Cerebral dissecting aneurysm and intimal fibroelastic thickening of cerebral arteries

Case report

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✓ A 19-year-old white man developed aphasia and right hemiplegia after several falls while waterskiing. Cerebral angiography displayed a ripple appearance and a “string of beads” sign along the left middle cerebral artery, with occlusion or stenosis of most of its branches. The patient died after 6 days, of transtentorial herniation due to massive left cerebral infarction. At necropsy, the infarct was found to be due to a subintimal dissecting aneurysm of the left middle cerebral artery. Multifocal areas of intimal fibroelastic thickening (IFT) were found not only at the site of dissection, but also in the other cerebral arteries, most prominent at the bifurcations of the vessels.

A systematic study of cerebral arteries performed in six control cases revealed that IFT was present in a similar distribution to that seen in the patient described. However, the degree of IFT in this patient was greater than in the controls. Some individuals with excessive IFT may be more susceptible to cerebral dissecting aneurysm under a variety of stresses, especially trauma.

Article Information

Present address for Dr. Harper: Department of Pathology (Neuropathology), Royal Perth Hospital, West Australia 60001.

Address reprint requests to: Tomohiko Mizutani, M.D., Division of Neurology, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo 105, Japan.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Frontal (left) and lateral (right) projection of the left common carotid angiogram, mid-arterial phase. The middle cerebral artery (MCA) demonstrates mild diffuse nodular narrowing from its origin to its insular segment, where more prominent ring-like areas of constriction resembling “a string of beads” are apparent (large arrow). There is blunt occlusion of the anterior temporal branch (arrowhead) of the MCA and nonfilling of the orbital frontal, ascending frontal, and posterior temporal branches. The first several centimeters of the Rolandic branch reveal a ripple appearance (small double arrows). A similar-appearing short segment of stenosis is present at the origin of the posterior parietal branch (small single arrow).

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    Distribution of intimal fibroelastic thickening (IFT) in the present case. Shaded area: site of the subintimal dissecting aneurysm of the left middle cerebral artery (MCA). Degree of IFT: 0 = normal artery; 1 = mild IFT; 2 = moderate IFT; 3 = marked IFT. Abbreviations: ACA = anterior cerebral artery; BA = basilar artery; VA = vertebral artery; ACoA = anterior communicating artery; PCoA = posterior communicating artery; PCA = posterior cerebral artery.

  • View in gallery

    Photomicrographs of sections of the cerebral arteries. Upper Left: The beginning of the subintimal dissecting aneurysm at the origin of the left middle cerebral artery (MCA). A small single arrow indicates a tear of the internal elastic lamina which exhibits fraying, duplication, and hyperplasia (small double arrows). Double large arrows: subintimal hematoma. Elastica-van Gieson, × 18.5. Upper Right: Cerebral dissecting aneurysm of the left MCA proximal to its trifurcation (in the region of the “string of beads” seen in Fig. 1). Single arrows show the internal elastic lamina, double arrows subintimal hematoma. Elastica-van Gieson, × 18.5. Lower Left: A marked degree of intimal fibroelastic thickening (arrows) of the internal elastic lamina at the termination of the left internal carotid artery just proximal to the section shown (upper left). Elastica-van Gieson. × 74. Lower Right: Intimal fibroelastic thickening (arrows) of the internal elastic lamina at the trifurcation of the nondissected MCA on the right. Elastica-van Gieson, × 74.

References

1.

Alexander CBBurger PCGoree JA: Dissecting aneurysms of the basilar artery in 2 patients. Stroke 10:2942991979Alexander CB Burger PC Goree JA: Dissecting aneurysms of the basilar artery in 2 patients. Stroke 10:294–299 1979

2.

Bergan JJMacDonald JR: Recognition of cerebrovascular fibromuscular hyperplasia. Arch Surg 98:3323351969Bergan JJ MacDonald JR: Recognition of cerebrovascular fibromuscular hyperplasia. Arch Surg 98:332–335 1969

3.

