Double lumen dissecting aneurysms of the internal carotid artery in fibromuscular dysplasia: case report

A young man with cerebral infarction, skeletal, cardiac and renal malformations was found to have on angiography a rare lesion involving the cervical left internal carotid artery, formed by the superposition of two arterial lumina. Anti-platelet therapy did not prevent thrombosis of the lesion and reinfarction. Extracranial-intracranial bypass graft was performed, followed by excision of the arterial lesion. Pathological examination revealed fibromuscular dysplasia and dissecting aneurysm. The few reported cases associating fibromuscular dysplasia of the internal carotid artery with dissecting aneurysm are reviewed. Surgical therapy is recommended in such cases when symptomatology progresses. Fibromuscular dysplasia occasionally coexists with somatic malformations, suggesting a congenital origin of this condition.     

Dissecting hematoma of intracranial internal carotid artery in an 8-year-old girl.

BACKGROUND: An 8-year-old girl had a minor fall without head trauma and she collapsed the following day while playing. She was awake but mute with focal neurologic signs when admitted to hospital. Radiologic imaging studies showed a progressive left cerebral infarct with left hemisphere vascular narrowing and beading. She died on the third hospital day. METHODS: Autopsy including exploration of neck vessels and neuropathological examination was performed. Postmortem studies included immunostaining for immunoglobulins and fixed complement. RESULTS: Subtotal subintimal dissections of both proximal supraclinoid internal carotid arteries were found microscopically. On the left, the subintimal dissection extended into the major branches of the left internal carotid artery as dissecting hematomas with a major compromise of the arterial lumina. Specific IgM deposition at the dissection sites was found. A literature review shows that subintimal dissection of the intracranial internal carotid artery or its branches occurs rarely, it is often fatal, and it is present in patients with a mean age of 17.5 years in cases studied pathologically. Trauma and physical exertion are the most common associated factors. CONCLUSIONS: Among the causes of ischemic stroke in young individuals, dissecting hematomas of the intracranial portions of the internal carotid artery system rank low. Few reported cases have identifiable pre-existing pathology. The pathogenesis of dissecting hematomas in this region is reviewed and expanded with speculation regarding relevant developmental, anatomical, flow stress and possibly humoral factors that are involved in the disruption of the arterial elastica and subsequent development and extension of a subintimal hematoma resulting in luminal closure and often death.     

Bilateral dissecting aneurysms of the intracranial internal carotid arteries in an 8-year-old boy.

Nontraumatic intracranial dissecting aneurysms have rarely been reported as the cause of acute infantile and childhood hemiplegia. The present case is unique because dissecting aneurysms occurred bilaterally in two clinically distinct episodes. A recent dissecting aneurysm of the right intracranial internal carotid artery was present with a healed dissecting aneurysm of left internal carotid artery in an 8-year-old boy.     

Dissecting aneurysm of the internal carotid artery and isolated Claude Bernard-Horner syndrome

In 2 cases of dissecting aneurysm of the internal carotid artery the only clinical sign was a Claude Bernard-Horner's syndrome, with pain in the neck and face.     

Reticular fiber deficiency in the intracranial arteries of patients with dissecting aneurysm and review of the possible pathogenesis of previously reported cases

Summary The pattern of reticular fibers in the tunica media of the major intracranial arteries was investigated in two patients with dissecting aneurysm. In numerous circumscribed areas, the reticular fibers were absent close to the internal elastic lamina in all major arteries of each patient. It is suggested that the subintimal deficiency in reticular fibers results in insufficient fixing of the tunica intima to the media contributing to their separation when the internal elastic lamina becomes defective. The presumed etiologies of the previously reported cases are reviewed and the possible origin of the deficiency in reticular fibers is discussed.     

Dissecting aneurysm associated with a double origin of the posterior inferior cerebellar artery causing subarachnoid hemorrhage

Two cases of the posterior fossa dissecting aneurysm associated with a double origin of the posterior inferior cerebellar artery (DOPICA) causing subarachnoid hemorrhage are presented. After observing a relationship between the aneurysm and DOPICA on a three dimensional rotational angiogram (3DRA), the dissecting aneurysms were successfully obliterated by surgical trapping and endovascular internal trapping, respectively. This report warrants suspecting DOPICA of an associating anomaly predisposing to dissecting aneurysm in the vertebral artery-posterior inferior cerebellar artery territory and highlights the role of 3DRA in pretreatment evaluation of unusual aneurysms accompanying a particular anatomical variation.     

