Acta Neurol Belg DOI 10.1007/s13760-014-0401-0
NEURO-IMAGES
Blooming artery sign in proximal posterior inferior cerebellar artery dissection Hiroshi Yokota • Miho Kakutani • Seisuke Miyamae Taiji Yonezawa
•
Received: 3 November 2014 / Accepted: 27 November 2014 Ó Belgian Neurological Society 2014
Keywords Posterior inferior cerebellar artery dissection Blooming effect Magnetic resonance imaging Gradient echo image Ischemia Subarachnoid hemorrhage
Case A 46-year-old man developed vertigo and vomiting, and came to us the next day. The patient had no risk factors related to cerebrovascular disease except for current smoking status. Neurological examinations demonstrated a left-beating horizontal nystagmus and cerebellar sign on the left side. Non-contrast computed tomography (CT) revealed a low-density area in the left cerebellum in the area of the posterior inferior cerebellar artery (PICA) (Fig. 1a). In magnetic resonance (MR) angiography findings, the left PICA was invisible and the vertebral artery (VA) was intact (Fig. 1b), while a hypo-intense ‘‘blooming’’ artery sign was noted in the left PICA in T2*weighted MR image (Fig. 1c). Digital subtraction angiography (DSA) demonstrated abruption of the PICA without definite aneurysmal dilatation (Fig. 1e). We treated the patient with an intravenous administration of glycerol and the free radical scavenger edaravone. No anticoagulant or antiplatelet agents were given. Seven days after the ischemic onset, the patient had a sudden severe headache and vomiting, and CT demonstrated a newly developed diffuse subarachnoid hemorrhage (SAH) (Fig. 1d). DSA revealed a saccular-like aneurysm at proximal PICA just after branching off from the left VA H. Yokota (&) M. Kakutani S. Miyamae T. Yonezawa Department of Neurosurgery, Osaka Police Hospital, Kitayama-cho 10-31, Tennouji-ku, Osaka 543-0035, Japan e-mail: [email protected]
(Fig. 1f). Emergency surgery was performed via a lateral suboccipital approach. Intraoperatively, the aneurysm was saccular in shape and arose at the bend of the PICA itself just after branching off from the intact VA, while the aneurysmal sac and continuous distal PICA wall were dark purple in color. The PICA was occluded by surgical clipping at its origin. No new ischemic lesions developed after the operation.
Discussion Early diagnosis of PICA dissection is important to manage the probable complicated clinical course. However, it can be difficult to detect isolated PICA dissection, as dissection of a small caliber PICA can be manifested as abruption or occlusion [1]. Acute arterial thrombus can be detected on MR imaging, in which hypo-intense intravascular sign on gradient echo or susceptibility-weighted imaging (SWI) sequences has been reported as blooming artery sign in patients with major intracranial artery thrombotic occlusion [2]. Park et al. [3] emphasized the usefulness of SWI findings to show the blooming effect of the affected PICA in 6 of 7 patients with isolated PICA dissection. And we presented a case showing proximal PICA dissection initially visualized as ischemic PICA occlusion with T2*weighted MR image of a blooming artery sign. As initial treatment, intravenous administrations of glycerol and edaravone were given based on the Japanese guidelines for management of ischemic stroke [4]. Subsequently, the patient suffered from SAH, despite no anticoagulant or antiplatelet treatment. A case similar to ours, with ischemic onset and secondary SAH due to proximal PICA dissection, has also been reported [5], in which the patient was initially treated with anticoagulant and antiplatelet agents,
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Acta Neurol Belg
Fig. 1 a Infarction in territory of left PICA depicted by CT. b Intact VA without depiction of PICA on the left shown by MR angiogram. c Blooming effect of left PICA demonstrated by T2*-weighted MR imaging. d CT showing SAH in addition to previous infarction.
e Abruption of left PICA without aneurysmal dilatation (arrowheads) shown by 3-dimensional (3D)-DSA. f Saccular-like aneurysm of the proximal PICA (arrow) demonstrated by 3D-DSA. L-VA left vertebral artery
and developed SAH 24 h later. Also, a Japanese survey revealed occurrence of SAH after ischemic onset of intracranial dissecting aneurysm in 3.4 % (4 of 118) of reported cases [6]. All 4 showed vertebrobasilar arterial dissection and 2 received antiplatelet administration as an initial treatment. The present case demonstrated two clinical presentations associated with intracranial arterial dissection, ischemia and SAH. The dynamic nature of the evolution from occlusion to aneurysm strongly suggested the pathogenesis. Blooming artery sign shown by MR imaging may be helpful to detect an underlying arterial dissection.