Bouissou HEmery MCSorbara R: Age related changes of the middle cerebral artery and a comparison with the radial and coronary artery. Angiology 26:2572681975Bouissou H Emery MC Sorbara R: Age related changes of the middle cerebral artery and a comparison with the radial and coronary artery. Angiology 26:257–268 1975

4.

Chang VRewcastle NBHarwood-Nash DCFet al: Bilateral dissecting aneurysms of the intracranial internal carotid arteries in an 8-year-old boy. Neurology 25:5735791975Chang V Rewcastle NB Harwood-Nash DCF et al: Bilateral dissecting aneurysms of the intracranial internal carotid arteries in an 8-year-old boy. Neurology 25:573–579 1975

5.

Duman SStephens JW: Post-traumatic middle cerebral artery occlusion. Neurology 13:6136161963Duman S Stephens JW: Post-traumatic middle cerebral artery occlusion. Neurology 13:613–616 1963

6.

Edwards JH JrKricheff IIGorstein Fet al: Atherosclerotic subintimal hematoma of the carotid artery. Radiology 133:1231291979Edwards JH Jr Kricheff II Gorstein F et al: Atherosclerotic subintimal hematoma of the carotid artery. Radiology 133:123–129 1979

7.

Frens DBPetajan JHAnderson Ret al: Fibromuscular dysplasia of the posterior cerebral artery: report of a case and review of the literature. Stroke 5:1611661974Frens DB Petajan JH Anderson R et al: Fibromuscular dysplasia of the posterior cerebral artery: report of a case and review of the literature. Stroke 5:161–166 1974

8.

Grosman HFornasier VLBonder Det al: Dissecting aneurysm of the cerebral arteries. Case report. J Neurosurg 53:6936971980Grosman H Fornasier VL Bonder D et al: Dissecting aneurysm of the cerebral arteries. Case report. J Neurosurg 53:693–697 1980

9.

Harrison EG JrMcCormack LJ: Pathologic classification of renal arterial disease in renovascular hypertension. Mayo Clinic Proc 46:1611671971Harrison EG Jr McCormack LJ: Pathologic classification of renal arterial disease in renovascular hypertension. Mayo Clinic Proc 46:161–167 1971

10.

Hartman JDYoung IBank AAet al: Fibromuscular hyperplasia of internal carotid arteries. Stroke in a young adult complicated by oral contraceptives. Arch Neurol 25:2953011971Hartman JD Young I Bank AA et al: Fibromuscular hyperplasia of internal carotid arteries. Stroke in a young adult complicated by oral contraceptives. Arch Neurol 25:295–301 1971

11.

Hassler O: Physiological intima cushions in the large cerebral arteries of young individuals. 1. Morphological structure and possible significance for the circulation. 2. Location. 3. Individual distribution among different ages and arterial groups. Acta Pathol Microbiol Scand 55:19341962Hassler O: Physiological intima cushions in the large cerebral arteries of young individuals. 1. Morphological structure and possible significance for the circulation. 2. Location. 3. Individual distribution among different ages and arterial groups. Acta Pathol Microbiol Scand 55:19–34 1962

12.

Hauser OWBaker HL JrSadok BAet al: Cephalic arterial fibromuscular dysplasia. Radiology 101:6056111971Hauser OW Baker HL Jr Sadok BA et al: Cephalic arterial fibromuscular dysplasia. Radiology 101:605–611 1971

13.

Huber PFuchs WA: Gibt es eine fibromuskuläre Hyperplasie zerebraler Arterien? Fortschr Geb Roentgenstr Nuklearmed 107:1191261967Huber P Fuchs WA: Gibt es eine fibromuskuläre Hyperplasie zerebraler Arterien? Fortschr Geb Roentgenstr Nuklearmed 107:119–126 1967

14.

Iosue AKier ELOstrow D: Fibromuscular dysplasia involving the intracranial vessels. Case report. J Neurosurg 37:7497521972Iosue A Kier EL Ostrow D: Fibromuscular dysplasia involving the intracranial vessels. Case report. J Neurosurg 37:749–752 1972

15.