血管内支架技术治疗破裂的椎动脉夹层动脉瘤

目的 评价血管内支架技术治疗破裂的椎动脉夹层动脉瘤的安全性及有效性. 方法 回顾性分析第三军医大学西南医院神经外科自2004年7月至2007年1月收治的采用支架技术治疗的9例椎动脉夹层动脉瘤患者的临床资料,其中3例行单纯支架植入术,6例行支架辅助微弹簧圈栓塞术. 结果 9例患者均在首次治疗中成功植入支架或行支架辅助微弹簧圈栓塞术,椎动脉均保留通畅,无动脉瘤破裂、血栓形成等并发症发生.所有患者获4～39个月临床随访,随访过程中无再出血表现.6例患者获3～18个月造影随访,其中2例行支架辅助弹簧圈栓塞术者随访发现动脉瘤再通或增大,再次行血管内孤立术及椎动脉近端闭塞术;2例行单纯支架植入术者随访造影示动脉瘤闭塞;另1例不全闭塞. 结论 血管内支架技术能保存患侧椎动脉畅通,是一种安全有效的治疗方法,但术后应严密随访,远期疗效仍有待进一步观察.     

覆膜支架血管内治疗颅内动脉瘤：附九例报告

目的探讨覆膜支架治疗颅内动脉瘤的适应证和临床疗效。方法经脑血管造影检查明确诊断的9例颅内动脉瘤患者（4例颈内动脉海绵窦段宽颈动脉瘤未破裂、5例椎动脉颅内段梭形或夹层动脉瘤破裂致蛛网膜下隙出血）,动脉瘤直径4～16mm,均接受Jostent覆膜支架治疗。结果共计植入9枚Jostent覆膜支架,均获技术成功,支架顺利到达病变部位且释放后动脉瘤颈即刻覆盖完全,动脉瘤不思影,载瘤动脉血流通畅,达到即刻影像学满意效果。随访9～24个月,5例患者（2例颈内动脉、3例椎动脉）脑血管造影检查颈内动脉支架段血流通畅、无狭窄（2例）,椎动脉支架段血管呈无症状性闭塞（2例）或支架内轻度狭窄（1例）,动脉瘤均未显影;其余4例未行脑血管造影患者门诊随访。9例患者手术后均恢复正常生活与工作,无一例死亡或永久性病残。结论覆膜支架治疗颈内动脉海绵窦段宽颈大动脉瘤、椎动脉颅内段梭形或夹层动脉瘤疗效较好,值得在有手术适应证韵患者中推荐使用。     

覆膜支架血管内治疗颅内动脉瘤:附九例报告

目的探讨覆膜支架治疗颅内动脉瘤的适应证和临床疗效。方法经脑血管造影检查明确诊断的9例颅内动脉瘤患者(4例颈内动脉海绵窦段宽颈动脉瘤未破裂、5例椎动脉颅内段梭形或夹层动脉瘤破裂致蛛网膜下隙出血),动脉瘤直径4～16mm,均接受Jostent覆膜支架治疗。结果共计植入9枚Jostent覆膜支架,均获技术成功,支架顺利到达病变部位且释放后动脉瘤颈即刻覆盖完全,动脉瘤不显影,载瘤动脉血流通畅,达到即刻影像学满意效果。随访9～24个月,5例患者(2例颈内动脉、3例椎动脉)脑血管造影检查颈内动脉支架段血流通畅、无狭窄(2例),椎动脉支架段血管呈无症状性闭塞(2例)或支架内轻度狭窄(1例),动脉瘤均未显影;其余4例未行脑血管造影患者门诊随访。9例患者手术后均恢复正常生活与工作,无一例死亡或永久性病残。结论覆膜支架治疗颈内动脉海绵窦段宽颈大动脉瘤、椎动脉颅内段梭形或夹层动脉瘤疗效较好,值得在有手术适应证的患者中推荐使用。     

Two autopsy cases with ruptured dissecting aneurysm of the intracranial vertebral artery

Two autopsy cases with ruptured dissecting aneurysm of the intracranial portion of the vertebral artery are reported. Both patients developed subarachnoid hemorrhage and died within 9 days after onset. Autopsy disclosed dissecting aneurysms symmetrically on the bilateral vertebral arteries but there was no evidence of underlying vasculopathy in either patient. The etiology of the dissecting aneurysm of the intracranial vertebral artery is obscure, but the repeated minor trauma associated with head movement is considered as an important factor.     