References
Conflict of interest
123
Authors declare no conflict of interest.
1. Ishihara H, Tateshima S, Jahan R, Gonzalez N, Duckwiler G, Vinuela F (2013) Endovascular treatment of ruptured dissecting aneurysms of the posterior inferior cerebellar artery. J Neurointerv Surg 5:557–561 2. Rovira A, Orellana P, Alvarez-Sabin J, Arenillas JF, Aymerich X, Grive E, Molina C, Rovira-Gols A (2004) Hyperacute ischemic stroke: middle cerebral artery susceptibility sign at echo-planar gradient-echo MR imaging. Radiology 232:466–473 3. Park MG, Choi JH, Yang TI, Oh SJ, Baik SK, Park KP (2014) Spontaneous isolated posterior inferior cerebellar artery dissection: rare but underdiagnosed cause of ischemic stroke. J Stroke Cerebrovasc Dis 23:1865–1870 4. Kern R, Nagayama M, Toyoda K, Steiner T, Hennerici MG, Shinohara Y (2013) Comparison of the European and Japanese guidelines for the management of ischemic stroke. Cerebrovasc Dis 35:402–418
Acta Neurol Belg 5. Takumi I, Mizunari T, Mishina M, Fukuchi T, Nomura R, Umeoka K, Kobayashi S, Teramoto A (2007) Dissecting posterior inferior cerebellar artery aneurysm presenting with subarachnoid hemorrhage right after anticoagulant and antiplatelet therapy against ischemic event. Surg Neurol 68:103–107
6. Yamaura A, Yoshimoto T, Hashimoto N, Ono J (1998) Nationwide study of nontraumatic intracranial arterial dissection: clinical features and outcome (in Japanese with English abstract). Surg Cereb Stroke (Jpn) 26:79–86
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NEURO-IMAGES
Blooming artery sign in proximal posterior inferior cerebellar artery dissection Hiroshi Yokota • Miho Kakutani • Seisuke Miyamae Taiji Yonezawa
•
Received: 3 November 2014 / Accepted: 27 November 2014 Ó Belgian Neurological Society 2014
Keywords Posterior inferior cerebellar artery dissection Blooming effect Magnetic resonance imaging Gradient echo image Ischemia Subarachnoid hemorrhage
Case A 46-year-old man developed vertigo and vomiting, and came to us the next day. The patient had no risk factors related to cerebrovascular disease except for current smoking status. Neurological examinations demonstrated a left-beating horizontal nystagmus and cerebellar sign on the left side. Non-contrast computed tomography (CT) revealed a low-density area in the left cerebellum in the area of the posterior inferior cerebellar artery (PICA) (Fig. 1a). In magnetic resonance (MR) angiography findings, the left PICA was invisible and the vertebral artery (VA) was intact (Fig. 1b), while a hypo-intense ‘‘blooming’’ artery sign was noted in the left PICA in T2*weighted MR image (Fig. 1c). Digital subtraction angiography (DSA) demonstrated abruption of the PICA without definite aneurysmal dilatation (Fig. 1e). We treated the patient with an intravenous administration of glycerol and the free radical scavenger edaravone. No anticoagulant or antiplatelet agents were given. Seven days after the ischemic onset, the patient had a sudden severe headache and vomiting, and CT demonstrated a newly developed diffuse subarachnoid hemorrhage (SAH) (Fig. 1d). DSA revealed a saccular-like aneurysm at proximal PICA just after branching off from the left VA H. Yokota (&) M. Kakutani S. Miyamae T. Yonezawa Department of Neurosurgery, Osaka Police Hospital, Kitayama-cho 10-31, Tennouji-ku, Osaka 543-0035, Japan e-mail: [email protected]
(Fig. 1f). Emergency surgery was performed via a lateral suboccipital approach. Intraoperatively, the aneurysm was saccular in shape and arose at the bend of the PICA itself just after branching off from the intact VA, while the aneurysmal sac and continuous distal PICA wall were dark purple in color. The PICA was occluded by surgical clipping at its origin. No new ischemic lesions developed after the operation.
