Innovative use of a stent retriever for temporary revascularization in acute internal carotid artery dissection.

Internal carotid artery dissection is rare but can be a cause of stroke in young people. In a case of revascularization for stroke associated with internal carotid artery dissection, we initially used a stent retriever for thrombectomy. Since an appropriately-sized stent for permanent treatment was not available, we innovatively maintained temporary revascularization with the stent retriever for 90 minutes. Here we demonstrate the adaptability of the stent retriever for emergency care. A 49-year-old man suddenly developed severe right hemiplegia and aphasia. Magnetic resonance imaging showed occlusion of a left internal carotid artery with moderate ischemic changes in the left hemisphere cortex. Angiography showed dissection of the left internal carotid artery at the cervical level and secondary thrombus formation extending into the left middle cerebral artery. We initially attempted thrombectomy with a stent retriever and achieved successful reperfusion in the middle cerebral artery. An appropriately-sized stent was not available in the hospital at that time. During the 90-minute wait, the stent retriever was kept in place and temporary angioplasty was performed in the internal carotid artery dissection to maintain blood flow. Eventually, the stent was delivered and permanent revascularization was achieved. While there is no standard treatment for arterial dissection, endovascular strategies like stenting have been demonstrated to be beneficial. The innovative use of stent retrievers for temporary angioplasty of dissected lesions underscores their efficacy in swift deployment and maintenance of uninterrupted blood flow, particularly during emergency thrombectomy.

Iatrogenic Aorto-Coronary Dissection: A Rare Complication With Fatal Prognosis.

Iatrogenic aorto-coronary dissection (IACD) is a rare complication of interventional and surgical cardiac procedures, with a very high mortality burden. Here, we report the case of a 71-year-old female with a past medical history of paroxysmal atrial fibrillation, mild to moderate aortic insufficiency, hypertension, and hyperlipidemia, who presented with classic anginal symptoms and underwent a cardiac catheterization, during which she suffered Iatrogenic right coronary artery (RCA) dissection and ascending aortic dissection resulting in sudden death. IACD is a rare complication, with a fatal prognosis. Coronary angiography and percutaneous coronary intervention (PCI) are considered safe, with a low risk of major complications including coronary perforations, and a very low risk of Iatrogenic aortic dissection (IAD). The coronary injury occurs more commonly during PCI of chronic total occlusion (CTO) or RCA interventions and can extend to the aortic root. IAD is often fatal and has worse outcomes than spontaneous dissection.

A Sudden Unilateral Visual Field Loss in a Recreational Tennis Player: Cervical Internal Carotid Artery Dissection Associated With Low-Impact Sports.

Traumatic cervical internal carotid artery dissection (CICAD) is a rare condition caused by blunt trauma to the neck, often through automobile- or sports-related collisions, assaults, or falls. Herein, we report an unusual case in which engaging in a low-impact sport (tennis) caused CICAD, without a direct injury. A 56-year-old man with hypertension suddenly experienced a visual field loss in his right eye while playing tennis. Carotid echocardiography revealed severe stenosis of the right internal carotid artery (ICA). Angiography revealed severe and irregular stenosis of the right ICA from the bifurcation to the petrous portion, suggesting CICAD. Upon admission, the patient had left upper visual field defects in his right eye and neck pain. Antiplatelet therapy was initiated with prasugrel (3.75 mg/day), with the intent to treat surgically if the stenosis or symptoms progressed. Follow-up angiography and magnetic resonance imaging showed gradual resolution of the stenosis, and the patient was discharged on day 28 with a modified Rankin Scale score of 1. The CICAD should be considered as a diagnosis for neurological symptoms, even in the context of low-impact sports such as tennis. Antithrombotic therapy is a reasonable first-line treatment for stable CICAD.

The Association between PDE5 Inhibitors and Aneurysm/Arterial Dissection:A Pharmacovigilance Study Using WHO Safety Database.

