Multi-Contrast High-Resolution Magnetic Resonance Findings of Spontaneous and Unruptured Intracranial Vertebral Artery Dissection: Qualitative and Quantitative Analysis According to Stages

Background: Although high-resolution magnetic resonance imaging (HR-MRI) has been used as a strong imaging method for diagnosing intracranial vertebral artery dissection (IVAD), the diagnosis is sometimes challenging because a dissection has geometric changes in the natural course. The radiologic features may change or disappear over time, which makes the diagnosis confusing. Our study was to present radiological findings according to the stages in spontaneous and unruptured, IVAD on 3T HR-MRI and to guide the age estimation of IVAD with the distinguishing findings according to the stages. Methods: From January 2011 to July 2014, the 41 vertebral arteries (M:F = 18:12; age range 32-67 years) were retrospectively enrolled. Spontaneous, unruptured IVAD was diagnosed if it had a clear onset based on clinical and radiological findings. The stages were classified as acute (0-3 days), early subacute (3-10 days), late subacute (10-60 days) and chronic stage (>60 days; recovery and non-recovery groups) according to the time intervals from symptom onset, based on the prior published studies. HR-MR findings were assessed and compared in the intimal flap, double lumen, aneurysmal dilatation (maximal outer diameter, maximal wall thickness, wall thickness index and remodeling index), intramural hematoma (relative signal intensity) and vessel wall enhancement according to the stages with qualitative and quantitative methods. Two radiologists analyzed the HR-MR findings with consensus reading. Results: IVAD was classified into acute (n = 6), early subacute (n = 8), late subacute (n = 16) and chronic (n = 11) stages. HR-MR dissection findings such as intimal flap, double lumen, aneurysmal dilatation and intramural hematoma significantly decreased from the earlier stages to the chronic stage (p < 0.05). The quantitative indices in aneurysmal dilatation and the relative signal intensity of intramural hematoma showed significant higher values in the earlier stages followed by a significant decrease in the chronic stage recovery group (p < 0.05). The degree of vessel wall enhancement was higher in the earlier stage and decreased in the chronic stage (p < 0.05), but mild vessel wall enhancement was identified 900 days after symptom onset. Conclusion: The 3T HR-MRI reveals the vessel wall characteristics and provides distinguishing findings between earlier stages and the chronic stage in spontaneous and unruptured IVAD. Characterization of these radiological findings according to stages may assist with the age estimation of the dissection and may help to understand IVAD as a whole.

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Abstract WP231: Detection of Intramural Hematoma by Susceptibility Weighted Image in Vertebral Artery Dissection

Stroke ◽

10.1161/str.44.suppl_1.awp231 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Tae-Won Kim ◽

Jaseong Koo ◽

Hyun Seok Choi ◽

Kwang Soo Lee ◽

Si Baek Lee

Keyword(s):

Ischemic Stroke ◽

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Intramural Hematoma ◽

Artery Dissection ◽

Aneurysmal Dilatation ◽

Exact Test ◽

Weighted Image ◽

Susceptibility Weighted Image ◽

Phase Map

Objectives The radiologic diagnosis of vertebral artery dissection (VAD) depends on the characteristic intraluminal findings on angiographic study although the pathology of VAD is intramural hematoma. We aimed to know whether ‘intramural hematoma sign (IHS)’ on susceptibility weighted image (SWI) in vertebral artery is specific for VAD. Methods We retrospectively analyzed SWI and phase map images of the consecutive patients with ischemic stroke in the vertebral artery territory from August 2009 to July 2012. We divided the patients into 2 groups; VAD related stroke and atherosclerotic stroke. Diagnostic criteria of VAD related stroke were (a) presence of posterior neck pain or occipital headache and (b) features of VAD at computed tomography angiography or contrast enhanced magnetic resonance angiography or digital subtraction angiography. Angiographic evidence of VAD which is subdivided into three groups: aneurysmal dilatation without stenosis, pearl-and string, and steno-occlusive without aneurysmal dilatation. IHS was considered positive if the patient had (a) eccentric hypointense signal lesion in vertebro-basilar artery on SWI and (b) this signal should be hyperintense on phase map suggesting blood products other than calcification. An experienced neuroradiologist blinded to clinical information was asked to judge the presence of IHS. For statistical analysis, two by two contingency tables by Fisher’s exact test were performed. Results Among the 137 patients with ischemic stroke in the vertebral artery territory, SWI and phase map images were available in 47 patients who were included for our analysis. Among them, 14 patients were diagnosed as an ischemic stroke due to VAD and 33 patients had no VAD (atherosclerotic stroke). Compared to atherosclerotic stroke patients, patients with VAD-related stroke had more headache (64% vs 15%, P=0.016). Among the 14 patients with VAD-related stroke, IHS was detected in 9 cases while only 2 of 33 patients with atherosclerotic stroke showed IHS (sensitivity 64% and specificity 94%). In Fisher’s exact test analysis, the IHS was significantly associated with VAD (p < 0.001). Conclusion The intramural hematoma sign on SWI was significantly associated with vertebral artery dissection.

