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Query: UMLS:C0018681 (headache)
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A spontaneous dissecting aneurysm of the intracranial portion of the dominant right vertebral artery presented as massive subarachnoid hemorrhage, excruciating headache, and respiratory arrest in a 57-year-old white man with a history of systemic hypertension. He died on the 3rd day. Postmortem examination revealed a dissecting hemorrhage extending for 2.1 cm along the artery; rupture of the intima, media, and adventitia could be demonstrated. The intramural accumulation of blood in the proximal segments appeared to be related to retrograde dissection within a media weakened by cystic degeneration. Accumulation of pools of mucoid ground substance was also demonstrated in other intracranial and extracranial arteries. Hemodynamic stresses due to arterial hypertension and physical exertion may have played a contributory role in the etiopathogenesis of this uncommon form of cerebrovascular accident. A comprehensive literature review permits a comparison of supratentorial and infratentorial dissecting aneurysms; vertebral and basilar artery dissections are presented in tabular form.
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PMID:Dissecting aneurysm of intracranial vertebral artery: case report and review of literature. 619 70

Fourteen patients with a spontaneous dissecting aneurysm of an internal carotid artery (ICA) have been admitted in our service since 1979 (incidence of 0,5 per 100,000 inhabitants per year). All these patients have been prospectively followed in order to determine their functional prognosis and a possible recanalization of the ICA. Three patients quickly died from an extensive middle cerebral artery infarct with brainstem compression. Among the 11 survivors, 7 completely recovered their functional ability or were left with very minor sequelae, and could go back to work. The 4 other patients remained with severe sequelae and could not work anymore. In the latter patients Doppler ultrasonographic study showed a persisting occlusion of the ICA, whereas a complete recanalization occurred in the former 7, usually as soon as the first month, on anticoagulant treatment. The presence on admission of a minor or moderate neurological deficit, a normal state of consciousness, an age above 45 years, and a patent collateral circulation allows to predict a favorable evolution (p less than 0.05). The same is true for the development of a partial or complete recanalization of the ICA on Doppler ultrasonography performed 2 to 4 weeks after admission. Sex, angiographic aspects of the dissection, and occurrence of headache or warning transient ischemic attacks had no prognostic significance in our study. Spontaneous dissecting aneurysms of the ICA can be a very serious disease, though nearly 50 p. 100 of the patients completely recover during the first months. Immediate anticoagulant therapy is still the treatment of choice and surgery is indicated only in those patients with recurrent episodes or a progressing stroke despite adequate anticoagulation.
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PMID:[Spontaneous dissecting aneurysms of the internal carotid artery. Prospective evaluation of the prognosis and arterial repermeation in 14 cases]. 639 Jun 25

Cervical cephalic dissections are uncommon acute disruptions of the arterial wall occurring predominantly in middle-aged women. Clinically, most patients present with unilateral headache, oculosympathetic palsy, or ischemic neurologic symptoms. Usually, a single internal carotid artery, predominantly the right, is affected, but simultaneous multivessel dissections are evident in about one-third of patients. Angiographically, the appearance of the dissection varies, depending on its severity, extent, and the interval between onset and angiography. In the patients reported, the disruption was manifested initially by eccentric tapered stenosis in 47%, tapered stenosis and a dissecting aneurysm in 28%, occlusion in 18%, or a dissecting aneurysm alone in 7%. Subsequently, stenotic dissections resolved in 60%, improved in 20%, and progressed in 15%, while dissecting aneurysms diminished in half and resolved in one-fourth of patients. An angiographic residuum, temporally remote to its onset, was evident in 25% of dissections. Hence, carotid arterial dissections tend to resolve, sometimes progress, but seldom recur.
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PMID:Spontaneous cervical cephalic arterial dissection and its residuum: angiographic spectrum. 642 Nov 22

