Unruptured intracranial vertebral artery dissection. Clinical course and serial radiographic imagings

Abstract

Background and purpose: Intracranial vertebral artery dissection is an increasingly recognized cause of stroke. However, little is known about its natural history and clinical manifestations, and appropriate management protocol has not yet been established. This study was performed to clarify its clinical course and determine the best management protocol.

Methods: This study is a retrospective clinical and radiographic review of 11 patients with 13 lesions who presented between 1990 and 1996. Patients with a history of trauma and those who presented with subarachnoid hemorrhage were excluded. The 11 patients comprised seven men and four women, who ranged in age from 34 to 71 years, with a mean age of 47 years. Ten patients presented with ischemic symptoms.

Results: Although recurrent ischemic attacks were observed in two patients, most (90%) subsequently made a good recovery and returned to their previous lifestyle. Five arteries showed the typical "string sign" or "pearl and string sign" on initial angiography. They changed in the follow-up examinations, which demonstrated either resolution of the stenosis or progression to complete occlusion. In contrast, the angiographic signs of complete occlusion (three arteries) or aneurysmal dilatation without luminal stenosis (four arteries) remained unchanged during the observation period of 5 months to 2.5 years. MRI was a sensitive tool for diagnosing intracranial vertebral artery dissection; intramural thrombus and intimal flap were the two major findings. MR angiography was also useful for demonstrating abnormalities of the arterial signal column such as pseudolumen or aneurysmal dilatation.

Conclusions: The natural history of unruptured intracranial vertebral artery dissection seems relatively benign, with a high probability (62%) of spontaneous angiographic cure. Some persistent aneurysmal dilatation may be amenable to intravascular coil embolization.