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Monitoring Intramural Hematoma on Vessel Wall Imaging to Evaluate the Healing of Intracranial Vertebral Artery Dissection

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2021.105992 ◽

2021 ◽

Vol 30 (9) ◽

pp. 105992

Author(s):

Yukishige Hashimoto ◽

Toshinori Matsushige ◽

Koji Shimonaga ◽

Michitsura Yoshiyama ◽

Hiroki Takahashi ◽

...

Keyword(s):

Vertebral Artery ◽

Vessel Wall ◽

Vertebral Artery Dissection ◽

Intramural Hematoma ◽

Vessel Wall Imaging ◽

Artery Dissection ◽

Wall Imaging

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Radiological Findings of Vertebral Artery Dissection

Journal of the Korean Radiological Society ◽

10.3348/jkrs.1995.33.4.507 ◽

1995 ◽

Vol 33 (4) ◽

pp. 507

Author(s):

Ik Won Kang ◽

Kil Woo Lee ◽

Ji Hun Kim ◽

Hong Kil Suh ◽

Kyu Sun Kim ◽

...

Keyword(s):

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Artery Dissection ◽

Radiological Findings

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Intracranial vessel wall MR imaging of an intradural vertebral artery dissection

Clinical Imaging ◽

10.1016/j.clinimag.2020.06.024 ◽

2020 ◽

Vol 68 ◽

pp. 108-110 ◽

Cited By ~ 1

Author(s):

Kofi-Buaku Atsina ◽

Aaron Rothstein ◽

Steven R. Messé ◽

Jae W. Song

Keyword(s):

Mr Imaging ◽

Vertebral Artery ◽

Vessel Wall ◽

Vertebral Artery Dissection ◽

Artery Dissection ◽

Intracranial Vessel

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Abstract TP84: Prognostic Factor of Intracranial Vertebral Artery Dissection: High Resolution Vessel Wall Magnetic Resonance Imaging Study

Stroke ◽

10.1161/str.51.suppl_1.tp84 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jae-Hwan Kim ◽

Hyung Jun Kim ◽

Ye Sel Kim ◽

Woo-Keun Seo ◽

Oh Young Bang ◽

...

Keyword(s):

Ischemic Stroke ◽

High Resolution ◽

Prognostic Factor ◽

Vertebral Artery ◽

Vessel Wall ◽

Independent Predictor ◽

Vertebral Artery Dissection ◽

Posterior Circulation ◽

Artery Dissection ◽

Poor Outcomes

Background: Vertebral artery dissection (VAD) is well recognized cause of stroke in young and middle aged individuals. But, prognostic factor of posterior circulation ischemic stroke or transient ischemic attack (TIA) caused by intracranial VAD has been rarely discussed. Our aim was to evaluate the predictors of poor outcomes in posterior circulation ischemic stroke caused by intracranial VAD. Methods: We retrospectively reviewed patients with posterior circulation ischemic stroke or TIA caused by intracranial VAD using high-resolution vessel wall MRI who were recruited from Samsung Medical Center Stroke Registry (between January 1, 2011 and April 30, 2019). Poor outcomes were defined as a 3-months modified Rankin scale (mRS) score ≥ 2. Results: We registered 96 patients (74 males; mean age, 58.9±14.2 years) with acute posterior circulation ischemic stroke or TIA caused by intracranial VAD. Trauma history associated with VAD was presented in 23 (24%) of patients. Headache and neck pain around neurological symptom onset were presented in 41 (42.7%) and 19 (19.8%) of patients, respectively. Dissecting aneurysm, bilateral vertebral artery involvement, basilar artery involvement and wall hematoma with dissection were presented in 26 (27.1%), 26 (27.1%), 12 (12.5%) and 66 (68.8%) of patients, respectively. Of the 96 VADs, 26 (27.1%) presented with focal stenosis, 21 (21.9%) with multifocal stenosis, and 57 (59.4%) with occlusion. Lateral medulla involvement and multiple territory involvement were presented in 35 (36.5%) and 31 (32.3%) of patients. Recurrence rate of ischemic stroke or TIA within 90 days of symptom onset was 6.25%. Twenty-nine patients (30.2%) had poor outcomes at 3 months. Lateral medulla involvement was an independent predictor for poor outcome (odds ratio=3.293, 95% confidence interval=1.301-8.333, p=0.012). Conclusion: Posterior circulation ischemic stroke or TIA caused by intracranial VAD is associated with relatively benign clinical course. But the presence of lateral medulla involvement is independent predictor for poor outcome. Patients presenting lateral medullary infarction caused by intracranial VAD should be monitored closely.

