-Cerebral Arterial Dissections Flashcards
Dissection vs dissecting aneurysm vs pseudoaneurysm
Dissection ▶️ Extravasation of 🩸 between intima and media
Dissecting aneurysm➡️ 🩸 media and adventitia ➡️ aneurysm ➡️aSAH
Pseudoaneurysm➡️ rupture of artery 🧨 ➡️ encapsulation of extra vascular hematoma 🩸 in subadventitial
Pathophysiology
trans-intimal extravasation of blood from the true lumen into the vessel wall ➡️
Subintema ➡️ elastic membrane ➡️ narrowing 💢 ( common intracranial ) vs
Media and adventitia ( aorta)
Dissect in subadventitial ➡️ pseudoaneurysm
Spontaneous” dissections associated w/
fibromuscular dysplasia (FMD)
cystic medial necrosis (or degeneration):fetal
saccular aneurysm
● Marfan syndrome AD FBN1 ch 15q21
Ehlers-Danlos syndrome
● atherosclerosis
Takayasu’s disease
● medial degeneration
● syphilitic arteri
autosomal dominant polycystic kidney disease 🔼 aneurysm
periarteritis nodosa
● allergic arteritis
● homocystinuria
● moyamoya disease
● strenuous physical activity
Spontaneous dissection common in.
Middle age 45 , male
Vs traumatic ➡️ younge age
Common site
VA ➡️ asso w/aSAH
Multiple dissection ▶️ bilateral VBA
Sx cause by
🔺 embolization ( platelet , thrombus) , 🔽 flow , SAH
SAH atypical presentation common in posterior circulation dissection
🥸 < 30 ICA d w/o H/A
🧓🏼> VBA d w/ SAH
Diagnosis of dissection
CT r/ o infarction
CTA 🔼 accuracy
DSA gold 💎 ;
MRI T1 with fat suppression axial cut ➡️➡️ crescent 🌙 sign , intemial flap dissection x fusiform aneurysm.
DDX
saccular aneurysm (the most common misdx w/ dissection )
Vasopsasm
Atherosclerosis ( involve carotid bulb) vs cervical ICA dissection not 🚫 involved bulb )
Finding in DSA
Pathonemonic ⭐️ double lumen sign
wavy “ripple” appearance
kinking mc bilateral , With VBA lesions ➡️ dolichoectasia
string of beads 🫛 , asso FMD
intimal flap: in proximal end of dissection
Outcome of dissection
High mortality SAH , VBA , ICA
ICA dissection spontaneous
Postturmatic> spontaneous
Sx;;
1- Spontnouse ➡️ uni- lateral H/ A ➡️ periorbitla 👀, arucular 👂,frontal , temporal
2- carotidynia
3- Incomplete Horner syndrome (oculosympathetic palsy):🔺 ptosis, mitosis ,🚫 anhidrosis 😥 why . ? involvement of plexus around the ICA, sparing the ECA plexus which innervates facial sweating g.😥
4- bruits
VA dissection mc site
Traumatic ➡️ At bone 🦴 prominence c1-2, c 6
Spontaneous e ➡️ intracranial, left VA , if high cervical ➡️ propagate intracranial
🚫 ICA dissection cervical not propagate to intracranial
RF VA dissection
FMD
Migraine
OCP
Truma
Sudden head motion
Sx VA dissection
Occipital or posterio cervical pain
Sever h/a
TIA ➡️ lateral medullary syndrome
cerebellar infarction ; V3rd , V 4 th
SAH 🔼 rebleeing
If extrdural dissection ➡️ EDH , neck hematoma
VA dissection DSA finding
misdiagnosis is ruptured saccular aneurysm
Irregularity of horizontal loop of V 3 behaind c1
MCC V1, V3 most mobile segment of VA
TX of VA dissection
Anticoagulant for 6 months = ASS effective
Intervention indication ;; SAH ➡️ 🔼 rebleed, intradural, extradural progressive , CI for medical , sx 🔽 flow
Endovascular ➡️ballon self expande stent
Surgery ; need ballon test
Clipping , wrapping
Hunterian occlusion
resection+ graft
bypass, options:
a) side-to-side PICA-PICA anastomosis
b) transplantation of the PICA origin to the VA outside the aneurysm
c) occipital artery-to-PICA bypass