Aneurysm and arterial dissection have been reported as adverse drug events, associated with angiogenesis inhibitors and fluoroquinolones. Specifically, several cases of severe arterial disease following cGMP-specific phosphodiesterase type 5 (PDE5) inhibitors usage have recently been reported. It is necessary to ascertain the risks of serious adverse events caused by PDE5 inhibitors. We aimed to evaluate the association of aneurysm and artery dissection with PDE5 inhibitors using VigiBase, which is a World Health Organization database of spontaneously reported adverse events, for explorative hypothesis-generating analysis. We performed disproportionality analysis using a dataset from inception in 1967 to December 2022 and calculated reporting odds ratios (ROR) between PDE5 inhibitors and arterial diseases. We extracted 195,839 reports on PDE5 inhibitors with 254 reports of arterial disease as adverse events from VigiBase. Disproportionality analysis showed disproportional signals for PDE5 inhibitors (ROR, 2.30;95% confidence intervals, 2.04-2.61);disproportional signals were detected in analyses restricting the lesion site to the aorta or cerebral arteries. From stratified analysis, disproportional signals were noted in females, as well as males, generally recognized as a risk factor for artery diseases. This real-world data analysis suggests that PDE5 inhibitors may play a role in the development of lethal arterial disease. J. Med. Invest. 71 : 134-140, February, 2024.

Extensive Type A Aortic Arterial Dissection Presenting With Stroke Symptoms: A Case Report.

Aortic dissection (AD) is a rare but often lethal condition if not properly and urgently treated. Most often, patients arrive with acute hemodynamic instability and ripping chest agony. The patient's life depends critically on a correct diagnosis made as soon as possible. We describe a 60-year-old man who arrived at the emergency room with symptoms of a brain stroke, including poor consciousness, left-sided weakness, and speech disturbance associated with hemodynamic instability, and chest pain. Thoracic aortic arch dissection was observed on CT angiography (CTA). In addition, CTA revealed that the dissection extends proximally into the left common carotid artery, left subclavian artery, brachiocephalic trunk, and right common carotid artery and distally to the left common iliac artery, coupled with significant stenosis of the left common iliac artery. Proper management of blood pressure (BP) parameters is life-saving for the patient. Since our hospital did not offer cardiothoracic surgery services, the patient was transferred to a different institution, where he received medical care immediately from an expert team and had surgery.

When the Tree Branch Affects the Fruits: A Case of Celiac Artery Dissection.

Arterial dissection is a laceration of an artery or arterial bed, that can extend to contiguous arteries and lead to accumulation of blood providing a great risk for thrombi formation, and possible ischemic events. Celiac artery dissection is a very rare pathology, with an unknown prevalence and a pathophysiology that still needs to be elucidated. Diagnosis has increased in the last decade due to higher imaging modalities and accessibility of such that provide simpler identification, as well as which treatment should be applied to a particular patient. In this case report, we present a 44-year-old male with abdominal pain, found to have on computed tomography angiography (CTA) a dissection of the celiac artery with extension to the splenic artery, causing multiple splenic infarcts, demonstrating that such lesions can be the cause of unexplained thrombosis in a certain patient population. Due to its complex presentation, management can differ based on the characteristics of the dissection as well as organ involvement, these modalities range from anticoagulation to surgical or endoscopic intervention. This case highlights the rare occurrence of an isolated dissection at a visceral artery causing thrombosis in a relatively healthy patient.

A Case of Isolated Superior Mesenteric Artery Dissection Resulting in Recurrent Necrosis of the Small Intestine.

Isolated superior mesenteric artery dissection (ISMAD) is a rare cause of acute abdominal conditions. Most cases of ISMAD have a favorable prognosis, and only a few cases of ISMAD-associated intestinal necrosis have been reported. A 75-year-old male was referred to our department because of abdominal pain and portal venous gas detected on imaging. Computed tomography suggested ileal necrosis, necessitating emergency surgery. Indocyanine green was used for blood flow assessment; however, no fluorescence was observed in the ileum proximal to the Bauhin valve, leading to the decision for ileocecal resection. On postoperative day 6, abdominal pain recurred when meals were resumed. As a surgical intervention for ISMAD, a bypass was created using the left great saphenous vein as a graft between the superior mesenteric artery and the right external iliac artery. This case highlights a rare occurrence where intestinal necrosis recurred due to ISMAD. We propose that in cases of ISMAD with concomitant intestinal necrosis, a more aggressive revascularization strategy for the dissected segment of the superior mesenteric artery may be required.