A 43-year-old man suddenly experienced severe headaches and involuntary flexion-extension movements of four limbs, which were followed by hypertonic extension of the limbs lasting for a few hours. Two days later, he experienced generalized tonic seizure without loss of consciousness. After the seizures, he remained hemiparetic on the right side. His past medical history was non-remarkable, and the histories of hypertension, diabetes mellitus, head trauma and significant infectious diseases were all denied. Cerebral angiography performed 22 days after the onset showed a segmental, irregular narrowing of the left A2 segment and an aneurysmal outpouching immediately proximal to the stenosis. CT scan revealed a low density area in the left frontal lobe, corresponding to the territory of the involved left anterior cerebral artery. Cerebral angiography was repeated twice in the succeeding 6 months. Each time, the involved A2 segment showed persistence of narrowing, but its shape showed definite changes with the passage of time. A diagnosis of dissecting aneurysm of the anterior cerebral artery was reached by the characteristic angiographic features, and the patient was treated conservatively. Dissecting aneurysm of the cerebral arteries have been reported much less frequently than those of the aorta or other extracranial arteries. Recently, however, such reports are increasing in number, seemingly due to enhancement of knowledge of typical angiographic features, such as string sign, rosette sign, pearl reaction, double lumen and several others. Most of intracranial dissecting aneurysms involve the middle cerebral artery or vertebral-basilar artery, and the ones involving solely the anterior cerebral artery as in this present case are very rare.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Dissecting aneurysm of the anterior cerebral artery: report of a case]. 650 59

Two cases of the spontaneous dissecting aneurysm (SDA) of the cervical carotid artery (ICA) were reported. Case 1: A 36 years old man was admitted with a sudden onset of right hemiparesis, aphasia and a one-week history of headache and neck pain. Serological examinations were normal. Angiography showed a severe stenosis with two intimal flaps of the left cervical ICA. Four weeks later, left STA-MCA anastomosis was performed. After six weeks from the onset, re-angiography showed the resolution of the left cervical ICA stenosis. Case 2: A 26 years old man experienced the transient monoocular blindness a week before admission. He was admitted with a sudden onset of right hemiparesis and aphasia. Serological examinations were normal. Angiography showed a postsinus tapering occlusion of the left cervical ICA. Four weeks later, left STA-MCA anastmosis was performed. After the operation, left hemiparesis improved remarkably. After two weeks from the operation, re-angiography showed the complete resolution of the left cervical ICA stenosis. As the differential diagnoses, spasm, arteritis, embolism and thrombosis with atherosclerosis were listed. But from the reason reported, we diagnosed the two cases as the resolution of the SDA of the ICA. From the previous literature, 129 cases of SDA of the ICA were reviewed and discussed about the symptom, angiographic findings and treatment. Some specific findings (high frequency of resolution, 87%, etc.) were found. SDA of the ICA occurs in the non-atherosclerotic age and causes the ischemic brain damage. SDA of the ICA should be paid more attention and will probably be identified more frequently.
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PMID:[Spontaneous dissecting aneurysm of the cervical internal carotid artery. Report of 2 cases and review of literature]. 652 29

A 53-year-old, non-hypertensive farmer, who had sudden attack of severe headache, was transferred to our clinic. He presented comatous state and tetraparesis without extraocular movements nor reactive pupils to light. CT scan, 7 hours after the ictus showed intracerebral hematoma in the right temporo-parietal region with ventricular extension. The following bilateral carotid angiograms established the diagnosis of the intracerebral hemorrhage due to cerebrovascular moyamoya disease. In angiograms of the affected side, irregular spotty stains spread from the periphei of the right posterior choroidal artery was delineated. The repeated CT scan after that indicated increment of hematoma. Fifty-three hours from the ictus, the patient died and an autopsy study was performed. After the fixation, the coronal brain section was made, and the careful observation of them elucidated the formation of an organized dissecting aneurysm in the angiographically extravasated vessel. About seven hundreds of serial specimen, 4 micron in thickness, was then investigated adjacent to the aneurysm. The organized dissecting aneurysm seemed to initiate from the branch of it, where marked fraying and undulation of the fibroelastic intima and internal elastic laminae were observed. The concavity toward the true lumen was completely disrupted and communicated to the extravascular space. As a result, the continuous part of it obstructed the lumen of the branch. These findings suggested the newly-developed dissection and it seemed to correspond to the angiographical extravasated points.
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PMID:[Angiographical extravasation in the intracranial hemorrhage due to cerebrovascular moyamoya disease--autopsy study]. 674 3

