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Cerebellar swelling after sacrifice of the superior petrosal vein during microvascular decompression for trigeminal neuralgia
Journal of Clinical Neuroscience 16 (2009) 1342–1344
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Reports
Cerebellar swelling after sacrifice of the superior petrosal vein during microvascular decompression for trigeminal neuralgia Jun Masuoka a,*, Toshio Matsushima a, Takashi Hikita b, Eiko Inoue b a b
Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan Department of Neurosurgery, Hamanomachi Hospital, Fukuoka, Japan
a r t i c l e
i n f o
Article history: Received 6 August 2008 Accepted 14 December 2008
Keywords: Microvascular decompression Complication Superior petrosal vein Venous infarction Brain edema
a b s t r a c t The importance of preserving the deep cerebral venous outflow has been recognized in microvascular decompression for trigeminal neuralgia; however, few reports have described the details of complications arising from the sacrifice of the superior petrosal vein (SPV). During the procedure in a 77-yearold woman, some tributaries of the SPV complex were sacrificed to achieve microvascular decompression for right trigeminal neuralgia. Postoperatively, the patient was conscious and pain free; however, on postoperative day 1 she developed headache and nausea followed by a decreased level of consciousness. MRI revealed an extensive venous infarction in the right cerebellum. Sacrifice of the SPV may lead to serious, potentially life-threatening complications. Neurosurgeons should pay close attention to the management of the SPV to reduce the risk of venous complications. Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction Microvascular decompression (MVD) is widely accepted as an effective method to treat trigeminal neuralgia (TN) in patients who are refractory to medical therapy. MVD has become a safer procedure due to advances in microsurgical techniques; however, undesirable sequelae, such as hearing loss, facial anaesthesia and cerebellar contusion, may occur following surgery.1 Recently, the importance of preserving the venous system has been emphasized,2 but few reports have described the details of complications arising from sacrificing the SPV. In our series of 170 patients treated with MVD for TN, one patient developed a serious complication resulting from the sacrifice of the SPV. We report a detailed clinical course of this patient and discuss the management of the SPV. 2. Case report A 77-year-old woman presented with a 5-year history of classical right-sided TN. Her symptoms were poorly controlled with increasing doses of carbamazepine. MRI revealed a vessel impinging on the right trigeminal nerve. No other abnormalities were found. She underwent MVD via a right lateral suboccipital craniotomy. After adequate cerebrospinal fluid drainage from the cerebellopontine angle cistern, the superolateral surface of the cerebellum was gently retracted, and the SPV was easily identified.
* Corresponding author. Tel.: +81 952 34 2346; fax: +81 952 34 2066. E-mail address: [email protected] (J. Masuoka).
The SPV complex was composed of four tributaries: the superior hemispheric vein, the vein of the cerebellopontine fissure, the pontotrigeminal vein and the vein of the middle cerebellar peduncle (Fig. 1). The former three tributaries joined to form a common stem, and the vein of the middle cerebellar peduncle drained directly into the superior petrosal sinus. During MVD, the common stem of the three tributaries was sacrificed to obtain a satisfactory view of the trigeminal nerve. A bifurcation of the superior cerebellar artery (SCA) compressed the trigeminal nerve at the medial side of the root entry zone (Fig. 2). The SCA was transposed and fixed to the tentorium in order to free the compressed trigeminal nerve. The surgical procedure was uneventful and the cerebellum remained slack until the dura mater was closed. Soon after the operation, the patient regained normal consciousness, and the neuralgia resolved completely; however, she developed a headache and vomiting, and her consciousness deteriorated to drowsiness on postoperative day 1. Fluid-attenuated inversion recovery MRI revealed a heterogeneously hyperintense area in the right cerebellum, suggesting haemorrhagic infarction (Fig. 3). The patient was treated conservatively and gradually improved until being discharged with mild cerebellar ataxia 4 months later.
3. Discussion The mechanism responsible for cerebellar edema in our patient is not clear, but we think that it was caused by the sacrifice of the SPV because: (i) the edema was most prominent in the deep part of the cerebellum, but was mild on the surface of the cerebellum where it was in direct contact with the retractor spatula; (ii) the
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1342–1344
Fig. 1. Intraoperative photograph showing the upper portion of the right cerebellopontine angle and the superior petrosal vein complex.
Fig. 2. Intraoperative photograph after sectioning the common stem of the three tributaries of the superior petrosal vein. The middle cerebellar peduncle vein (black arrows) drains directly into the superior petrosal sinus. The superior cerebellar artery (white arrows) compresses the trigeminal nerve. CN = cranial nerve.
Fig. 3. Axial fluid-attenuated inversion recovery MRI showing a heterogeneously hyperintense area in the right cerebellum, representing haemorrhagic infarction.