Discussion Early diagnosis of PICA dissection is important to manage the probable complicated clinical course. However, it can be difficult to detect isolated PICA dissection, as dissection of a small caliber PICA can be manifested as abruption or occlusion [1]. Acute arterial thrombus can be detected on MR imaging, in which hypo-intense intravascular sign on gradient echo or susceptibility-weighted imaging (SWI) sequences has been reported as blooming artery sign in patients with major intracranial artery thrombotic occlusion [2]. Park et al. [3] emphasized the usefulness of SWI findings to show the blooming effect of the affected PICA in 6 of 7 patients with isolated PICA dissection. And we presented a case showing proximal PICA dissection initially visualized as ischemic PICA occlusion with T2*weighted MR image of a blooming artery sign. As initial treatment, intravenous administrations of glycerol and edaravone were given based on the Japanese guidelines for management of ischemic stroke [4]. Subsequently, the patient suffered from SAH, despite no anticoagulant or antiplatelet treatment. A case similar to ours, with ischemic onset and secondary SAH due to proximal PICA dissection, has also been reported [5], in which the patient was initially treated with anticoagulant and antiplatelet agents,
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Acta Neurol Belg
Fig. 1 a Infarction in territory of left PICA depicted by CT. b Intact VA without depiction of PICA on the left shown by MR angiogram. c Blooming effect of left PICA demonstrated by T2*-weighted MR imaging. d CT showing SAH in addition to previous infarction.
e Abruption of left PICA without aneurysmal dilatation (arrowheads) shown by 3-dimensional (3D)-DSA. f Saccular-like aneurysm of the proximal PICA (arrow) demonstrated by 3D-DSA. L-VA left vertebral artery
and developed SAH 24 h later. Also, a Japanese survey revealed occurrence of SAH after ischemic onset of intracranial dissecting aneurysm in 3.4 % (4 of 118) of reported cases [6]. All 4 showed vertebrobasilar arterial dissection and 2 received antiplatelet administration as an initial treatment. The present case demonstrated two clinical presentations associated with intracranial arterial dissection, ischemia and SAH. The dynamic nature of the evolution from occlusion to aneurysm strongly suggested the pathogenesis. Blooming artery sign shown by MR imaging may be helpful to detect an underlying arterial dissection.
References
Conflict of interest
123
Authors declare no conflict of interest.
1. Ishihara H, Tateshima S, Jahan R, Gonzalez N, Duckwiler G, Vinuela F (2013) Endovascular treatment of ruptured dissecting aneurysms of the posterior inferior cerebellar artery. J Neurointerv Surg 5:557–561 2. Rovira A, Orellana P, Alvarez-Sabin J, Arenillas JF, Aymerich X, Grive E, Molina C, Rovira-Gols A (2004) Hyperacute ischemic stroke: middle cerebral artery susceptibility sign at echo-planar gradient-echo MR imaging. Radiology 232:466–473 3. Park MG, Choi JH, Yang TI, Oh SJ, Baik SK, Park KP (2014) Spontaneous isolated posterior inferior cerebellar artery dissection: rare but underdiagnosed cause of ischemic stroke. J Stroke Cerebrovasc Dis 23:1865–1870 4. Kern R, Nagayama M, Toyoda K, Steiner T, Hennerici MG, Shinohara Y (2013) Comparison of the European and Japanese guidelines for the management of ischemic stroke. Cerebrovasc Dis 35:402–418
Acta Neurol Belg 5. Takumi I, Mizunari T, Mishina M, Fukuchi T, Nomura R, Umeoka K, Kobayashi S, Teramoto A (2007) Dissecting posterior inferior cerebellar artery aneurysm presenting with subarachnoid hemorrhage right after anticoagulant and antiplatelet therapy against ischemic event. Surg Neurol 68:103–107
6. Yamaura A, Yoshimoto T, Hashimoto N, Ono J (1998) Nationwide study of nontraumatic intracranial arterial dissection: clinical features and outcome (in Japanese with English abstract). Surg Cereb Stroke (Jpn) 26:79–86
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