Occlusion of the basilar artery is mainly of atherosclerotic origin; embolic occlusion, dissecting aneurysm, trauma and arteritis are less frequent. Pathologic and angiographic findings allow to classify basilar artery occlusions in three types: segmental (superior, medial or inferior), plurisegmental and extensive. The infarcted areas involve brain stem, especially pons and cerebellum, also diencephalon and cerebral hemispheres, in various combinations. Clinically, there is typically a prodromic stage, with transient ischemic attacks (vertigo, headaches, visual disturbances, motor deficit). Few weeks later, a decreased level of consciousness and motor anomalies are the most important signs. A fatal outcome is noted in 85,98 p. 100. Among laboratory examinations, only angiography proves the occlusion: it also shows the arterial supply (carotido-basilar reflux; inter-cerebellar anastomosis). Computed tomography usually eliminates an expanding mass of the posterior fossa. Management is only of general type. Surgical management of carotid arteries stenosis may ameliorate the anastomotic flow.
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PMID:[Occlusion of the basilar artery. A review with 17 personal cases (author's transl)]. 703 22

Children presenting after trauma with headache, seizures, hemiplegia and coma may have an intracranial dissecting aneurysm. Specific angiographic findings provide confirmation of this diagnosis. The dissection occurs subintimally and differs clinically and pathologically from dissecting aneurysms of extracranial arteries. The course in children beyond infancy is catastrophic, justifying consideration of potentially life saving surgical intervention.
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PMID:Intracranial dissecting aneurysms in childhood. 706 92

A 54 year old man without pathologic past history but mild hypertension, obesity and gastric ulcer, presented with a syndrome of Wallenberg. He had complained for five days of progressive and diffuse headache. The neurological condition improved initially, but the patient died suddenly two weeks later. Pathological examination showed no significant alteration except for left ventricular enlargement and mild arteriosclerosis. There was a hemodissection (dissecting aneurysm) of the left vertebral artery next to the inferior oliva. It induced a lateral infarct and a limited dorsal infarct at the middle third level of medulla oblongata. Although the location of the arterial changes is usual, their nature is exceptional. The cause of the arterial hemodissection could not be ascertained: fibrous arterial dysplasia, atherosclerosis or congenital abnormalities of internal elastic layer may be discussed. But no definite conclusion can be reached.
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PMID:[Wallenberg's syndrome due to a dissecting aneurysm of the vertebral artery]. 713 26

Inflammation of the upper respiratory tract if frequently contiguous with the ICA and the HN in the neck. If severe, the inflammation of itself may occlude or directly extent into the ICA wall. The resulting scar produces a fixed relationship between artery and nerve that is vulnerable to lymph node enlargement, by head position, or blood pressure elevation. Trauma in the absence of scar may result in intimal injury of the ICA. Hypoglossal carotid entrapment may give rise to arterial stricture or diaphragm formation, microembolism, dissecting aneurysm, and arterial occlusion. Hypoglossal palsy with hemiatrophy of the tongue, unilateral headache, facial pain, or sympathetic disturbance of the upper face are less common than carotid or vertebral basilar symptoms. The diagnosis of HCE depends on understanding the pathological anatomy, hemodynamics, and mechanics of its production and aggravation. Patient history is important and close attention should be given to a history of tonsillitis, abscesses of the neck, unilateral headache, facial or orbital pain, and symptoms related to activity or elevation of blood pressure. The judicious use of noninvasive hemodynamic evaluation, EEG, neurotologic studies, CT scan, and CT dynamic scanning has been of value in diagnosis before surgery and in the documentation of hemodynamic benefit after surgery. Surgical reconstruction has been successful in the relief of ICA obstruction due to HCE and of associated symptoms and disability.
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PMID:Hypoglossal carotid entrapment syndrome. 730 1


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