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Query: UMLS:C0018681 (headache)
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Dissection of the extra- and ntracranial portions of vertebral arteries, as well as basilar artery and their branches are discussed based on the up-to-date literature. Formerly, arterial dissections were found exclusively at necropsy, yet they have currently arisen to the field of interest of not only neurologists but also radiologists, neurosurgeons, and vascular surgeons. Ischemic strokes frequently result from arterial dissection, in particular subintimal dissection (most often in the extracranial portion of vertebral artery), by formation of emboli or reduced perfusion. Conversely, subadventitial and transmedial dissections produce aneurysms (most often in the intracranial portion of vertebral arteries and basilar artery) which may result in subarachnoid or intracerebral hemorrhages. The other possible mechanism of focal lesions is the compression of adjacent structures by dissected artery, most frequently by dolichoectasia of basilar artery which originates from its multiple intramural lesions. The dissections may present with cranial nerve palsies, symptoms of ischemia of cervical spine, cerebellum, and cerebral trunk, as well as occipital lobe syndromes. Arterial dissection may occur in adolescents and young adults. The clinical symptom that should be stressed is headache which precedes the occurrence of stroke for several days. The right diagnosis gives a chance for proper treatment, including operative procedures, and improved prognosis.
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PMID:[Spontaneous dissection of carotid and vertebral arteries. II. Vertebral arteries and their branches]. 1046 36

We described a dissecting aneurysm of the vertebral artery (VA), which was associated with neurofibromatosis type 1 (NF1). A 41-year-old man was referred to our hospital because of abrupt, severe headache. A CT scan revealed diffuse subarachnoid hemorrhage (SAH) predominantly in the prepontine cistern. The angiograms showed a string sign in the left VA, just distal to the posterior inferior cerebellar artery (PICA). The vertebral dissection was considered responsible for SAH, and endovascular occlusion of the left VA was attempted. During the intervention, the patient complained of severe neck pain at the time of selective vertebral angiography, which revealed an arteriovenous fistula. The VA was occluded proximal to the PICA with GDC, which covered the fistula. Open surgery confirmed the two unruptured aneurysms. Intracranial dissection is rarely reported in association with NF1. However, ateriovenous fistula is not an uncommon combination with dissecting aneurysm and the extracranial segment of the VA is a characteristic target. Anatomical feasibility is conceivably the pathogenesis.
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PMID:[A case of neurofibromatosis type 1 associated with arteriovenous fistula caused by re-bleeding of a vertebral dissecting aneurysm]. 1053 82

A 37-year-old female with toxemia of pregnancy suffered sudden headache and loss of consciousness on the day following a cesarean delivery. Computed tomography revealed subarachnoid hemorrhage (SAH). Vertebral angiography revealed a fusiform dilatation near the origin of the right superior cerebellar artery (SCA) with distal luminal narrowing. She underwent surgery within 24 hours of the ictus. A SAH clot was carefully removed from the prepontine cistern, and subadventitial discoloration was seen in the wall of the right SCA just distal to the aneurysmal protuberance (rupture site). The dissecting aneurysm was treated with body clipping by directly clipping the rupture site and with additional wrapping of the proximal SCA, including the aneurysmal protuberance and discolored site. The postoperative clinical course was uneventful. Postoperative angiography revealed complete obliteration of the aneurysm and patency of the SCA. Therapeutic intervention should be considered for patients with ruptured dissecting aneurysm who present with recurrent SAH.
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PMID:Postpartum dissecting aneurysm of the superior cerebellar artery--case report. 1063 12

We present a surgical case of a dissecting aneurysm of the right middle cerebral artery associated with subarachnoid hemorrhage and intracranial hemorrhage. A 61-year-old woman with consciousness disturbance and left hemiplegia was referred to our hospital. She had suffered severe headache for a week. CT scan showed a subarachnoid hemorrhage in the right Sylvian fissure and intracranial hemorrhage in the right putamen. The right carotid angiogram revealed string sign in M1 portion and occlusion at M2 lower branch of the right middle cerebral artery. On the 12th day, we undertook surgery to confirm whether it was a dissecting aneurysm or not. In the operation, it was reddish in the M1 portion corresponding to the "string sign" and dark-purplish in the lower M2 portion corresponding to an "aneurysm-like lesion". To prevent bleeding, the arterial wall in the M1 portion was coated using muscle. Though the left hemiplegia was unchanged, the postoperative course was uneventful. The patient was transferred to another hospital and underwent rehabilitation. There has been no reccurrence during the four years since surgery. The middle cerebral artery dissecting aneurysm is extremely rare. We presented this case with review of the literature.
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PMID:[Dissecting aneurysm of the middle cerebral artery: case report]. 1064 95

