Case Report
Vertebral Artery Dissection: Can We Afford to Miss It?
Ojha PT, Shashank N*, Patil S, Chheda A, Kadam NS and Ansari A
Department of Neurology, Grant Medical College and Sir JJ Group of Hospitals, India
*Corresponding author: Shashank N, Department of Neurology, Grant Medical College and Sir JJ Group of Hospitals, India
Published: 19 Apr, 2018
Cite this article as: Ojha PT, Shashank N, Patil S, Chheda
A, Kadam NS, Ansari A. Vertebral
Artery Dissection: Can We Afford to
Miss It?. Clin Oncol. 2018; 3: 1431.
Abstract
Vertebral Artery Dissection (VAD) is an infrequent occurrence but is a leading cause of stroke in
young and otherwise healthy patients. CTA, MRI and catheter angiography can all be used to detect
vertebral artery dissection and each has pros and cons. Here we discuss two cases of stroke in young
where the presence of double lumen sign on axial sequences of GRE provided the clue to intracranial
arterial dissection as the etiology of stroke. This helped avoid unnecessary and expensive etiological
evaluation of stroke in young.
Keywords: Vertebral artery dissection; Double lumen sign
Abbreviations
VAD: Vertebral Artery Dissection; CTA: CT Angiography; MRI: Magnetic Resonance Imaging; GRE: Gradient ECHO; ER: Emergency Room; LMWH: Low Molecular Weight Heparin
Case Presentation
Case 1
A 43 year old male developed sudden weakness of left side of body, along with imbalance and
dizziness after strenuous exercise in gymnasium. On presentation in ER after 1 hour of the onset
of symptoms, his blood pressure was found elevated to 180/110 mm Hg. Though, he was fully
conscious, left side limb power was reduced to 3 MRC to 4/5 MRC grade with marked ipsilateral
appendicular ataxia.
Urgent MRI Brain imaging showed Left cerebellar infarct (Figure 1a,b). MRI Brain Angiography
showed poor visualisation of left vertebral artery (possibilities being: hypoplastic artery or affected by
dissection, stenosis or thrombosis) (Figure 2a). None of the commonly described signs of dissection
were observed, but there was a strong suspicion of vertebral artery dissection. On close observation,
GRE brain axial sequences showed presence of both true and false lumen (double lumen sign)
(Figure 2b), confirming our suspicion of dissection of the intracranial segment of left vertebral
artery. Patient was thrombolysed with intravenous alteplase and improved nearly completely within
next 24 hours. He was administered LMWH for then next 5 days and discharged on antiplatelets.
Follow up MRI brain angiography, showed complete recanalisation of the left vertebral artery with
resolution of double lumen sign (Figure 3a,b).
Case 2
A 39 year old male had been experiencing shooting pain in the neck along with transient
difficulty in swallowing and tingling in left side of the body for the last one week. He was admitted
in hospital when he further developed for left upper limb weakness and imbalance occuring for over
12 hours. On examination his Blood pressure was 160/100 mm Hg. Clinical examination revealed
left lateropulsion of stance, left upper limb incoordination and gait ataxia. This was accompanied by
dysarthria, dysphagia to solids and left hemianesthesia.
MRI Brain showed Left medullary acute infarct (Figure 4a,b) and MRI Brain Angiography
showed poor visualisation of the left vertebral artery (Figure 5a). GRE axial brain sequences revealed
double lumen sign in intracranial segment of left vertebral artery thereby indicating dissection.
Patient was started on antiplatelets with LMWH. As he was out of time window for IV
thrombolysis, it was withheld. He improved rather quickly in a matter of few days. Follow up MRI
brain angiography showed complete recanalisation of the intracranial left vertebral artery with
resolution of double lumen sign (Figure 5b).
Discussion
Intracranial Arterial Dissection (ICAD), especially Vertebral Artery Dissection (VAD) is an
increasingly recognized cause of stroke in patients younger than
45 years., Advances in neuro-imaging have contributed to growing
awareness of this entity.