颅内外动脉夹层及夹层动脉瘤的发病机制研究进展

颅内外动脉夹层和夹层动脉瘤多见于青年,自发性多见,病因目前不甚明确。内膜和内弹力 板的不可逆损伤可能是脑动脉夹层形成的病理学基础。高分辨率磁共振成像的出现提高了颅内夹层 及夹层动脉瘤的检出率,为此类疾病的病因和病理生理机制提供了新的研究方向。本文综述了颅内 外动脉夹层及夹层动脉瘤的病因、发病机制、病理类型及目前现状与展望。     

Pathological study of Willis's circle in autopsy cases of polycystic kidney disease

Two autopsy cases of polycystic kidney disease with intracranial aneurysms were reported. We made a pathological study of their vascular system with special reference to Willis's circle in order to prove the inherent abnormality of vascular system in patients with polycystic kidney disease. A 57-year-old man was revealed to have polycystic kidney disease with left middle cerebral artery aneurysm and aortic stenosis. The other 58-year-old man was revealed to have polycystic kidney disease with cerebral aneurysms both in anterior communicating artery and basilar artery, aortic dissecting aneurysm, cerebral infarction and myocardial infarction. Histologically, both abrupt interruption and partial disappearance of internal elastic lamina are found frequently in the wall of Willis's circle. This abnormality of internal elastic lamina may be attributable to congenital factors and rise the frequency of occurrence of intracranial aneurysms in polycystic kidney disease.     

Pathology of a dissecting intracranial aneurysm

The pathological findings of six autopsy cases of dissecting intracranial aneurysm are studied. Clinically, all cases exhibited systemic hypertension or left ventricular hypertrophy. Macroscopically, all cases exhibited rupture of the vertebral artery and subarachnoid hemorrhage. Two types of lesion were present. First, all cases showed the formation of a dilatated pseudoaneurysm with widespread disruption of the entire arterial wall, which was composed of thin adventitia. Second, a medial disruption of the arterial wall and subadventitial dissecting hemorrhage, which formed a false lumen and stenosis of the ‘true’ lumen of the artery, was also found. However, these lesions were found to be connected to the site of rupture. The autopsy cases within 1 day of onset of intracranial dissecting aneurysm showed the formation of fibrin thrombus, a marked degree of leukocyte infiltration and necrosis of the arterial wall at the site of the lesion. The cases that survived more than 1 week showed smooth muscle cell proliferation, macrophage accumulation and lymphocytic infiltration. No arteriosclerosis was found in any lesion studied. These data suggest that the disruption of the entire arterial wall might initially occur and cause medial disruption and subadventitial hemorrhage. Hypertension and arteriosclerosis might function as causal and protective factors in the pathogenesis of dissecting intracranial aneurysms, respectively.     

Traumatic production of an intracranial berry-like aneurysm in a monkey

A berry-like dissecting intracranial aneurysm resulted from inadvertent puncture of the internal carotid artery during trans-palatal section of a monkey's optic nerve. The light and ultrastructural features are rather similar to those of human berry aneurysms supporting the notion that the latter are degenerative rather than congenital in origin.     

Antegrade recanalization of parent artery after internal trapping of ruptured vertebral artery dissecting aneurysm

We report a patient with a ruptured vertebral artery (VA) dissecting aneurysm that was treated by internal trapping of the aneurysm and parent artery using detachable coils with subsequent antegrade recanalization of occluded vertebral artery during the follow-up period. A 38-year-old man was admitted with a ruptured right VA dissecting aneurysm just distal to origin of right posterior inferior cerebellar artery. The dissected segment of the VA was occluded by coil embolization. The 14 months follow-up angiography showed that dissected aneurysm was completely occluded, but the parent artery was recanalized in an antegrade fashion. Based on this unique case, the authors suggest that careful angiographic follow-up of dissecting aneurysm is required, even in patients successfully treated with endovascular occlusion of the affected artery and aneurysm.     

Dissecting intracranial vertebral artery aneurysms.

Dissecting aneurysms of the intracranial arteries are exceedingly rare vascular lesions that can produce acute cerebral or brain stem infarction in young healthy adults. They carry a high mortality rate. Two cases of dissecting vertebral artery aneurysms that presented with bleed, were successfully operated by trapping and excision of the dissecting segment. Both dissecting aneurysms were located distal to PICA origin. Both the patients developed post operative lower cranial nerve paresis and one developed lateral medullary syndrome, which improved subsequently. Dissecting aneurysms presenting with bleed should be surgically managed by trapping and excising the involved segment sparing the PICA origin or by interventional radiological techniques. Revascularisation procedures should be considered in addition to trapping of the main vertebral segment if PICA is involved in the trapped segment. The diagnostic and therapeutic difficulties associated with dissecting vertebral artery aneurysms and the controversies regarding their management have been reviewed.     