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Spontaneous intracranial vertebral artery dissection with acute ischemic stroke: High-resolution magnetic resonance imaging findings

The Neuroradiology Journal ◽

10.1177/1971400918764129 ◽

2018 ◽

Vol 31 (3) ◽

pp. 262-269 ◽

Cited By ~ 4

Author(s):

Soo Young Yun ◽

Young Jin Heo ◽

Hae Woong Jeong ◽

Jin Wook Baek ◽

Hye Jung Choo ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

High Resolution ◽

Diffusion Mri ◽

Vertebral Artery Dissection ◽

Intramural Hematoma ◽

Artery Dissection ◽

Resonance Imaging ◽

Mri Findings ◽

Remodeling Index

Background Acute ischemic stroke (AIS) more frequently develops in patients with intracranial vertebral artery dissection (VAD) than extracranial VAD, and is associated with possible poor clinical outcomes. The aim of this study is to compare high-resolution magnetic resonance imaging (HR-MRI) findings and clinical features of VAD with and without AIS. Methods Twenty-nine lesions from 27 patients (15 male and 12 female patients; age range = 28–73 years) who underwent diffusion MRI and 3T HR-MRI within seven days were included. We classified VAD according to the presence of AIS lesions on diffusion MRI. Clinical features and HR-MRI findings (angiographic patterns, presence of double lumen sign, dissecting flap, posterior inferior cerebellar artery involvement, remodeling index, length of affected vessels, T1-signal intensity, area of intramural hematoma, and grades and patterns of vessel wall enhancement) were evaluated. Results Thirteen VADs with AIS and 16 without AIS were included. There were no significant differences in the clinical parameters (sex, age, risk factors, symptoms). More VADs with AIS presented as a steno-occlusive pattern than VADs without AIS. More VADs without AIS presented with aneurysmal dilation, larger mean remodeling index and longer mean length than VADs with AIS. Presence of intramural hematoma, T1-iso-signal intensity of intramural hematoma and contrast enhancement were significantly more common in VADs with AIS than without AIS. Conclusions Our study showed some differences in HR-MRI comparing intracranial VAD patients with and without AIS. Differing findings may facilitate a better understanding of intracranial VAD and risk assessment of AIS in these patients.

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Cervicocranial Artery Dissection

Acta Radiologica ◽

10.1177/02841851960373p220 ◽

1996 ◽

Vol 37 (3P2) ◽

pp. 529-534 ◽

Cited By ~ 4

Author(s):

S. J. Bakke ◽

H.-J. Smith ◽

E. Kerty ◽

A. Dahl

Keyword(s):

Doppler Ultrasound ◽

Internal Carotid ◽

False Negative ◽

Vertebral Artery Dissection ◽

Artery Dissection ◽

Pulsed Doppler ◽

Double Lumen ◽

Conventional Angiography ◽

Pulsed Doppler Ultrasound

Purpose: To evaluate pulsed Doppler ultrasound and MR angiography (MRA) in the diagnosis of cervicocranial dissection. Material and Methods: Fourteen patients with cervicocranial artery dissection were examined over a 3-year period. Twelve patients had dissection of the extracranial part of the internal carotid artery, and 2 had vertebral artery dissection. All patients were examined with pulsed Doppler ultrasound. In addition, all patients had conventional angiography (n=9) and/or MR imaging including MRA (n=9). Results: Doppler ultrasound disclosed unspecific abnormalities in 11 of 14 dissected vessels; 3 patients had false-negative Doppler findings. MRA showed vessel abnormalities in 9 of 9 patients; 2 vessels were occluded, and 7 vessels had changes typical of dissection (double lumen and/or string sign). Twelve patients had follow-up examinations with pulsed Doppler ultrasound (n=12), conventional angiography (n=3), and MRA/MR (n=11). Follow-up Doppler showed complete or partial normalization in 61 of 9 patients, all confirmed by either angiography or MRA. Conclusion: Our findings suggest that Doppler ultrasound may be used in follow-up of pathologic Doppler findings in known dissections, and that MRA may replace angiography in the confirmative diagnosis of cervicocranial dissection.

