1. Cervicocephalic Vascular Occlusion: Thinking Beyond Atherosclerosis Samuel I Frost DO, Yiping Li MD, Beverly Aagaard-Kienitz MD, Tabassum Kennedy MD 54th Annual Meeting of the American Society of Neuroradiology
Abstract Number: eEdE-26

2. Disclosure
The authors of this presentation have no financial disclosures to make
All diagrams used in this exhibit were created by the authors

3. Objectives Brief review of cervicocephalic dissection including:
Pathophysiology
Demographics
Imaging characteristics
Treatment

4. Cervicocephalic Dissection
Dissection: tear of the intimal vessel wall (yellow arrow) which allows flowing blood to penetrate into and delaminate the layers of the vessel wall.
Dissecting aneurysm
(pseudoaneurysm)
Hematoma (white arrow) narrows and potentially occludes parent vessel lumen.
Dissection with focal outpouching (black arrow)

5. Who Gets Dissection? All ages are affected 2.5-3 cases per 100,000
Mostly young and middle aged adults with peak age of 40 years
Accounts for 10-25% of ischemic strokes in middle aged patients
DSA
62 y/o female with spontaneous dissection of the V2 segment of the right vertebral artery. Note dissection flap (arrow)

6. Etiology Nontraumatic Iatrogenic Traumatic “Idiopathic” Vasculopathy
Fibromuscular dysplasia
Marfan Syndrome
Ehlers-Danlos Type 4
Less common
Hypertension
Migraine headaches
Physical activity
Hyperhomocysteinuria
Pharyngeal infection.
Iatrogenic
Endovascular interventions
Traumatic
Direct
Indirect
Iatrogenic internal carotid artery dissection after elective coil embolization of anterior choroidal artery aneurysm. Note dissection flap (curved arrow) and false lumen opacification (yellow arrow)

7. Internal carotid artery
Location
Dissections occur at the most mobile vessel segment
Start or end in regions of transition from fixed to mobile
Encasing bony canal, dural reflection
Internal carotid artery
Vertebral artery
between skull base and C1
between C1 an C2
Spare the carotid bulb
Usually stop at the skull base

8. Blunt Cerebrovascular Injury Grading
Digital subtraction angiography
Denver Criteria
grade I : mild intimal injury or irregular intima.
grade II : dissection with raised intimal flap / intramural hematoma with luminal narrowing > 25% / intraluminal thrombosis
grade III : pseudoaneurysm
grade IV : vessel occlusion / thrombosis
grade V : vessel transection
Grade I
Grade II
Grade III
Grade IV
Grade V

9. Flame shaped occlusion
Dissection Imaging
Optimal evaluation involves techniques that allow visualization of the vessel lumen
CTA, MRA, Angiography
Classic Signs
CTA
FS T1 MR
CTA
DSA
Double lumen
Eccentric thrombus
Intimal flap
Flame shaped occlusion
Nonspecific signs
Vessel occlusion
Aneurysmal dilation
Stenosis
Double lumen and intimal flap are present in less than 10% of cases

10. Prognosis Disease progression 90% of non-occlusive stenosis resolve
60% of occlusions recanalize
<5% of injuries lead to death
Day 0
Day 3
Sequential TOF MRA studies demonstrating improved vessel patency in a 33 y/o female with spontaneous dissection of the V3 segment of the right vertebral artery (arrows)
Day 21
Day 68

11. Case Examples

12. 36 y/o female with headache, anisocoria, left hemiparesis and aphasia
Dissection resulting in ischemic stroke
36 y/o female with headache, anisocoria, left hemiparesis and aphasia
DWI CT T2
CT shows hyperdense thrombus within the right internal carotid artery (yellow arrow) with corresponding T2 hyperintense thrombus narrowing the vessel lumen (curved arrow) and right posterior middle cerebral artery territory infarct (white arrow)