We described a case of cerebellar hemorrhage after trapping of a vertebral artery dissecting aneurysm. A forty-eight-year-old man had suffered from severe headache, vomiting and disturbance of consciousness. He was transferred to our hospital in an ambulance. Emergency CT scan showed subarachnoid hemorrhage in the posterior fossa predominantly, intraventricular hemorrhage and hydrocephalus change. Chest X-ray showed radiological evidence of pulmonary edema. The initial blood-gas determinations demonstrated a marked reduction in PaO2 and increased PaCO2. Five days after admission, the patient's condition was improving. Cerebral angiography was performed using the Seldinger method. It revealed a right vertebral artery dissecting aneurysm just distal to the posterior inferior cerebellar artery. We performed an operation to trap the VA dissecting aneurysm. Blood pressure was well controlled under 140 mmHg during the operation and he recovered from anesthesia completely. On the day after the operation, suddenly the patient's consciousness began to deteriorate. Emergency CT scan was performed and it showed SAH, cerebellar hemorrhage and diffuse swelling of the cerebellum on the same side as the operation. We suspected rebleeding of the aneurysm due to a clip's having slipped. Reoperation was performed, but the clip was not displaced and there were no definite bleeding vessels on the operative field. Consequently only external decompression and resection of the right cerebellum were performed. We discuss pathogenesis of the occurrence of hemorrhage in this particular case after trapping. We also review the relevant literature.
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PMID:[Postoperative hemorrhage due to normal pressure hyperperfusion breakthrough after a trapping of VA-PICA dissecting aneurysm]. 1072 26

We present a case of a spontaneous dissecting aneurysm at the vertebrobasilar artery including the right PICA in a 44-year-old man, who suffered from headache, hiccup and ataxic gait. The arteriograms showed an irregular narrowing and dilatation in the right PICA and in the vertebrobasilar artery, and showed fusiform dilatations in the bilateral middle cerebral arteries. We observed intramural hematoma and true lumen at the right PICA dissecting aneurysm on T1-weighted images on magnetic resonance imaging (1.5T, MRI), and the intimal flap was enhanced on T1-weighted image after intravenous injection of Gd-DTPA. The shape of the intramural hematoma showed a unique "two dumplings on a skewer" appearance, and the intensity of its hematoma in the false lumen decreased in gradient from adventitia to intimal flap on T1-weighted image on MRI. The dissecting aneurysm of the PICA was occluded spontaneously 1 month later, and it caused cerebellar infarction. However, the patient has been left only with the symptom of slight trunkal ataxia. Various shapes of intramural hematomas on MRI have been reported by Kitanaka in association with intracranial vertebrobasilar dissections. We suggest that "two dumplings on a skewer" shape which corresponds to the flow void of the true lumen, accompanied by intramural hematoma and enhanced intimal flap, on contrast-enhanced T1-weighted image, should be regarded as a true "diagnostic sign" of a dissecting aneurysm.
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PMID:[Spontaneous occlusion of a dissecting aneurysm in the shape of "two dumplings on a skewer" at righ posterior inferior cerebellar artery (PICA): report of a case and neuroradiological findings]. 1087 15

