Regressing intracranial carotid occlusions in childhood

3T MRI - 3D DSA Fusion Technique on Posterior Cerebral Artery Dissecting Aneurysm: Understanding a Potential Pathophysiologic Mechanism

SUMMARY

We aimed to show the anatomical relationship between a dissecting aneurysm of the posterior cerebral artery (PCA) and tentorial free edge to understand the pathophysiologic mechanism. A 52-year-old woman with a history of head trauma presented with dizziness and numbness in her left fingers. 3D DSA showed a dissecting aneurysm of the right P2-P3 segment of PCA. The fusion of 3D DSA and 3T MRI was performed at the dedicated workstation using three pairs of landmarks including the ICA termination, MCA bifurcation and A1-A2 junction of the right ACA. Fusion of 3D DSA and 3T MRI clearly demonstrated the dissected segment of PCA crossed the tentorial free edge twice. The fusion images support the direct trauma hypothesis of dissecting aneurysm of the P2-P3 segment of PCA. This novel imaging technique shows future potential to be used to understand the anatomical relationships between various vascular lesions and surrounding structures.

Ischaemic stroke from dissection of the craniocervical arteries in childhood: report of 12 patients

Dissection of craniocervical arteries is the most common non-atherosclerotic cause of stroke in young adults. During childhood, it is described primarily as isolated reports. Among 59 patients with arterial ischaemic stroke seen consecutively in the same institution, 12 had a dissection of a cervical or cerebral artery. The diagnosis was established through imaging features. The dissection involved the cervical arteries in five patients and intracranial arteries in seven. A cervical or facial trauma preceded the onset of cerebral ischaemic symptoms in four patients with extracranial dissection by a few minutes to 10 days. For another six patients, the stroke occurred during physical exertion. The neurological deficit was preceded or associated with an intense headache or neck pain in nine patients. Initial treatment consisted of anticoagulation therapy in two patients with extracranial dissection, and aspirin in nine. There was only one recurrence of stroke after a mean follow-up of 3 years and 6 months. Four patients had persistent disabling neurological deficit. Dissection of cervical or cerebral arteries appears to be a common cause of stroke in childhood.

[Specifics in pediatric arterial cerebral infarctions]

Despite the number of potential causes, most children with ischemic cerebrovascular disease are classified into a few major categories: 1) cardioembolic stroke; 2) moyamoya syndrome; 3) complication(s) connected with systemic disease, with a known risk of a cerebrovascular event; 4) cervicocephalic arterial dissection; and 5) transient cerebral arteriopathy of undefined origin (probable arteritis). The etiological diagnosis is rapidly established by complementary investigations based on the initial clinical and imaging findings: cardiac exploration, magnetic resonance imaging and angiography or echo-doppler of the cervical arteries if cervical dissection is suspected; intra-arterial catheter cerebral angiography and analysis of the cerebrospinal fluid to investigate an intracranial arteriopathy. The outcome and treatment depend on the type of stroke, on its accurate identification, and on prediction regarding the risk of recurrence. Although there is a constitutional predisposition to cerebrovascular accidents, environmental triggers such as trauma, infectious disease and cardiac surgery also play a major role.

Cerebrovascular arterial dissection in children and young adults

Dissection of the cervical and intracranial portions of the carotid and vertebrobasilar arteries may occur spontaneously or in association with trauma or other underlying risk factors. Astute recognition allows appropriate diagnostic and therapeutic protocols to be instituted. Dissection of extracranial carotid and vertebral arteries differ from their intracranial counterparts, both in terms of presentation and prognosis. Limited data are available regarding the most effective medical treatment of dissection in children and young adults. Interventional neuroradiology may offer a new approach in difficult cases. A multicenter controlled clinical trial is needed to assess the most effective treatment.

Transient cerebral arteriopathy: a disorder recognized by serial angiograms in children with stroke

Repeated clinical evaluation and cerebral arteriography during the evolution of ischemic strokes of idiopathic origin allowed us to characterize a transient cerebral arteriopathy. We retrospectively studied the clinical characteristics, course, and neuroimaging features of this disorder in nine children. Of 34 children with ischemic strokes seen consecutively between 1984 and 1995, 9 (26%) were diagnosed as having transient attack of the cerebral arterial wall, termed transient cerebral arteriopathy. All of these patients had previously been in good health. The mean age at the time of the first stroke was 6 years (range, 2 9/12 years to 13 4/12 years). All children presented with acute hemiplegia. A recurrence of the stroke took place 3 months at the latest after the initial infarct in three children (mean clinical follow-up 2 7/12 years). Cerebral imaging in all the patients showed small subcortical infarcts located in basal ganglia or internal capsule. Arteriography revealed multifocal lesions of the arterial wall (focal stenosis or segmental narrowing), mostly located in the initial parts of basal arteries of the carotid system. Longitudinal arteriographic follow-up showed initial worsening of these arterial lesions (n = 5) for a maximum duration of 7 months followed by complete regression (n = 2), improvement (n = 5), or stabilization of the lesions (n = 2). Five patients had a complete clinical recovery. Further studies are necessary to confirm a presumed inflammatory cause of this arteriopathy.