Intracranial vertebral artery dissection with subarachnoid hemorrhage: clinical characteristics and outcomes in conservatively treated patients

2004 ◽  
Vol 101 (1) ◽  
pp. 25-30 ◽  
Author(s):  
Masaru Yamada ◽  
Takao Kitahara ◽  
Akira Kurata ◽  
Kiyotaka Fujii ◽  
Yoshio Miyasaka
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Conservative Treatment ◽  
Vertebral Artery ◽  
Vertebral Artery Dissection ◽  
Delayed Diagnosis ◽  
Acute Stage ◽  
Artery Dissection ◽  
Content Type ◽  
String Structure ◽  
Fine Print

Object. Intracranial vertebral artery (VA) dissection with subarachnoid hemorrhage is notorious for frequent rebleeding and a poor prognosis. Nevertheless, some patients survive with a good final outcome. The factors associated with the prognosis of this disease are not fully understood and appropriate treatment strategies continue to be debated. The authors retrospectively evaluated the clinical features of conservatively treated patients to elucidate the relationship between the clinical and angiographic characteristics of the disease and final outcomes. Methods. This study includes 24 patients who were treated by conservative methods between 1990 and 2000. Conservative treatment was chosen because of delayed diagnosis, poor clinical condition, or anatomical features such as bilateral lesions and contralateral VA hypoplasia. Of nine patients with an admission Hunt and Kosnik Grade I or II, eight had good outcomes (mean follow-up period 8 years and 4 months). All 15 patients with Grade III, IV, or V died and in 10 of these the cause of death was rebleeding. Among the 24 patients, 14 suffered a total of 35 rebleeding episodes; in 10 (71.4%) of these 14 patients rebleeding occurred within 6 hours and in 13 (93%) within 24 hours. Compared with the survivors, there was a female preponderance (0.022) among patients who died. These patients also had significantly shorter intervals between onset and hospital admission (p = 0.0067), a higher admission Hunt and Kosnik grade (p = 0.0001), a higher incidence of prehospitalization (p = 0.0296) and postadmission (p = 0.0029) rebleeding episodes, and a higher incidence of angiographically confirmed pearl-and-string structure of the lesion (p = 0.0049). Conclusions. In our series of preselected patients, poor admission neurological grade, rebleeding episode(s), and lesions with a pearl-and-string structure were predictive of poor outcomes. Our findings indicate that patients with these characteristics may be candidates for aggressive attempts to prevent rebleeding during the acute stage. Patients without these characteristics may be good candidates for conservative treatment, especially those who survive the acute phase without rebleeding.

scholarly journals A case of unilateral vertebral artery dissection progressing in a short time period to bilateral vertebral artery dissection

2019 ◽  
Vol 10 ◽  
pp. 126
Author(s):  
Kiyoshi Tsuji ◽  
Akira Watanabe ◽  
Nobuhiro Nakagawa ◽  
Amami Kato
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Vertebral Artery ◽  
De Novo ◽  
Vertebral Artery Dissection ◽  
Contralateral Side ◽  
Sudden Onset ◽  
Acute Stage ◽  
Artery Dissection ◽  
Lateral Medullary Infarction ◽  
The Right

Background: Vertebral artery dissection (VAD) is an important cause of stroke in young and middle- aged people. Bilateral occurrence of VAD is generally considered rare, but the number of reports of bilateral VAD has been increasing in recent years. In this paper, we report a case of de novo VAD on the contralateral side presenting with subarachnoid hemorrhage in the acute stage of cerebral infarction due to unilateral VAD. Case Description: A 52-year-old man developed sudden-onset left occipital headache, dizziness, dysphagia, and right-sided hemiparesthesia and was admitted to our hospital. Head magnetic resonance imaging on admission showed a left lateral medullary infarction due to the left VAD. At this point, the right vertebral artery was normal. However, on day 9 after onset, he suddenly presented with subarachnoid hemorrhage due to the right VAD. Emergency endovascular treatment was performed for the dissecting aneurysm of the right vertebral artery. The patient’s condition improved gradually after the procedure, and he was discharged with a modified Rankin Scale score of 1. Conclusion: Bilateral occurrence of VAD may be more common than previously believed. Even in cases of unilateral VAD, we need to pay attention to the occurrence of de novo VAD on the contralateral side.

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

1994 ◽  
Vol 80 (4) ◽  
pp. 667-674 ◽  
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.