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Intramural Hematoma Detection by Susceptibility-Weighted Imaging in Intracranial Vertebral Artery Dissection

Cerebrovascular Diseases ◽

10.1159/000354811 ◽

2013 ◽

Vol 36 (4) ◽

pp. 292-298 ◽

Cited By ~ 31

Author(s):

Tae-Won Kim ◽

Hyun Seok Choi ◽

Jaseong Koo ◽

So Lyung Jung ◽

Kook-Jin Ahn ◽

...

Keyword(s):

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Intramural Hematoma ◽

Artery Dissection ◽

Susceptibility Weighted Imaging

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Nonsurgical treatment of unruptured intracranial vertebral artery dissection with serial follow-up angiography

Journal of Neurosurgery ◽

10.3171/jns.1994.80.4.0667 ◽

1994 ◽

Vol 80 (4) ◽

pp. 667-674 ◽

Cited By ~ 102

Author(s):

Chifumi Kitanaka ◽

Jun-Ichi Tanaki ◽

Masanori Kuwahara ◽

Akira Teraoka ◽

Tomio Sasaki ◽

...

Keyword(s):

Vertebral Artery ◽

Vertebral Artery Dissection ◽

Bed Rest ◽

Arterial Dissection ◽

Artery Dissection ◽

Aneurysmal Dilatation ◽

Content Type ◽

Brain Stem Ischemia ◽

Fine Print

✓ The question of whether unruptured intracranial vertebral artery dissections should be treated surgically or nonsurgically still remains unresolved. In this study, six consecutive patients with intracranial vertebral artery dissection presenting with brain-stem ischemia without subarachnoid hemorrhage (SAH) were treated nonsurgically with control of blood pressure and bed rest, and five received follow-up review with serial angiography. No further progression of dissection or associated SAH occurred in any of the cases, and all patients returned to their previous lifestyles. In the serial angiograms in five patients, the findings continued to change during the first few months after onset. Four cases ultimately showed “angiographic cure,” while fusiform aneurysmal dilatation of the affected vessel persisted in one case. In one patient, arterial dissection was visualized on the second angiogram despite negative initial angiographic findings. These results indicate that intracranial vertebral artery dissection presenting without SAH can be treated nonsurgically, with careful angiographic follow-up monitoring. Persistent aneurysmal dilatation as a sequela of arterial dissection seemed to form a subgroup of fusiform aneurysms of the posterior circulation. These aneurysms may be prone to late bleeding and may require surgical treatment.

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Magnetic resonance imaging in the diagnosis of the outcomes of brachiocephalic artery dissection

Diagnostic radiology and radiotherapy ◽

10.22328/2079-5343-2021-12-2-92-97 ◽

2021 ◽

Vol 12 (2) ◽

pp. 92-97

Author(s):

T. A. Lesnykh ◽

M. V. Dreval’ ◽

M. S. Danilova ◽

M. A. Kravchenko ◽

L. А. Kalashnikova ◽

...

Keyword(s):

Differential Diagnosis ◽

Vessel Wall ◽

Artery Dissection ◽

Brachiocephalic Artery ◽

Resonance Imaging ◽

Double Lumen ◽

Aneurysmal Dilation ◽

Before And After ◽

Wall Imaging

Introduction. Vessel wall imaging in patients with dissection plays an impotent role in the differential diagnosis of stenoocclusive processes of the main arteries of the head. However, the interpretation of changes in long-term periods remains difficulties. Purpose: to determine and compare the imaging patterns of the consequences of the postponed dissection using MRI and ultrasound.Materials and methods. 30 patients with confirmed dissection were examined for more than 1 year from the date of diagnosis. MRI was performed using vessel wall protocol imaging before and after contrast enhancement.Results. Postpone dissection imaging patterns were revealed: aneurysmal dilation of the artery (27%) and double lumen (20%) at the site of dissection; prolonged stenosis in 10% of cases, intimal flap — in 3% of cases. Occlusion persisted in 40% of cases.Conclusion. The use of MRI can improve the differential diagnosis of the causes of the stenоocclusive process of the main arteries of the head.

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