Factors associated with false lumen changes in patients with superior mesenteric artery dissection.

BACKGROUND: False lumen changes (FLCs) are the main reference for the prognosis judgment and treatment plan selection for type IIa superior mesenteric artery dissection (SMAD). METHODS: For this retrospective study, 55 patients with symptomatic type IIa SMAD were included. Computational fluid dynamics (CFD) analysis was used to explore the hemodynamic basis of FLCs. Correlation and multiple linear regression analyses were performed to identify clinical, morphological and hemodynamic factors associated with FLCs. RESULTS: The FLCs of patients with successful conservative treatment (n = 29) are significantly higher than those with failed conservative treatment (n = 26) (58.5 ± 21.1% vs 10.9 ± 17.4%, p < 0.0001). Positive correlations were seen between FLCs and the morphological parameters false lumen length (FLL)/dissection entrance length (DEL) and FLL. In terms of hemodynamic parameters, negative correlations were seen between FLCs and time-averaged wall shear stress (TAWSS), vorticity, and high areas of TAWSS and vorticity, whereas positive correlations were seen between FLCs and oscillatory shear index (OSI), relative residence time (RRT), and high areas of OSI and RRT. Multiple linear regression analysis identified symptom duration (odds ratio [OR], 0.93; 95% CI, 0.91-0.96; p < 0.0001), FLL/DEL (OR, 1.30; 95% CI, 1.01-1.67; p = 0.044), and high RRT area (OR, 2.03; 95% CI, 1.48-2.78; p < 0.0001) as predictors of FLCs. CONCLUSION: The clinical predictor symptom duration, morphological factor FLL/DEL, and the hemodynamic factor high RRT area can serve as predictors of FLCs in patients with symptomatic type IIa SMAD.

Emerging Concept of Intracranial Arterial Diseases: The Role of High Resolution Vessel Wall MRI.

Intracranial arterial disease (ICAD) is a heterogeneous condition characterized by distinct pathologies, including atherosclerosis. Advances in magnetic resonance technology have enabled the visualization of intracranial arteries using high-resolution vessel wall imaging (HR-VWI). This review summarizes the anatomical, embryological, and histological differences between the intracranial and extracranial arteries. Next, we review the heterogeneous pathophysiology of ICAD, including atherosclerosis, moyamoya or RNF213 spectrum disease, intracranial dissection, and vasculitis. We also discuss how advances in HR-VWI can be used to differentiate ICAD etiologies. We emphasize that one should consider clinical presentation and timing of imaging in the absence of pathology-radiology correlation data. Future research should focus on understanding the temporal profile of HR-VWI findings and developing quantitative interpretative approaches to improve the decision-making and management of ICAD.

Vascular Ehlers-Danlos syndrome: A null COL3A1 variant found in a patient with loin pain without marked cutaneous features (case report).

Patients with null variants may have milder vascular Ehlers-Danlos syndrome, presenting with seemingly non-specific complaints and subtle cutaneous features that may be missed. A high index of suspicion and early genetic testing (aided by next-generation sequencing) were crucial for prevention of life-threatening complications in the patient and family members.

Spontaneous intracranial vertebral artery dissections presenting with subarachnoid hemorrhage.

