Natural course of intracranial arterial dissections

Clinical article

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Object

Noninvasive neuroimaging techniques are increasingly identifying unruptured intracranial arterial dissections (IADs) at examination for headache or ischemic symptoms. Approximately 3% of cases of aneurysmal subarachnoid hemorrhage (SAH) are caused by IADs in Japan, but the natural history of unruptured IADs is not known.

Methods

Clinical data obtained in 190 patients with 206 IADs were retrospectively analyzed on the basis of long-time follow-up of geometry and clinical event. The IADs were divided into an unruptured group and SAH group depending on the patient's clinical status at the initial diagnosis. Day 0 was defined as the day preceding diagnosis of IAD—that is, the day of symptom onset. This was retrospectively determined from the clinical history.

Results

The 206 IADs included 98 unruptured lesions and 108 SAH. In both groups, the vertebral artery was the most frequent site. In the unruptured group, 93 IADs were followed for a mean of 3.44 years. The mean interval between symptom onset (Day 0) and neuroimaging diagnosis was 9.8 days. Subsequent geometry change was seen in 78 (83.9%) of 93 IADs. Major change was almost completed within 2 months, and complete normalization was seen on neuroimaging in 17 (18.3%) of 93 IADs, with the earliest on Day 15. Rupture of the IAD in the unruptured group occurred in only 1 patient on Day 11.

In the SAH group, 84 of the 108 patients complained of preceding headache before onset of SAH. In 81 (96.4%) of the 84 patients, SAH occurred on Day 0–3 with the latest on Day 11. In all patients in the unruptured and SAH groups, the latest day of SAH from the onset of preceding headache was Day 11.

Conclusions

Most IADs causing SAH bleed within a few days of occurrence. Most IADs that are unruptured already have little risk for bleeding at diagnosis because of the repair process. Intracranial arterial dissections may be much more common than previously thought, and the majority may occur and heal without symptom manifestation.

Abbreviations used in this paper: IAD = intracranial arterial dissection; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Tohru Mizutani, M.D., 3-8-29 Musashidai, Fuchu City, Tokyo 183-8524, Japan. email: mizutani-nsutky@umin.net.

Please include this information when citing this paper: published online October 15, 2010; DOI: 10.3171/2010.9.JNS10668.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Geometry of each type and subsequent change. A: Aneurysmal dilation with stenosis in a 51-year-old woman in noninfarction group. Angiography on Day 15 showed an IAD of aneurysmal dilation with stenosis in right vertebral artery. Subsequent angiography on Day 33 showed reduction in size. B: Aneurysmal dilation with stenosis in a 49-year-old man in the noninfarction group. Angiography on Day 10 showed an IAD of aneurysmal dilation with stenosis in the right vertebral artery. This IAD caused SAH on Day 11. C: Irregular stenosis in a 35-year-old woman in the infarction group. Magnetic resonance angiography revealed an IAD of irregular stenosis in the right posterior cerebral artery (Day 6) with subsequent improvement (Day 21, Day 118). D: Double lumen in a 41-year-old woman in the infarction group. Angiography showed an IAD of double lumen in the right internal carotid artery (arrow). E: Stenosis and occlusion in a 54-year-old man in the headache group. Angiography demonstrated IAD in the right vertebral artery (Day 7) with subsequent development of stenosis (Day 22), occlusion (Day 38), and recanalization (Day 120).

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    Graph demonstrating the interval between onset of preceding headache (Day 0) and the occurrence of SAH and infarction.

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