1343
lesion contained a haemorrhagic component believed to be caused by venous hypertension, which is an indirect sign of venous infarction and; (iii) the topography of the lesion was not consistent with a known arterial territory, but was compatible with the drainage territory of the SPV. SPV is an important venous drainage system in the posterior fossa. This venous complex drains the anterior aspect of the brainstem and cerebellum, and empties into the superior petrosal sinus. The most common tributaries of the SPV are the vein of the cerebellopontine fissure, the vein of the middle cerebellar peduncle, the transverse pontine vein, the pontotrigeminal vein and the veins draining the lateral cerebellar hemisphere (Fig. 4).3,4 In MVD for TN, SPV is a major obstacle as well as an anatomical landmark. The management of SPV during surgery is controversial. Some authors report that SPV can be sectioned without related complications: Samii et al. reported that SPV can be transected safely in patients with petrous apex tumours because the vein is markedly displaced and/or compressed by the tumour, and the collateral veins are already developed.5 In a large series of MVD procedures reported by McLaughlin et al., the SPV was frequently sacrificed without any significant morbidity.1 They reported that the frequency of cerebellar damage was not a result of the SPV sacrifice, but was related to cerebellar retraction.6 Conversely, there have been several reports describing complications arising from coagulation of the SPV.7–12 Sacrifice of the SPV may not cause problems in most patients; however, major complications can occur in a few individuals. The complication rate may depend on individual variations in the anatomy of the SPV and on the degree of compensation by venous collaterals. In addition to sacrifice of the vein, brain retraction that is too long or too strong may promote serious brain damage; however, predicting the patients at high risk of venous complications is difficult. In our series of 170 patients treated with MVD for TN who were operated on by the same neurosurgeon (TM), two patients, including the patient described here, suffered complications resulting from the sacrifice of the SPV. The other patient has already been described in detail.12 In brief, a 63-year-old woman with TN underwent MVD. When a venous haemorrhage occurred during surgery, the SPV was sacrificed. Postoperatively, the patient developed visual and auditory hallucinations, which continued until postoperative day 5 and subsided gradually. In both patients, sectioning of the SPV might have been avoided by a wide dissection of the arachnoid membrane around the vein. Sufficient dissection of the arachnoidal sleeve over the SPV is an important procedure to increase the flexibility of the vein. Fujimaki et al. reported a com-
Fig. 4. Cadaveric specimen showing the veins in the left cerebellopontine angle. Cer. = cerebellar, Cer. Med = cerebellomedullary, Cer. Pon. = cerebellopontine, Fiss. = fissure, Hem. = hemispheric, Mid. = middle, Ped. = peduncle, Pon. = pontine, Pon. Trig. = pontotrigeminal, Sup. = superior, Trans. = transverse, V. = vein.
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Case Reports / Journal of Clinical Neuroscience 16 (2009) 1344–1346
bined transhorizontal-supracerebellar approach to MVD for TN.13 In addition to a supracerebellar approach, arachnoid dissection of the cerebellar horizontal fissure and the vein of the great horizontal fissure allowed easy observation of the whole surface of the trigeminal nerve. Nonetheless, sectioning of the SPV is sometimes necessary to obtain adequate exposure of the trigeminal nerve. In such situations, sectioning of the vein should be restricted to small-calibre tributaries, and the vein of the cerebellopontine fissure, which is the largest vein among the tributaries of the SPV and drains most of the petrosal surface of the cerebellum and much of the lower brainstem,3,4 must be preserved. Sacrifice of the vein of the cerebellopontine fissure may lead to extensive venous infarction of the posterior fossa. TN is not a life-threatening disorder, and steps should be taken to minimize the morbidity and mortality resulting from MVD. The SPV should be closely monitored to reduce the risk of venous complications, even though they occur rarely. References 1. McLaughlin MR, Jannetta PJ, Clyde BL, et al. Microvascular decompression of cranial nerves: lessons learned after 4400 operations. J Neurosurg 1999;90:1–8. 2. Choudhari KA. Superior petrosal vein in trigeminal neuralgia. Br J Neurosurg 2007;21:288–92.