BACKGROUND: Vertebral artery dissection (VAD) is an infrequent source of subarachnoid hemorrhage (SAH), with a high mortality rate, primarily due to the risk of rebleeding both before and after medical intervention. This paper provides a comprehensive analysis of the anatomy, pathophysiology, clinical presentation, treatment strategies, and outcomes of intracranial vertebral artery dissections that result in subarachnoid hemorrhage. METHODS: Comprehensive five-year literature review (2018-2022) and a retrospective analysis of patient records from our institution between 2016 and 2022. We included studies with a minimum of 5 patients. RESULTS: The study incorporated ten series from the literature and 22 cases from CHUM. Key anatomical factors increasing the risk of VAD include the vertebral artery's origin from the aortic arch, asymmetry of the vertebral artery, and its tortuosity. Patients may display specific collagen and genetic abnormalities. The occurrence of VAD appears to be more prevalent in men. Those with a ruptured intracranial VAD typically show prodromal symptoms and present with severe SAH. Rebleeding within the first 24 h is frequent. While standard imaging methods are usually adequate for VAD diagnosis, they may not provide detailed information about the perforator anatomy. Treatment approaches include both deconstructive and reconstructive methods. CONCLUSION: Ruptured VAD is a critical, life-threatening condition. Many patients have a poor neurological status at presentation, and rebleeding prior to treatment is a significant concern. Deconstructive techniques are most effective in preventing rebleeding, whereas the efficacy of reconstructive techniques needs more investigation.

Thrombophilia Testing in Stroke: A Case Report and Review of Evidence.

Thrombophilia is commonly associated with venous thromboembolism, but its relationship with arterial thrombosis, specifically stroke, is not as clearly established. Several large studies have failed to establish a significant connection between inherited thrombophilia and stroke. While tests for Factor V Leiden mutation, prothrombin mutation, protein C deficiency, protein S deficiency, antithrombin deficiency, and antiphospholipid antibodies are typically done for thrombophilia diagnosis, there appears to be little or no correlation between these markers and stroke. In this article, we discuss a case of a 26-year-old male admitted with right neck pain that developed after playing basketball; he was found to have a right cerebellar infarction. He underwent extensive tests for hypercoagulable disorders, which were negative. We also review current evidence and reassess the value of thrombophilia testing in stroke patients.

Disección arterial cérvico-cefálica post trauma en pediatría / Cervicocephalic arterial dissection post trauma in children

Introducción: la disección arterial cérvico-cefálica (DACC) es una causa importante de accidente cerebrovascular (ACV) en pediatría. Dentro de los factores de riesgo más relevantes están los traumas cervicales y cefálicos, presentes en el 50% de los casos. El pronóstico es variable y depende de la magnitud de oclusión de la arteria afectada. Es importante la detección precoz de esta patología, que muchas veces se presenta con pocos síntomas en pediatría, lo que genera retraso en el diagnóstico y tratamiento. Objetivo:presentar la evidencia disponible sobre DACC incluyendo DACC post trauma para familiarizar a los médicos generales y especialistas sobre la sospecha diagnóstica, diagnóstico enfocado en neuroimágenes y posibles manejos de esta patología. Métodos: se llevó a cabo una revisión bibliográfica de la literatura científica sobre esta condición. Dentro de los criterios de selección de los estudios se consideró la fecha de publicación, el diseño y la relevancia.Conclusiones: la DACC post trauma es una causa frecuente de ACV en pediatría. Se puede presentar con escasa sintomatología, por lo que es importante mantener una alta sospecha en contexto de trauma cervical o cefálico, implementando un diagnóstico y tratamiento precoces para mejorar el pronóstico de los pacientes.

Introduction:Craniocervical arterial dissection (CCAD) is a major cause of arterial ischemic stroke (AIS) in children. The most important risk factors are cervical and cephalic traumas, present in 50% of all cases.The prognosis changes depending on the magnitude of the artery affected. Early detection of this pathology is important. It many times presents itself with few symptoms, which generates a de-lay in its diagnosis and treatment. Objective: To present the evidence available on CCAD, including CCAD post-trauma,to familiarize general physicians and specialists with this diagnosis, neuroimages required, and possible treatments.Methods: Extensive revision of bibliographic scientific literature about this condition. The criteria selection to include studies in this review were the date of publication, the design of the study, and their relevance.Conclusions: the CCAD post-trauma is asignificant cause of AIS in children. It can present itself with mild symptomatology, which is why it is relevant to suspect it in the context of cervical or cephalic trauma, aiming for an early diagnosis and treatment to improve the outcome of patients.

