Benign arterial dissections of the posterior circulation

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✓ Four young adults with spontaneous dissection of the vertebrobasilar system are reported. Clinically, two patients presented with subarachnoid hemorrhage and two with brain-stem ischemia. In two cases of ruptured arterial dissection of the posterior cerebral artery, angiography demonstrated fusiform and “sausage-like” dilatation of the involved vessel. In two cases of occlusive dissection of the basilar artery, angiography revealed the typical “string sign.” All four patients were treated conservatively: three survive in good clinical condition and one remains disabled. Follow-up angiograms showed spontaneous healing of the lesion with return to an almost normal arterial configuration in two cases; residual narrowing corresponding to the dissection was the most notable finding in the other two. It is recommended that, in a subset of neurologically stable patients, angiographic monitoring is undertaken to assess the tendency for spontaneous repair before surgical intervention is planned.

Article Information

Address reprint requests to: Eugenio Pozzati, Divisione di Neurochirurgia, Ospedale Bellaria, 40139 Bologna, Italy.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Vertebral angiograms, anteroposterior view. Left: Admission study showing an almost complete tapering occlusion (“string sign,” arrow) of the midportion of the basilar artery. Right: Angiogram obtained 4 years later demonstrating normal caliber of the basilar artery.

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    Case 2. Vertebral angiograms, anteroposterior view. Left: Admission study showing a “sausage-like” swelling of the right posterior cerebral artery (PCA, arrow) with diffuse narrowing of the basilar artery and the left PCA. Right: Angiogram obtained 1 month later demonstrating normal caliber in the previous dilated and narrowed arterial segments. A residual “wedge-shaped” defect (arrow) of the proximal right PCA is present.

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    Case 3. Computerized tomography scan demonstrating diffuse subarachnoid bleeding and punctate hyperdensity in the left peduncular region (arrow) corresponding to the posterior cerebral artery.

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    Case 3. Vertebral angiograms. Left: Admission study showing stenosis of the intracranial vertebral artery and a fusiform aneurysm (arrow) of the left posterior cerebral artery (PCA). Right: Angiogram obtained 2 months later showing residual narrowing of the left PCA at the site of the previous dilatation.

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    Case 4. Vertebral angiograms. Left: Admission angiogram, lateral view, late arterial phase, showing tapering occlusion of the distal basilar artery (“string sign,” arrow). Center and Right: Angiograms, lateral (center) and anteroposterior (right) views, obtained 3 weeks later showing residual stenosis of the distal basilar artery and nodular narrowing of the posterior cerebral arteries with occlusion of the distal branches on the right side.

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