Repair of a vertebral artery dissection

1986 ◽  
Vol 64 (4) ◽  
pp. 662-665 ◽  
Author(s):  
J. Jeffrey Alexander ◽  
Seymour Glagov ◽  
Christopher K. Zarins
Keyword(s):  
Vertebral Artery ◽  
Surgical Therapy ◽  
Vertebral Artery Dissection ◽  
Artery Dissection ◽  
Aggressive Approach ◽  
Content Type ◽  
Satisfactory Recovery ◽  
Fine Print

✓ The case is presented of a 38-year-old woman who suffered multiple cerebellar infarctions as a result of emboli from a vertebral artery dissection. Surgical therapy led to a satisfactory recovery. This case emphasizes the importance of an aggressive approach to such lesions.

Endovascular treatment of vertebral artery dissections and pseudoaneurysms

1993 ◽  
Vol 79 (2) ◽  
pp. 183-191 ◽  
Author(s):  
Van V. Halbach ◽  
Randall T. Higashida ◽  
Christopher F. Dowd ◽  
Kenneth W. Fraser ◽  
Tony P. Smith ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Vertebral Artery Dissection ◽  
Transluminal Angioplasty ◽  
Artery Dissection ◽  
Parent Artery ◽  
Content Type ◽  
Balloon Test Occlusion ◽  
Endovascular Occlusion ◽  
Proximal Occlusion ◽  
Fine Print

✓ 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.

Rebleeding from vertebral artery dissection after proximal clipping

1992 ◽  
Vol 77 (3) ◽  
pp. 466-468 ◽  
Author(s):  
Chifumi Kitanaka ◽  
Tadashi Morimoto ◽  
Tomio Sasaki ◽  
Kintomo Takakura
Keyword(s):  
Surgical Technique ◽  
Vertebral Artery ◽  
Vertebral Artery Dissection ◽  
Artery Dissection ◽  
Content Type ◽  
Fine Print

✓ 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.

An experimental study of the acute stage of subarachnoid hemorrhage

1983 ◽  
Vol 59 (6) ◽  
pp. 917-924 ◽  
Author(s):  
Ken Kamiya ◽  
Hideyuki Kuyama ◽  
Lindsay Symon
Keyword(s):  
Blood Flow ◽  
Subarachnoid Hemorrhage ◽  
Acute Stage ◽  
Flow Measurements ◽  
Content Type ◽  
Baboon Model ◽  
Differential Increase ◽  
Blood Flow Measurements ◽  
Fine Print ◽  
Made In

✓ A baboon model of subarachnoid hemorrhage (SAH) has been developed to study the changes in cerebral blood flow (CBF), intracranial pressure (ICP), and cerebral edema associated with the acute stage of SAH. In this model, hemorrhage was caused by avulsion of the posterior communicating artery via a periorbital approach, with the orbit sealed and ICP restored to normal before SAH was produced. Local CBF was measured in six sites in the two hemispheres, and ICP monitored by an implanted extradural transducer. Following sacrifice of the animal, the effect of the induced SAH on ICP, CBF, autoregulation, and CO2 reactivity in the two hemispheres was assessed. Brain water measurements were also made in areas of gray and white matter corresponding to areas of blood flow measurements, and also in the deep nuclei. Two principal patterns of ICP change were found following SAH; one group of animals showed a return to baseline ICP quite quickly and the other maintained high ICP for over an hour. The CBF was reduced after SAH to nearly 20% of control values in all areas, and all areas showed impaired autoregulation. Variable changes in CO2 reactivity were evident, but on the side of the hemorrhage CO2 reactivity was predominantly reduced. Differential increase in pressure lasting for over 7 minutes was evident soon after SAH on the side of the ruptured vessel. There was a significant increase of water in all areas, and in cortex and deep nuclei as compared to control animals.

Lethal Vertebral Artery Dissection in Pregnancy: A Case Report and Review of the Literature

2006 ◽  
Vol 130 (4) ◽  
pp. 533-535 ◽  
Author(s):  
Madalina Tuluc ◽  
Daniel Brown ◽  
Bruce Goldman
Keyword(s):  
Case Report ◽  
Pregnant Woman ◽  
Subarachnoid Hemorrhage ◽  
Vertebral Artery ◽  
Fatal Outcome ◽  
Vertebral Artery Dissection ◽  
Rare Event ◽  
Artery Dissection ◽  
Review Of The Literature ◽  
In Pregnancy

Abstract Subarachnoid hemorrhage represents a rare event in pregnancy with a high mortality rate. We present the case of a 39-year-old pregnant woman who developed right vertebral artery dissection with subsequent massive subarachnoid hemorrhage with fatal outcome. The macroscopic and microscopic autopsy findings are described. A review of the literature with a discussion of the varied predisposing factors for vertebral artery dissection and subarachnoid hemorrhage and the rarity of these events in pregnancy is provided.

