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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 5  |  Page : 570-571

A case of vertebral artery dissection coincides with ipsilateral posterior inferior cerebellar artery dissection


Department of Neurosurgery, Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu, Yamaguchi, Japan

Date of Submission21-Oct-2014
Date of Decision21-Oct-2014
Date of Acceptance21-Oct-2014
Date of Web Publication12-Nov-2014

Correspondence Address:
Takeo Anda
Department of Neurosurgery, Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu, Yamaguchi
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.144504

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How to cite this article:
Honda M, Anda T. A case of vertebral artery dissection coincides with ipsilateral posterior inferior cerebellar artery dissection. Neurol India 2014;62:570-1

How to cite this URL:
Honda M, Anda T. A case of vertebral artery dissection coincides with ipsilateral posterior inferior cerebellar artery dissection. Neurol India [serial online] 2014 [cited 2019 Sep 15];62:570-1. Available from: http://www.neurologyindia.com/text.asp?2014/62/5/570/144504


Sir,

Dissection of the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) is extremely rare even in cases of intracranial arterial dissection and most cases present with either subarachnoid hemorrhage (SAH) or cerebellar/brainstem infarction. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] We report our experience with VA dissection followed by spontaneous ipsilateral PICA dissection.

A 53-year-old man felt sudden onset of occipital pain, vertigo, nausea, vomiting, and transient left hemiparesis. Magnetic resonance imaging (MRI) revealed dilated left VA [Figure 1]a with a high signal in the wall of dilated VA on T1-weighted imaging (T1WI), indicating VA dissection. No PICA signal was identified even in the source images of MR-angiography (MRA). The clinical course was uneventful with conservative treatment. MRA 2 weeks after onset showed unchanged VA dissection. Cerebral angiography revealed the dissected VA with filling remnant in the venous phase. The left PICA filled in a retrograde manner via right anterior inferior cerebellar artery (AICA) without anterograde flow from the PICA origin. He was discharged after one month of admission. However, the patient was readmitted on day-46 of onset with transient occipital pain. MRI revealed unchanged left VA dissection and appearance of left PICA with posterior medullary segment dilatation, which indicated PICA dissection [Figure 1]b and c. The patient was treated conservatively, and this newly developed PICA dissection showed gradually reductions in signal hyperintensity, subsequently returning to normal caliber with no changes in left VA dissection [Figure 1]d.
Figure 1: Magnetic resonance angiography on admission (a), 46 days after (b) and 6 months after (d). T1weighted image (c) revealed intramural thrombus in both of vertebral (VA) and posterior inferior cerebellar (PICA) arteries as high signal intensity. White arrowhead; VA, white arrow; PICA

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In the present patient, we speculated that acute VA dissection transiently occluded the PICA origin, and transient cerebellar and Wallenberg's syndrome signs subsequently occurred. However, well-developed collateral flow from the AICA compensated for disturbed blood flow to the brainstem and cerebellum. [4],[6] Such collateral flow depends on factors such as the age and/or atherosclerotic status of the patient. [4],[6] The main cause of PICA dissection remains controversial. PICA dissection might have some associations with giant cell arteritis, persistent primitive trigeminal artery, fenestration of both VAs, giant cerebral aneurysm at the vertebral artery-basilar artery junction, middle cerebral artery aneurysm, and left side VA dissection at the V2-3 portion. [9] Both unknown systemic arteriopathy or VA dissection itself may be risk factors. [7],[9],[10] Contributing factors in the present patient were thought to be smoking, age, sex, hypertension, left sidedness, and existence of VA dissection. [7],[10] This PICA dissection progressed with conservative treatment during the recanalization of the PICA itself. Some inflammatory particles might migrate from the pseudolumen of the dissected VA and cause mechanical irritation or chronic systemic vascular damage as a result of smoking habit, and untreated hypertension might accelerate the dissection. If VA dissection progressed and became symptomatic, we would have chosen proximal ligation with sacrifice of the PICA due to the well-developed collateral flow from the AICA. Considering the clinical course of VA dissection, regression starts 2-3 months after onset, and in half of the cases, the artery returns to the normal shape, so the prognosis of this rare condition seems favorable. [3],[9] Threfore the decision to perform surgical intervention should be reserved for select cases with utmost care because it may be counterproductive. Meticulous follow-up is definitely needed. [3],[9] In this case, conservative therapy was chosen, and considering the absence of parenchymal damage and the natural course, appeared to be the most suitable treatment. Coincidence of these rare entities should be taken into consideration when encountering cases with VA dissection involving PICA. Further discussion is needed with accumulation of additional cases.

 
  References Top

1.
Demirgil B, Günaldi O, Tugcu B, Postalci L, Colluoglu B, Tanriverdi O, et al. Multiple aneurysms of the distal posterior inferior cerebellar artery: Two case reports. Minim Invasive Neurosurg 2008;51:249-52.  Back to cited text no. 1
    
2.
Jao T, Liu HM, Tang SC, Jeng JS. Dissection of the posterior inferior cerebellar artery in a young adult with cerebellar infarct. Acta Neurol Taiwan 2008;17:243-7.  Back to cited text no. 2
    
3.
Kwak YS, Kang DH, Woo HJ. Simultaneous vertebral artery dissection and contralateral posterior inferior cerebellar artery dissecting aneurysm. J Cerebrovasc Endovasc Neurosurg 2012;14:228-32.  Back to cited text no. 3
    
4.
Mizushima H, Sasaki K, Kunii N, Nishino T, Jinbo H, Abe T, et al. Dissecting aneurysm in the proximal region of the posterior inferior cerebellar artery presenting as Wallenberg′s syndrome-case report. Neurol Med Chir (Tokyo) 1994;34:307-10.  Back to cited text no. 4
    
5.
Niijima K. Dissecting aneurysm of the vertebral artery with an accessory posterior inferior cerebellar artery: Successful management with clipping between the two posterior inferior cerebellar arteries. Cerebrovasc Dis 2001;11:138-40.  Back to cited text no. 5
    
6.
Nussbaum ES, Madison MT, Myers ME, Goddard J, Janjua T. Dissecting aneurysms of the posterior inferior cerebellar artery: Retrospective evaluation of management and extended follow-up review in 6 patients. J Neurosurg 2008;109:23-7.  Back to cited text no. 6
    
7.
Sedat J, Chau Y, Mahagne MH, Bourg V, Lonjon M, Paquis P. Dissection of the posteroinferior cerebellar artery: Clinical characteristics and long-term follow-up in five cases. Cerebrovasc Dis 2007;24:183-90.  Back to cited text no. 7
    
8.
Takumi I, Mizunari T, Mishina M, Fukuchi T, Nomura R, Umeoka K, et al. Dissecting posterior inferior cerebellar artery aneurysm presenting with subarachnoid hemorrhage right after anticoagulant and antiplatelet therapy against ischemic event. Surg Neurol 2007;68:103-7.  Back to cited text no. 8
    
9.
Tawk RG, Bendok BR, Qureshi AI, Getch CC, Srinivasan J, Alberts M, et al. Isolated dissections and dissecting aneurysms of the posterior inferior cerebellar artery: Topic and literature review. Neurosurg Rev 2003;26:180-7.  Back to cited text no. 9
    
10.
Yamaura A, Isobe K, Karasudani H, Tanaka M, Komiya H. Dissecting aneurysms of the posterior inferior cerebellar artery. Neurosurgery 1991;28:894-8.  Back to cited text no. 10
    


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