Jacques SShelden CHRogers DT Jret al: Posttraumatic bilateral middle cerebral artery occlusion. Case report. J Neurosurg 42:2172211975Jacques S Shelden CH Rogers DT Jr et al: Posttraumatic bilateral middle cerebral artery occlusion. Case report. J Neurosurg 42:217–221 1975

16.

Klassen ACSung JHStadlan EM: Histological changes in cerebral arteries with increasing age. J Neuropathol Exp Neurol 27:6076231968Klassen AC Sung JH Stadlan EM: Histological changes in cerebral arteries with increasing age. J Neuropathol Exp Neurol 27:607–623 1968

17.

Kunze SISchiefer W: Angiographic demonstration of a dissecting aneurysm of the middle cerebral artery. Neuroradiology 2:2012061971Kunze SI Schiefer W: Angiographic demonstration of a dissecting aneurysm of the middle cerebral artery. Neuroradiology 2:201–206 1971

18.

Lemahieu SFMarchau MMB: Intracranial fibromuscular dysplasia and stroke in children. Neuroradiology 18:991021979Lemahieu SF Marchau MMB: Intracranial fibromuscular dysplasia and stroke in children. Neuroradiology 18:99–102 1979

19.

Ojemann RGFisher CMRich JC: Spontaneous dissecting aneurysm of the internal carotid artery. Stroke 3:4344401972Ojemann RG Fisher CM Rich JC: Spontaneous dissecting aneurysm of the internal carotid artery. Stroke 3:434–440 1972

20.

Pilz PHartjes HJ: Fibromuscular dysplasia and multiple dissecting aneurysms of intracranial arteries. A further cause of moyamoya syndrome. Stroke 7:3933981976Pilz P Hartjes HJ: Fibromuscular dysplasia and multiple dissecting aneurysms of intracranial arteries. A further cause of moyamoya syndrome. Stroke 7:393–398 1976

21.

Rinaldi IHarris WO JrKopp JEet al: Intracranial fibromuscular dysplasia: report of two cases, one with autopsy verification. Stroke 7:5115161976Rinaldi I Harris WO Jr Kopp JE et al: Intracranial fibromuscular dysplasia: report of two cases one with autopsy verification. Stroke 7:511–516 1976

22.

Robert FMaltais RGiroux JC: Dissecting aneurysm of middle cerebral artery. Case report. J Neurosurg 21:4134151964Robert F Maltais R Giroux JC: Dissecting aneurysm of middle cerebral artery. Case report. J Neurosurg 21:413–415 1964

23.

Sandok BAHauser OWBaker HL Jret al: Fibromuscular dysplasia. Neurologic disorders associated with disease involving the great vessels in the neck. Arch Neurol 24:4624661971Sandok BA Hauser OW Baker HL Jr et al: Fibromuscular dysplasia. Neurologic disorders associated with disease involving the great vessels in the neck. Arch Neurol 24:462–466 1971

24.

Sato OBascon JFLongothetis J: Intracranial dissecting aneurysm. Case report. J Neurosurg 35:4834871971Sato O Bascon JF Longothetis J: Intracranial dissecting aneurysm. Case report. J Neurosurg 35:483–487 1971

25.

Scott GENeubuerger KTDenst J: Dissecting aneurysms of intracranial arteries. Neurology 10:22271960Scott GE Neubuerger KT Denst J: Dissecting aneurysms of intracranial arteries. Neurology 10:22–27 1960

26.

Shaw CMFoltz EL: Traumatic dissecting aneurysm of middle cerebral artery and carotid-cavernous fistula with massive intracerebral hemorrhage. Case report. J Neurosurg 28:4754791968Shaw CM Foltz EL: Traumatic dissecting aneurysm of middle cerebral artery and carotid-cavernous fistula with massive intracerebral hemorrhage. Case report. J Neurosurg 28:475–479 1968

27.