Symptomatic internal carotid artery dissection and kinking in a patient with fibromuscular dysplasia / Dissecção e acotovelamento sintomáticos da artéria carótida interna em paciente com displasia fibromuscular

Abstract Isolated dissection of the internal carotid artery (ICA) is rare in young patients and is a cause for strong suspicion of fibromuscular dysplasia (FMD), especially when associated with artery elongation and tortuosity. The natural history of cerebrovascular FMD is unknown and management of symptomatic patients can be challenging. We report the case of a 44-year-old female patient with a history of transient ischemic attack in the absence of cardiovascular risk factors, associated with an isolated left ICA dissection and kinking. Carotid duplex ultrasound confirmed the diagnosis of dissection and demonstrated severe stenosis of the left ICA. The patient underwent surgical repair and histopathological evaluation confirmed the diagnosis of FMD with dissection. An autogenous great saphenous vein bypass was performed and the patient had an uneventful recovery. Cervical carotid artery dissection can be related to underlying arterial pathologies such as FMD, and the presence of ICA tortuosity highlights certain peculiarities for optimal management, which might be surgical.

Resumo A dissecção isolada da artéria carótida interna em pacientes jovens é rara, e a displasia fibromuscular deve ser altamente suspeitada principalmente quando estiver associada a alongamento e tortuosidade da artéria. A história natural da displasia fibromuscular cerebrovascular é desconhecida, e o manejo de pacientes sintomáticos pode ser desafiador. Apresentamos o caso de uma paciente de 44 anos com histórico de ataque isquêmico transitório sem fatores de risco cardiovasculares, associado a dissecção e acotovelamento isolados da artéria carótida interna esquerda. O ultrassom duplo das carótidas confirmou o diagnóstico de dissecção e demonstrou estenose grave na artéria carótida interna esquerda. A paciente foi submetida a reparo cirúrgico, e a avaliação histopatológica confirmou o diagnóstico de displasia fibromuscular com dissecção. Foi realizada cirurgia de ressecção do segmento e reconstrução com veia safena magna autógena, e a paciente se recuperou sem complicações. A dissecção da artéria carótida cervical pode estar relacionada a doenças arteriais subjacentes, como a displasia fibromuscular, e a presença da tortuosidade da artéria carótida interna destaca algumas particularidades no manejo ideal, o qual pode ser cirúrgico.

Dissecção espontânea da artéria carótida interna em paciente jovem: relato de caso / Spontaneous dissection of the internal carotid artery in a young patient: case report

O objetivo é relatar um caso de acidente vascular encefálico isquêmico provocado por dissecção não traumática da artéria carótida interna em uma paciente jovem. Dissecções espontâneas de carótida interna e de artéria vertebral ocasionam aproximadamente 25% dos acidentes vasculares encefálicos isquêmicos em indivíduos com idade inferior a 45 anos. Confirmou-se o diagnóstico dessa entidade com imagens de ressonância magnética e angiotomografia cerebral. Seu tratamento incluiu anticoagulantes, fonoterapia e fisioterapia. Com melhora clínica, recebeu alta para controle ambulatorial, orientada sobre os riscos de anticoncepcionais orais. Relatos de caso podem aumentar o índice desuspeita dessa condição pouco diagnosticada.

The objective of this work is to report a case of ischemic brain stroke due to non-traumatic dissection of the internal carotid artery in a young patient.Spontaneous dissections of the internal carotid and of the vertebral artery cause nearly 25% of all ischemic strokes in individuals younger than 45 years of age. Imaging studies obtained from magnetic resonance and angiotomography of the brain confirmed the diagnosis. Treatment involved anticoagulation drugs, phonotherapy and physiotherapy. Based on herclinical improvement, she was discharged from the hospital and is now receiving outpatient care and has been advised about the risks of oral contraceptives. Case reports may raise the suspicion index about thisunderdiagnosed condition.