We report a case of delayed subarachnoid hemorrhage (SAH) from a vertebrobasilar artery dissecting aneurysm (VBA-DA). The patient was a healthy 32-year-old woman with a sudden onset of severe occipitalgia. Next day, her headache improved gradually, and she consulted with our department. Although we initially suspected that she was suffering from SAH, neurological findings, CT, and cerebrospinal fluid examination did not reveal any abnormal conditions, including SAH. Therefore, she was treated conservatively with analgesics. Twelve days after the initial onset of the headache, she was admitted because of severe re-attack of headache, rt. hemiparesis with rt. oculomotor nerve palsy and loss of consciousness. CT revealed moderate SAH and cerebral angiograms showed VBA-DA. After the cerebral angiography, bleeding reoccurred two times and she lost her life. We present the case, review the literature and discuss the relationship between presenting symptom of headache and non-hemorrhagic VBA-DA. A few cases of non-hemorrhagic VBA-DA have been reported in the literature in which the only presenting symptom was headache, followed by delayed SAH from non-hemorrhagic dissecting aneurysm. Consequently, we concluded that her initial symptom of headache was due to dissection of vertebrobasilar artery, and that SAH was due to delayed hemorrhage of non-hemorrhagic VBA-DA. Even when neurological findings, CT and cerebrospinal fluid examination reveal no abnormalities in the early stage after the sudden onset of headache, especially in the occiptal or nuchal regions, non-hemorrhagic VBA-DA, which has a risk of fatal hemorrhage, cannot be ruled out with certainty. Therefore, MRI, MRA, three-dimensional CT, or cerebral angiography should be performed in such cases.
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PMID:[A case of delayed subrachnoid hemorrhage from vertebrobasilar artery dissecting aneurysm]. 1106 72

A 45-year-old male presented with spontaneous dissecting aneurysm in the anterior cerebral artery manifesting as headache persisting for several days and speech disturbance. Neurological and laboratory examinations showed no abnormalities. Magnetic resonance imaging revealed infarction in the right cingulate gyrus. Angiography revealed occlusion of the right A2. Repeat angiography 8 months later showed a saccular aneurysm had developed. The interhemispheric approach exposed the aneurysm at the junction between the right frontopolar artery and the pericallosal artery. The aneurysm was fusiform due to the right A2 dissection. The aneurysm was trapped and resected. One month after the operation, the patient was discharged without neurological deficits. Cases of dissecting aneurysms in the anterior cerebral artery with ischemic onset are usually treated conservatively. Cases requiring surgery include those due to trauma, growing aneurysms, giant aneurysms, and uncontrolled hypertension. Some dissecting aneurysms of the distal anterior cerebral artery require only resection without bypass surgery.
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PMID:Dissecting aneurysm of the anterior cerebral artery requiring surgical treatment--case report. 1115 92

We report a SAH case of a ruptured dissecting aneurysm of the middle cerebral artery following parietooccipital subcortical hemorrhage. A 68-year-old woman was admitted to our hospital, complaining of headache. On admission she was alert with left homonymous hemianopsia. A CT scan disclosed subcortical hemorrhage in the right parieto-occipital lobe. An angiogram revealed no abnormal vessels. Seven days after admission, she suddenly lapsed into unconsciousness with left hemiparesis. A CT scan demonstrated subarachnoid hemorrhage with a right sylvian hematoma. A second angiogram revealed fusiform dilatation of the M2 branches and aneurysmal dilatation at the M1-M2 bifurcation. Following conservative therapy, she died 21 days after admission. The relationship between subcortical hemorrhage and the subsequent subarachnoid hemorrhage was not certain. We discuss and review the treatment of a dissecting aneurysm of the middle cerebral artery.
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PMID:[Dissecting aneurysm of the middle cerebral artery (M1-2 portion) with subarachnoid hemorrhage: a case report]. 1134 15

Two rare cases of dissections which involve the anterior cerebral artery (ACA) are reported. A 58-year-old woman presented with a ruptured dissecting aneurysm manifesting as sudden onset of severe headache and consciousness disturbance followed by aphasia, right hemiparesis, paresis of the left lower extremity, and choreoathetotic movements of the upper arms and face. Computed tomography and angiography revealed subarachnoid hemorrhage due to a dissecting aneurysm at the left A1 segment. The dissecting aneurysm was trapped surgically on the day of onset. Her neurological deficits disappeared within a month. A 39-year-old woman experienced continuous dull headache from the day before onset, and then suffered right hemiparesis. Magnetic resonance (MR) imaging revealed cerebral infarction at the left globus pallidus. Angiography and MR imaging revealed a dissecting aneurysm at the left A1 segment and occlusion of the left Heubner's artery. She received conservative treatment and her neurological findings were improved. Dissections or dissecting aneurysms involving the ACA can be classified into three types: Extension of a dissection to the ACA from the internal carotid artery, dissection at the A1 segment, and dissection at the A2-A4 segments. These types of dissection have distinct uniform clinical features.
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PMID:Dissecting aneurysms at the A1 segment of the anterior cerebral artery--two case reports. 1139 8


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