Shields WDZiter FAOsborn AGet al: Fibromuscular dysplasia as a cause of stroke in infancy and childhood. Pediatrics 59:8999011977Shields WD Ziter FA Osborn AG et al: Fibromuscular dysplasia as a cause of stroke in infancy and childhood. Pediatrics 59:899–901 1977

28.

Simionescu NSimionescu M: The cardiovascular system in Weiss LGreep RO (eds): Histologyed 4. New York: McGraw-Hill1977 pp 373431(see p 392)Simionescu N Simionescu M: The cardiovascular system in Weiss L Greep RO (eds): Histology ed 4. New York: McGraw-Hill 1977 pp 373–431 (see p 392)

29.

Slagsvold JEBergsholm PLarsen JL: Fibromuscular dysplasia of intracranial arteries in a patient with multiple enchondromas (Ollier disease). Neurology 27:116811711977Slagsvold JE Bergsholm P Larsen JL: Fibromuscular dysplasia of intracranial arteries in a patient with multiple enchondromas (Ollier disease). Neurology 27:1168–1171 1977

30.

Spudis EVScharyj MAlexander Eet al: Dissecting aneurysms in the neck and head. Neurology 12:8678751962Spudis EV Scharyj M Alexander E et al: Dissecting aneurysms in the neck and head. Neurology 12:867–875 1962

31.

Stehbens WE: Cerebral atherosclerosis. Intimal proliferation and atherosclerosis in the cerebral arteries. Arch Pathol 99:5825911975Stehbens WE: Cerebral atherosclerosis. Intimal proliferation and atherosclerosis in the cerebral arteries. Arch Pathol 99:582–591 1975

32.

Stehbens WE: Focal intimal proliferation in the cerebral arteries. Am J Pathol 36:2893011960Stehbens WE: Focal intimal proliferation in the cerebral arteries. Am J Pathol 36:289–301 1960

33.

Stehbens WE: Intimal proliferation and spontaneous lipid deposition in the cerebral arteries of sheep and steers. J Atheroscler Res 5:5565681965Stehbens WE: Intimal proliferation and spontaneous lipid deposition in the cerebral arteries of sheep and steers. J Atheroscler Res 5:556–568 1965

34.

Stehbens WE: Pathology of the Cerebral Blood Vessels. St Louis: CV Mosby1972 pp 102113Stehbens WE: Pathology of the Cerebral Blood Vessels. St Louis: CV Mosby 1972 pp 102–113

35.

Stehbens WE: Pathology of the Cerebral Blood Vessels. St Louis: CV Mosby1972 pp 434445Stehbens WE: Pathology of the Cerebral Blood Vessels. St Louis: CV Mosby 1972 pp 434–445

36.

Takayanagi TRennels MLNelson E: An electron microscopic study of intimal cushions in intracranial arteries of the cat. Am J Anat 133:4154301972Takayanagi T Rennels ML Nelson E: An electron microscopic study of intimal cushions in intracranial arteries of the cat. Am J Anat 133:415–430 1972

37.

Watson AJ: Dissecting aneurysm of arteries other than the aorta. J Pathol Bacteriol 72:4394491956Watson AJ: Dissecting aneurysm of arteries other than the aorta. J Pathol Bacteriol 72:439–449 1956

38.

Wolman L: Cerebral dissecting aneurysms. Brain 82:2762911959Wolman L: Cerebral dissecting aneurysms. Brain 82:276–291 1959

39.

Yonas HAgamanolis DTakaoka Yet al: Dissecting intracranial aneurysms. Surg Neurol 8:4074151977Yonas H Agamanolis D Takaoka Y et al: Dissecting intracranial aneurysms. Surg Neurol 8:407–415 1977

40.

Zeumer HHauke PKotlarek F: Fibromuskuläre Dysplasie der Carotis interna und der intrazerebralen Gefässe. Dtsch Med Wochenschr 100:1321361975Zeumer H Hauke P Kotlarek F: Fibromuskuläre Dysplasie der Carotis interna und der intrazerebralen Gefässe. Dtsch Med Wochenschr 100:132–136 1975

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