Typical patients with VAD present with posterior neck pain or
headache, followed by ischemia of the vertebrobasilar system. Initial
manifestations of VAD however, are less distinct than those of carotid
artery dissection and usually interpreted as musculoskeletal pain [1,2].
Therefore, an accurate neurologic examination and detailed historytaking
are mandatory, particularly in young adults, in order to search
for symptoms or focal signs of brainstem stroke. Ischemic symptoms
occur in more than 90% of VAD patients and may involve the brain
stem, especially the lateral medulla (Wallenberg’s syndrome).
Though Catheter angiography is the gold standard for diagnosis
of VAD, it is not routinely available at many centers. Characteristic
features are vessel irregularity and/or stenosis, string sign, double
lumen, pseudoaneurysm formation or complete occlusion.
Magnetic resonance techniques [3,4] are now replacing conventional
angiography in the diagnosis of most strokes, especially dissections
of intracranial arteries. The resolution of magnetic resonance
angiography now approaches that of conventional angiography,
and magnetic resonance imaging very often shows the intramural
hematoma on routine sequences. The intramural hematoma
characteristically has a crescentic shape adjacent to the vessel lumen
and often spirals along the length of the artery. Gradient Echo/
SWI axial images of MRI brain have the capability to show blood/
thrombus in brain, hence can be used in early detection of ICAD/
VAD.
As MRI is being widely used, recognition of this “DOUBLE
LUMEN SIGN on GRE or SWI” is helpful in detecting intracranial
dissection. Detection of double lumen sign in intracranial VAD
helped in accurate etiologic diagnosis and adequate treatment in both
of these patients.
To prevent thromboembolic complications, anticoagulation with
intravenous heparin followed by oral warfarin has been recommended
for all patients with acute dissections of the vertebral artery, regardless
of the type of symptoms, unless there are contraindications such as the
presence of a large infarct with associated mass effect, hemorrhagic
transformation of the infarcted area, an intracranial aneurysm and
intracranial extension of the dissection [5]. Although antithrombotic
treatment has been advocated since the 1970s [6], no randomized
trials have been reported and the validity of such treatment has never
been proved and use of antiplatelets have been shown comparable to
the use of anticoagulation. Anticoagulation with a target international
normalized ratio (INR) of 2.0 to 3.0 is generally used for three to six
months.
While thrombolysis [7,8] in the setting of dissection may
theoretically cause enlargement of the intramural hematoma,
accumulating evidence suggests that the effectiveness and safety of
thrombolysis for patients with ischemic stroke related to cervical
artery dissection are similar to its effectiveness and safety for patients
with ischemic stroke from other causes.
Most VADs heal spontaneously [9]. However, an urgent
surgical intervention may be required in patients presenting with
SAH. Symptomatic aneurysmal dilatation of the artery may also
warrant surgery. Chronic VADs have also been treated by surgical
reconstruction to prevent further ischemic or thromboembolic
complications, if medical treatment with six month anticoagulation
fails or if the dissecting aneurysms and/or high grade stenosis persist.
Surgical interventions include endovascular treatment and the
arterial repair.
In conclusion, axial GRE/SWI sequences of MRI brain should
be examined carefully for presence of double lumen sign related
to intracranial artery dissection. Arterial dissection remains and
important cause of stroke in young. It might help save a lot of
unnecessary etiologic investigations in such patients. The further
management of such cases might also differ on the basis of type/
severity of dissection.
Figure 1a and 1b
Figure 2a
Figure 3a and 3b
Figure 3a and 3b
Follow up angiogram of the patient showing recanalisation
of left vertebral artery.
Figure 4a and 4b
Figure 5a
Figure 5a
MRI Angiography images showing left vertebral artery absent. 5b:
Double Lumen sign of left vertebral artery.
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