13. 51 y/o male with history of left sided numbness and weakness
Vasculopathy associated dissection
51 y/o male with history of left sided numbness and weakness
CTA
CTA MIP
CTA MIP
CTA images of bilateral cervical internal carotid artery dissections with classic double lumen sign (yellow arrows) in the setting of fibromuscular dysplasia. Note the beaded appearance of the internal carotid arteries (white arrows)

14. Classic internal carotid artery location
50 y/o female with new onset facial droop and expressive aphasia
CBV
CTA
CTA
MTT
CTA shows left internal carotid artery dissection extending from above the carotid bulb to the skull base (yellow arrows) with resultant left frontal lobe infarct (white arrow) and large area of ischemic penumbra (black arrows)

15. 44 y/o female with left facial droop and left sided weakness
Nonspecific signs of dissection
44 y/o female with left facial droop and left sided weakness
MTT
FS PD T2
CBV
FS PD and T2 images show hyperintense circumferential thrombus narrowing the cervical left internal carotid artery and resulting in prolonged transit to left cerebral hemisphere with compensated cerebral blood volume. This is atypical of atherosclerotic disease in both location and configuration and is consistent with spontaneous dissection

16. 44 y/o female with right arm numbness and tingling
Nonspecific signs of dissection
44 y/o female with right arm numbness and tingling
CBF
CTA
MTT
DSA
CTA shows nonspecific near occlusive stenosis of the cervical left internal carotid artery (yellow arrow) with associated prolonged transit and decreased cerebral blood flow. Digital subtraction angiography confirms vessel injury (white arrow) in the setting of fibromuscular dysplasia (curved arrow)

17. Posttraumatic intracranial dissection
11 y/o male presents after semi vs car moter vehicle accident CT
CTA
DSA
Comminuted basisphenoid fracture involves the right carotid canal (yellow arrow). CTA and DSA show multiple traumatic pseudoaneurysms of the cavernous and supraclinoid internal carotid artery (white and black arrows)

18. Posttraumatic vertebral artery occlusion
53 y/o male presents after rollover motor vehicle accident
CTA
CTA CT CT
CTA CT
CT images show type II dens fracture (white arrows) as well as left C2 transverse process fracture which involves the foramen transversarium (black arrows). Sequential CTA images show complete occlusion of the distal V2 segment of the left vertebral artery (yellow arrows)

19. Treatment Treatment options Imaging surveillance Antiplatelet
Anticoagulation
Endovascular repair
Open surgical repair
Treatment is based on injury grade, presentation, comorbities and injury etiology
Pre-Stent DSA
Post-Stent DSA
Endovascular stent repair (arrow) of a FMD associated dissection of the cervical left internal carotid artery

20. Treatment algorithm Injury Type Anticoagulation risk
Recommended Treatment
Grade I
High
Low
None
Antiplatelet II
None vs delayed antiplatelet
Antiplatelet +/- anticoagulation
III
Anticoagulation IV
Endovascular embolization V
Surgery vs endovascular repair

21. Endovascular treatment
40 y/o woman presents after motor vehicle accident
Pre-stent DSA
Pre-stent DSA
CTA
Post-stent DSA
AP and lateral DSA images show long segment traumatic internal carotid artery dissection (white arrows) with focal pseudoaneurym (curved arrow) which is treated with multiple overlapping stents (yellow arrows)

22. Endovascular treatment
69 y/o women presents after motor vehicle accident
3D DSA
Pre-stent DSA
DSA image shows large post traumatic pseudoaneurysm of the cervical left internal carotid artery (white arrow) which was successful treated with flow diverting stent (yellow arrow). Immediate post stent 3D DSA reformat from shows stent in good position relative to pseudoaneurysm (curved arrow)

23. Summary Look for classic intimal flap and double lumen signs
Additional clues: Eccentric thrombus, stenosis, occlusion or aneurysmal dilation
Evaluate lesion location and adjacent vasculature
Multiple sites, evidence of atherosclerotic disease or underlying vasculopathy?
Consider patient presentation and history
Spontaneous, traumatic and iatrogenic etiologies
Age, gender, risk factors, and comorbities

24. Thank You