血管内栓塞治疗15例假性动脉瘤

目的 回顾近十年来收治的15例假性动脉瘤，分析其发病机理、临床表现、影像学特点及治疗方法。方法 15例病人中男9例，女6例，平均年龄43．9岁（9－57岁）。外伤性9例，夹层所致4例，手术所致2例。颈内动脉11例，椎3例，颈外动脉1例。外伤性颈内动脉海绵窦瘘（TCCF）合并假性动脉瘤4例。影像学特点清嵝不位于血管分叉处，形状不规则，瘤底部常用“小壶”影。全部病例均采用局麻下经股动脉或颈动脉Seldinger′s穿刺，在系统抗凝情况下栓塞动脉瘤。结果 15例假性动脉瘤中保留载瘤动脉4例。全部病例栓塞后动脉瘤均消失。半年后血管造影随访复查未见动态瘤复发。结论 血管内栓塞是治疗假性动脉瘤的有效而首选的方法。     

LVIS支架辅助栓塞颈内动脉床突上段破裂夹层动脉瘤

目的 探讨LVIS支架辅助栓塞治疗颈内动脉床突上段破裂夹层动脉瘤的可行性、有效性。方法 回顾性分析2015年6月到2018年3月采用LVIS支架辅助栓塞治疗的9例颈内动脉床突上段破裂夹层动脉瘤的临床资料。结果 9例均成功实施LVIS支架辅助栓塞治疗,术后即刻造影显示Raymond分级Ⅰ级5例,Ⅱ级4例。术后DSA随访1周~24个月,2例双LVIS支架辅助栓塞术后2周DSA复查显示动脉瘤复发,血栓弹力图示ADP>90%,调整抗血小板方案后半年后复查动脉瘤未显影;其余病人动脉瘤均未显影,载瘤动脉通畅。出院时改良Rankin量表（mRS）评分0分5例,3分2例,4分1例,6分1例;术后90 d mRS评分0分6例,1分1例,3分1例。结论 LVIS支架辅助栓塞颈内动脉床突段破裂夹层动脉瘤是一种安全、有效的方法,调整抗血小板方案可提高术后复发动脉瘤的闭塞率     

Dissecting aneurysm of distal posterior inferior cerebellar artery--case report and review of the literature

A rare case of dissecting aneurysm of distal posterior inferior cerebellar artery (PICA) is reported. A 51-year-old woman was admitted to our hospital complaining of severe headache and nausea. CT scan revealed subarachnoid hemorrhage which was thicker in the posterior fossa. The vertebral angiography demonstrated an aneurysm on the telovelotonsillar segment (Lister's classification) of the left PICA. On the third day, the left suboccipital craniotomy was performed and the fusiform aneurysm was resected. The postoperative course was uneventful. Histological examination of the resected aneurysm showed a dissection between the ruptured elastic lamina and the tunica media. Dissecting aneurysm of distal PICA is still belong to a rare entity. In all three cases found in the literature, the dissecting aneurysms are sited in the anterior medullary segment of PICA. Probably, this is the first report described a dissecting aneurysm on the more distal part-telovelotonsillar segment of PICA. The clinical features, pathogenesis and treatment of intracranial dissecting aneurysms are briefly discussed with reviewing the literature.     

球囊闭塞试验联合血管内栓塞治疗小脑后下动脉夹层动脉瘤的临床分析

目的 探讨球囊闭塞试验联合血管内栓塞治疗小脑后下动脉(PICA)夹层动脉瘤的效果。方法 2013年12月-2018年12月共收治10例单纯PICA夹层动脉瘤,均行球囊闭塞试验联合血管内栓塞治疗。结果 10例患者手术效果均较满意,均随访1年,复查造影夹层动脉瘤均无复发,8例恢复良好,1例遗留头晕,1例遗留右侧肢体共济失调。结论 球囊闭塞试验联合血管内栓塞治疗PICA夹层动脉瘤的效果及预后良好,但需根据PICA夹层动脉瘤的具体情况,选择不同的血管内治疗方法。