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LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 1  |  Page : 104-105

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


Department of Neurosurgery, Shunan Memorial Hospital, Yamaguchi, Japan

Date of Web Publication4-Mar-2015

Correspondence Address:
Masaru Honda
Department of Neurosurgery, Shunan Memorial Hospital, Yamaguchi
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.152669

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How to cite this article:
Honda M, Anda T. A case of vertebral artery dissection associated with ipsilateral posterior inferior cerebellar artery dissection. Neurol India 2015;63:104-5

How to cite this URL:
Honda M, Anda T. A case of vertebral artery dissection associated with ipsilateral posterior inferior cerebellar artery dissection. Neurol India [serial online] 2015 [cited 2021 May 8];63:104-5. Available from: https://www.neurologyindia.com/text.asp?2015/63/1/104/152669


Sir,

Dissection of the vertebral artery (VA) along with posterior inferior cerebellar artery (PICA) is extremely rare. Most of these cases lead to either a subarachnoid hemorrhage (SAH) or a cerebellar/brainstem infarction. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] We report our experience with a VA dissection followed by spontaneous ipsilateral PICA dissection.

A 53-year-old man felt a sudden onset of suboccipital pain, vertigo, nausea, vomiting, and transient left hemiparesis. A magnetic resonance imaging (MRI) on admission revealed a dilated left VA [Figure 1]a with a high signal in its wall on T1-weighted (T1W) magnetic resonance imaging (MRI), indicating a VA dissection. PICA could not be visualized on magnetic resonance angiography (MRA). The clinical course was uneventful, and the patient underwent conservative treatment. The MRA 2 weeks later showed no change in the VA dissection. Cerebral angiography revealed the dissection of VA with filling of the remnant vessel in the venous phase. The left PICA filled in a retrograde manner via the right anterior inferior cerebellar artery (AICA) without any anterograde flow from its origin. The patient was discharged after a month following the ictus. He was readmitted on the 46th day following the ictus with transient occipitalgia. MRI revealed an unchanged left VA dissection with the recent appearance of left PICA having dilatation of the lateral medullary segment (that indicated ipsilateral PICA dissection) [Figure 1]b and c. He was treated conservatively. This recent onset PICA dissection showed a gradually reduction in the signal hyperintensity subsequently returning to a normal caliber. However, the left VA dissection remained unchanged [Figure 1]d.
Figure 1: Magnetic resonance angiography (MRA) on admission (a); 46 days after (b); and 6 months after (d). T1-weighted 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 case, we propose that acute VA dissection transiently occluded the origin of PICA, and transient cerebellar and Wallenberg's syndrome were seen. However, the well-developed collateral flow from AICA compensated for the compromised blood flow to the brainstem and cerebellum. [4],[6] This collateral flow depends on factors such as the age and/or the degree to which intracranial arteries have become atherosclerotic. [4],[6] The main etiology of PICA dissection remains a subject of conjecture. Spontaneous PICA dissection may have associations with giant cell arteritis, persistent primitive trigeminal artery, fenestration of both VAs, giant cerebral aneurysm at the VA-BA junction, PICA dissecting aneurysm and VA dissection at the V2-3 segment. [9] An unknown systemic arteriopathy or a VA dissection itself may be the precipitating risk factors. [7],[9],[10] The additional contributing factors in the present case included a history of smoking, elderly age, hypertension, left sidedness and co-existing VA dissection. [7],[10] If VA dissection had progressed and become symptomatic, we would have chosen proximal ligation of PICA due to the well-developed collateral flow from the AICA. If the dissected PICA had ruptured, trapping of PICA would have been performed. The prognosis of this rare condition seems favorable but meticulous follow-up is still needed. [3],[9] Considering the clinical course of VA dissection, its resolution starts 2-3 months after the onset of dissection and in half of the cases, the artery returns to its normal shape; therefore, the decision to perform surgical intervention for prevention of further ischemia should only be made with care. In this case, conservative therapy was chosen considering the absence of parenchymal damage and the natural normalization of VA dissection over time.

 
  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;243-47.  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. Neuro l 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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