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| LETTER TO EDITOR |
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| Year : 2014 | Volume
: 62
| Issue : 5 | Page : 570-571 |
A case of vertebral artery dissection coincides with ipsilateral posterior inferior cerebellar artery dissection
Masaru Honda, Takeo Anda
Department of Neurosurgery, Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu, Yamaguchi, Japan
| Date of Submission | 21-Oct-2014 |
| Date of Decision | 21-Oct-2014 |
| Date of Acceptance | 21-Oct-2014 |
| Date of Web Publication | 12-Nov-2014 |
Correspondence Address:
Takeo Anda
Department of Neurosurgery, Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu, Yamaguchi
Japan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.144504
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 |
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.
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