Cerebral circulation and metabolism in the acute stage of subarachnoid hemorrhage

2000 ◽  
Vol 93 (6) ◽  
pp. 1014-1018 ◽  
Author(s):  
Toshiaki Hayashi ◽  
Akifumi Suzuki ◽  
Jun Hatazawa ◽  
Iwao Kanno ◽  
Reizo Shirane ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Circulation ◽  
Cerebral Blood Volume ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Metabolism ◽  
Aneurysm Rupture ◽  
Acute Stage ◽  
Content Type ◽  
Positron Emission ◽  
Fine Print

Object. The mechanism of reduction of cerebral circulation and metabolism in patients in the acute stage of aneurysmal subarachnoid hemorrhage (SAH) has not yet been fully clarified. The goal of this study was to elucidate this mechanism further.Methods. The authors estimated cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), O2 extraction fraction (OEF), and cerebral blood volume (CBV) preoperatively in eight patients with aneurysmal SAH (one man and seven women, mean age 63.5 years) within 40 hours of onset by using positron emission tomography (PET). The patients' CBF, CMRO2, and CBF/CBV were significantly lower than those in normal control volunteers. However, OEF and CBV did not differ significantly from those in control volunteers. The significant decrease in CBF/CBV, which indicates reduced cerebral perfusion pressure, was believed to be caused by impaired cerebral circulation due to elevated intracranial pressure (ICP) after rupture of the aneurysm. In two of the eight patients, uncoupling between CBF and CMRO2 was shown, strongly suggesting the presence of cerebral ischemia.Conclusions. The initial reduction in CBF due to elevated ICP, followed by reduction in CMRO2 at the time of aneurysm rupture may play a role in the disturbance of CBF and cerebral metabolism in the acute stage of aneurysmal SAH.

Intracranial vertebral artery dissection resulting in fatal subarachnoid hemorrhage: clinical and histopathological investigations from a medicolegal perspective

2009 ◽  
Vol 110 (5) ◽  
pp. 948-954 ◽  
Author(s):  
Ayako Ro ◽  
Norimasa Kageyama ◽  
Nobuyuki Abe ◽  
Akihiro Takatsu ◽  
Tatsushige Fukunaga
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Vertebral Artery ◽  
Clinical Features ◽  
Cross Sections ◽  
Fatal Outcome ◽  
Vertebral Artery Dissection ◽  
Clinical History ◽  
Clinical Diagnostics ◽  
Artery Dissection ◽  
Prodromal Symptoms

Object Subarachnoid hemorrhage (SAH) due to a ruptured intracranial vertebral artery (VA) dissection sometimes results in a sudden fatal outcome. The authors analyzed the relationship between clinical features and histopathological characteristics among fatal cases to establish valuable information for clinical diagnostics and prophylaxis. Methods This study included 58 medicolegal autopsy cases of ruptured intracranial VA dissection among 553 fatal nontraumatic cases of SAH that occurred between January 2000 and December 2007. Their clinical features were obtained from autopsy records. Histopathological investigations were performed on cross-sections obtained from all 4-mm segments of whole bilateral intracranial VAs and prepared with H & E and elastica van Gieson staining. Results The autopsy cases included 47 males and 11 females, showing a marked predilection for males. The mean age was 46.8 ± 7.7 years, with 78% of the patients in their 40s or 50s. Hypertension was the most frequently encountered history; it was found in 36% of cases from clinical history and in 55% of cases based on autopsy findings. Prodromal symptoms related to intracranial VA dissections were detected in 43% of patients. Headache or neck pain lasting hours to weeks was a frequent complaint. Of patients with prodromal symptoms, 44% had consulted doctors; however, in none of these was SAH or intracranial VA dissection diagnosed at a preventable stage. Autopsy revealed fusiform aneurysms with medial dissecting hematomas. Apart from ruptured intracranial VA dissection, previous intracranial VA dissection was detected in 25 cases (43%); among them, 10 showed previous dissection of the bilateral intracranial VAs. The incidence of prodromal symptoms (60%) among the patients with previous intracranial VA dissection was significantly higher than that (30%) among cases without previous dissection (chi-square test; p = 0.023). Most previous intracranial VA dissections formed a single lumen resembling nonspecific atherosclerotic lesions, with the exception of 3 cases (12%) with a double lumen. Conclusions Intracranial VA dissection resulting in fatal SAH frequently affects middle-aged men with untreated hypertension. Related to the high frequency of prodromal symptoms, latent previous intracranial VA dissection was histopathologically detected. Furthermore, intracranial VA dissection tends to induce multiple lesions affecting both intracranial VAs recurrently. This suggests the importance of an awareness of sustained whole intracranial VA vulnerability for the prevention of recurrence. The incidence of prodromal symptoms was significantly higher among patients with previous intracranial VA dissections. Thus, earlier diagnosis of intracranial VA dissections at the unruptured stage is desirable for prophylaxis against fatal SAH.

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