig. 12.2) because ultrasound was neither specific nor sensitive enough. However, there is now a widespread consensus that cross-sectional MRI, to show thrombus within the widened arterial wall, combined with MR angiography is the safest and best option. 

A 32-year-old woman who had seen a traditional American bone-setter for shoulder problems was subjected to a sudden thrusting of the head upward and to the right (170). She had neck discomfort immediately afterwards. The pain persisted for 6 days, when she noted vertigo and left-sided ataxia. An MRI scan showed acute infarction in the middle left cerebellar hemisphere and vermis. An MRA scan showed left vertebral artery dissection with a probable embolus. 

When all 26 cases of vertebral artery dissection during the period 1989-99 were retrospectively analysed in a tertiary Canadian academic center, possible precipitating factors were identified in 14 patients (171). Chiropractic spinal manipulation and sporting activity were the most common factors (11% and 15% respectively). 

German neurologists have reported 10 cases of ischemic stroke due to either vertebral arterial dissection (n = 8) or internal carotid artery dissection (n — 2) after chiropractic spinal manipulation (179). There were no identifiable predisposing factors. In three cases the dissections were bilateral. The onset of sjmptoms was immediate (n = 5) or delayed by up to 2 days. Neurological deficits developed during up to 3 weeks. In five patients the eventual clinical outcome was good while marked deficits persisted in three patients. One patient continued to suffer from a locked-in sjmdrome and another was in a persistent vegetative state. 

A 34-year-old woman had pain, dizziness, vomiting, and diplopia immediately after cervical spinal manipulation (180). An MRI scan showed a left cerebellar infarction, and duplex sonography showed dissection of both vertebral arteries leading to 50% occlusion on the right side and total occlusion on the left side. 

Mas JL, Bousser MG, Hasboun D, Laplane D. Extracranial vertebral artery dissections a review of 13 cases. Stroke 1987 18(6) 1037- 7. 

Mas JL, Henin D, Bousser MG, Chain F, Hauw JJ. Dissecting aneurysm of the vertebral artery and cervical manipulation a case report with autopsy. Neurology 1989 39(4) 512-15. 

Quintana JG, Drew EC, Richtsmeier TE, Davis LE. Vertebral artery dissection and stroke following neck manipulation by Native American healer. Neurology 2002 58(9) 1434-5. 

Saeed AB, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection warning symptoms, clinical features and prognosis in 26 patients. Can J Neurol Sci 2000 27(4) 292-6. 

Fig. 4.15 Left vertebral artery (LVA) dissection on both axial images and as shown on a curved reformatted image arrows)...

In younger patients, dissection of the carotid and/ or vertebral arteries must be included in the differential diagnosis of acute stroke [101-103]. In 1999, Oelerich [104] reported satisfactory results with MRA... 

Provenzale JM (1995) Dissection of the internal carotid and vertebral arteries imaging features. Am J Roentgenol 165(5) 1099-1104. 

Fig. 6.18 Left vertebral artery dissection, (a) Axial T1 fat-saturated image of the neck shows a crescent of high signal at the left vertebral artery from intramural hemoglobin, (b) ceMRA shows a narrowed left vertebral artery (arrow)...

A recent meta-analysis showed that sensitivities for the detection of carotid and vertebral arterial dissection ranged from 50 to 100% and specificities ranged from 29 to 100% [63]. In the largest study comparing internal carotid and vertebral artery dissections with DSA, the conventional MR appearance alone had an estimated 84% sensitivity and 99% specificity for diagnosing ICA dissection, while 3D TOF MRA had a 95% sensitivity and 99% specihcity [64]. For vertebral artery dissections, MRI and MRA were less nsefnl MRI had sensitivity and specihcity for vertebral artery dissection of 60 and 58%, while 3D TOF MRA sensitivity was 20%, with 100% specihcity [64, 65]. 

---