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Progression of Vertebral Artery Dissection: Vessel Wall Enhancement and Aneurysm Dilation

Published online by Cambridge University Press:  18 July 2016

Song Lee Open the ORCID record for Song Lee [Opens in a new window] ,
Hyun Seok Choi ,
Jinhee Jang ,
So Lyung Jung ,
Kook-Jin Ahn ,
Bum-soo Kim ,
Jaseong Koo  and
Yong Sam Shin
Song Lee
Affiliation:
Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Hyun Seok Choi*
Affiliation:
Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Jinhee Jang
Affiliation:
Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
So Lyung Jung
Affiliation:
Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Kook-Jin Ahn
Affiliation:
Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Bum-soo Kim
Affiliation:
Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Jaseong Koo
Affiliation:
Department of Neurology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Yong Sam Shin
Affiliation:
Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
*
Correspondence to: Hyun Seok Choi, Department of Radiology, College of Medicine, The Catholic University of Korea, 11 Jalan Tan Tock, Seoul 137-701, Republic of Korea. Email: hschoi@catholic.ac.kr
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Abstract

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Keywords

DissectionNeuroimagingVascularMagnetic resonance imaging
Type
Neuroimaging Highlights
Information
Canadian Journal of Neurological Sciences , Volume 43 , Issue 5 , September 2016 , pp. 715 - 716
Copyright
Copyright © The Canadian Journal of Neurological Sciences Inc. 2016 

A 35-year-old female with right ptosis and right facial and left limb paraesthesia visited our emergency room. Initial diffusion-weighted MRI revealed right lateral medullary infarct. Digital subtraction angiography (DSA) demonstrated dissection of pearl-and-string type involving a segment including a posterior inferior cerebellar artery (PICA) origin of the right distal vertebral artery. The natural course of unruptured intracranial vertebral artery dissection had been reported to be benign, with a high chance of spontaneous healing.Reference Mokri, Houser, Sandok and Piepgras 1 , Reference Arnold, Bousser, Fahrni, Fischer, Georgiadis, Gandjour and Benninger 2 However, in this patient the dissection changed to saccular aneurysm type on follow-up contrast-enhanced MRI and DSA after nine months. The diameter of the dilated segment was also increased from 4 to 8 mm. Furthermore, wall enhancement was noted in the dissected arterial wall. The wall enhancement in the cervical artery dissection has been reported to be suggestive of inflammation and mostly resolve within six months.Reference Pfefferkorn, Saam, Rominger, Habs, Gerdes and Schmidt 3 Vessel wall enhancement can also be seen in such other arterial diseases as atherosclerosis, moyamoya disease and vasculitis.Reference Choi, Jung and Lee 4 Nevertheless, taking account of the change in geometry and the persistent vessel wall enhancement together, we concluded that the dissection had progressed despite conservative treatment. Thus, stent-assisted coil embolization was performed in the patient without complication.

Disclosures

SL, HSC, JJ, SLJ, KJA, BK, JK, and YSS hereby declare that they have no conflicts of interest to disclose.

Fig. 1 Initial MRI and DSA. Diffusion-weighted image (A) shows hyperintensity in right lateral medulla, suggestive of acute infarction. Magnetic resonance angiography (MRA) source image (B) and three-dimension (3D) rotational reconstructed image of DSA (C) show focal stenosis and fusiform dilatation (arrow) at distal vertebral artery, proximally to origin of PICA (arrowhead).

Fig. 2 Six-month follow-up MRI and DSA of the same patient. 3D-SPACE (A) shows wall enhancement (arrow) of dissecting aneurysm. MRA source image (B) and 3D-rotational reconstructed image of DSA (C) show interval change of saccular aneurysm formation at distal vertebral artery (arrow), proximally to PICA origin (arrowhead).

References

1. Mokri, B, Houser, OW, Sandok, BA, Piepgras, DG. Spontaneous dissections of the vertebral arteries. Neurology. 1988;38:880-885.CrossRefGoogle ScholarPubMed
2. Arnold, M, Bousser, MG, Fahrni, G, Fischer, U, Georgiadis, D, Gandjour, J, Benninger, D, et al. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke. 2006;37:2499-2503. Epub ahead of print Sep 7.CrossRefGoogle ScholarPubMed
3. Pfefferkorn, T, Saam, T, Rominger, A, Habs, M, Gerdes, LA, Schmidt, C, et al. Vessel wall inflammation in spontaneous cervical artery dissection: a prospective, observational positron emission tomography, computed tomography, and magnetic resonance imaging study. Stroke. 2011;42:1563-1568. Epub ahead of print Apr 21.CrossRefGoogle ScholarPubMed
4. Choi, YJ, Jung, SC, Lee, DH. Vessel wall imaging of the intracranial and cervical carotid arteries. J Stroke. 2015;17:238. Epub ahead of print Sep 30.Google Scholar
Figure 0

Fig. 1 Initial MRI and DSA. Diffusion-weighted image (A) shows hyperintensity in right lateral medulla, suggestive of acute infarction. Magnetic resonance angiography (MRA) source image (B) and three-dimension (3D) rotational reconstructed image of DSA (C) show focal stenosis and fusiform dilatation (arrow) at distal vertebral artery, proximally to origin of PICA (arrowhead).

Figure 1

Fig. 2 Six-month follow-up MRI and DSA of the same patient. 3D-SPACE (A) shows wall enhancement (arrow) of dissecting aneurysm. MRA source image (B) and 3D-rotational reconstructed image of DSA (C) show interval change of saccular aneurysm formation at distal vertebral artery (arrow), proximally to PICA origin (arrowhead).