A Study on the Clinical and Angiographic Spectrum of Spontaneous Extracranial Dissections in the Cerebral Vasculature

Abstract

Aim: To prospectively study the clinical profile, angiographic features, and functional outcomes, in consecutive cases of extracranial dissection seen at two tertiary stroke care centers in South India.

Materials and methods: In this observational study, spanning 4 years (December 12-December 16), a total of 442 patients presented with an acute ischemic stroke/transient ischemic attack (TIA) at our study centers. 14/546 (3.2%) of these patients had magnetic resonance angiography (MRA)/computed tomography angiography (CTA) evidence of extracranial dissections. All cases underwent detailed clinical evaluation on arrival, and data were recorded on a predesigned stroke pro forma. Contrast MRA was done on arrival in all cases as part of a standard stroke protocol, and CTA was done only if MRA was inconclusive. The pattern of the vessel involved and morphology of vessel dissection was analyzed as per a standard radiology protocol. All the cases were managed with short-term anticoagulation using low-molecular-weight heparin followed by oral anticoagulants for 3-6 months. All cases were followed up for 1-2 years and the functional outcomes were recorded using the modified Rankin Scale (mRS).

Results: There were 11 males and 3 females in the study, and the mean age was 45.1 years (range = 27-65 years). Focal neurological symptoms occurred in all these patients (10 patients had a stroke, and 4 had TIA). Nearly 64.2% of these (9/14) were stroke in young (age <45 years). The internal carotid artery was the most common vessel involved in 85.7% (12/14) cases. Of the ten patients with completed stroke, a good functional outcome (mRS 1-2) was seen in 8/10 (80%). Digital subtraction angiography and revascularization procedures were needed only in a minority of cases 3/14 (21%).\.

Conclusion: This hospital-based study highlights the importance of suspecting arterial dissections in young strokes of unexplained etiology, and offering optimum anticoagulant therapy in the acute phase, to achieve good long-term outcomes.

Keywords: Angiography; cerebral dissections; heparin.

Figure 1

Digital subtraction angiography left common carotid artery injection: Spontaneous dissection of Left carotid bulb with a filling defect and double lumen sign

Figure 2

Computed tomography angiogram maximum intensity projection (a) and volume rendering (b) showing flame shaped tapering of the right internal carotid artery distal to the carotid bulb with distal embolic infarcts (c) in right middle cerebral artery territory on diffusion magnetic resonance imaging

Figure 3

Digital subtraction angiography left common carotid artery injection: (a). Left internal carotid artery origin dissection with diffuse stenosis of internal carotid artery and complete external carotid artery cut off on the same side (b). Distal embolism to left middle cerebral artery with complete M1 cut off in the intra-cranial view (c). Re-canalization of left middle cerebral artery after thrombectomy with solitaire stentriever

Figure 4

Contrast enhanced-magnetic resonance angiography coronal images show right vertebral artery dissection (single arrow) near origin with diffuse narrowing and cut off in V2 segment (double arrow). Normal left vertebral artery (red arrow) is clearly seen. Axial T2 weighted image showing acute right posterior inferior cerebellar artery territory infarcts due to distal extension of dissection to involve the posterior inferior cerebellar artery branch from V4 segment of right vertebral artery