3. Matsushima T, Rhoton Jr AL, de Oliveira E, et al. Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 1983;59:63–105. 4. Rhoton Jr AL. The posterior fossa veins. Neurosurgery 2000;47(Suppl.):S69–92. 5. Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprameatal approach to Meckel’s cave and the middle fossa: surgical technique and outcome. J Neurosurg 2000;92:235–41. 6. McLaughlin MR, Jannetta PJ, Subach BR, et al. Coagulation of the petrosal vein for MVD (Letter). J Neurosurg 1999;90:1148. 7. Chen HJ, Lui CC. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: report of a case. J Formos Med Assoc 1995;94:503–5. 8. Daljit S, Anita J, Sanjiv S. Brain stem infarction: a complication of microvascular decompression for trigeminal neuralgia. Neurol India 2006;54:325–6. 9. Koerbel A, Wolf SA, Kiss A. Peduncular hallucinosis after sacrifice of veins of the petrosal venous complex for trigeminal neuralgia. Acta Neurochir (Wien) 2007;149:831–2. 10. Ryu H, Yamamoto S, Sugiyama K, et al. Neurovascular decompression for trigeminal neuralgia in elderly patients. Neurol Med Chir (Tokyo) 1999;39:226–30. 11. Strauss C, Naraghi R, Bischoff B, et al. Contralateral hearing loss as an effect of venous congestion at the ipsilateral inferior colliculus after microvascular decompression: report of a case. J Neurol Neurosurg Psychiatry 2000;69:679–82. 12. Tsukamoto H, Matsushima T, Fujiwara S, et al. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: case report. Surg Neurol 1993;40:31–4. 13. Fujimaki T, Kirino T. Combined transhorizontal-supracerebellar approach for microvascular decompression of trigeminal neuralgia. Br J Neurosurg 2000;14:531–4.
doi:10.1016/j.jocn.2008.12.024
Dolichoectasia involving the vertebrobasilar and carotid artery systems Satoru Takeuchi *, Yoshio Takasato, Hiroyuki Masaoka, Takanori Hayakawa, Naoki Otani, Yoshikazu Yoshino, Hiroshi Yatsushige, Takashi Sugawara Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa-shi, Tokyo 190-0014, Japan
a r t i c l e
i n f o
Article history: Received 8 September 2008 Accepted 14 December 2008
Keywords: Carotid artery Cerebral infarction Dolichoectasia Vertebrobasilar artery
a b s t r a c t Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries. It most frequently involves the vertebral and basilar arteries; involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems. Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries.1 The prevalence of dolichoectasia is estimated to be 0.05% to 0.06%.1–3 Dolichoectasia most frequently involves the vertebral and basilar arteries.1 Involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems.
A 67-year-old male presented with a reduced level of consciousness. On admission, physical examination revealed a conscious level of 5 on the Glasgow Coma Scale, a blood pressure of 189/124 mmHg and pulse rate of 117 beats per minute. Neurologic examination revealed tetraplegia. A brain CT scan showed remarkable dilatation of the vertebrobasilar and bilateral carotid artery systems (Fig. 1). A brain MRI revealed left-sided vertebral artery (VA) dolichoectasia compressing the left side of the medulla with deviation to the right. Cerebral infarcts of the right occipital lobe and the brainstem were also demonstrated (Fig. 2). Magnetic resonance angiography (MRA) of the brain and threedimensional CT angiography (3D-CTA) demonstrated dilatation that involved bilateral VAs, the basilar artery (BA), bilateral internal
* Corresponding author. Tel.: +81 42 526 5511; fax: +81 42 526 5548. E-mail address: [email protected] (S. Takeuchi).
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Reports
Cerebellar swelling after sacrifice of the superior petrosal vein during microvascular decompression for trigeminal neuralgia Jun Masuoka a,*, Toshio Matsushima a, Takashi Hikita b, Eiko Inoue b a b
Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan Department of Neurosurgery, Hamanomachi Hospital, Fukuoka, Japan
a r t i c l e
i n f o
Article history: Received 6 August 2008 Accepted 14 December 2008
Keywords: Microvascular decompression Complication Superior petrosal vein Venous infarction Brain edema
a b s t r a c t The importance of preserving the deep cerebral venous outflow has been recognized in microvascular decompression for trigeminal neuralgia; however, few reports have described the details of complications arising from the sacrifice of the superior petrosal vein (SPV). During the procedure in a 77-yearold woman, some tributaries of the SPV complex were sacrificed to achieve microvascular decompression for right trigeminal neuralgia. Postoperatively, the patient was conscious and pain free; however, on postoperative day 1 she developed headache and nausea followed by a decreased level of consciousness. MRI revealed an extensive venous infarction in the right cerebellum. Sacrifice of the SPV may lead to serious, potentially life-threatening complications. Neurosurgeons should pay close attention to the management of the SPV to reduce the risk of venous complications. Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction Microvascular decompression (MVD) is widely accepted as an effective method to treat trigeminal neuralgia (TN) in patients who are refractory to medical therapy. MVD has become a safer procedure due to advances in microsurgical techniques; however, undesirable sequelae, such as hearing loss, facial anaesthesia and cerebellar contusion, may occur following surgery.1 Recently, the importance of preserving the venous system has been emphasized,2 but few reports have described the details of complications arising from sacrificing the SPV. In our series of 170 patients treated with MVD for TN, one patient developed a serious complication resulting from the sacrifice of the SPV. We report a detailed clinical course of this patient and discuss the management of the SPV. 2. Case report A 77-year-old woman presented with a 5-year history of classical right-sided TN. Her symptoms were poorly controlled with increasing doses of carbamazepine. MRI revealed a vessel impinging on the right trigeminal nerve. No other abnormalities were found. She underwent MVD via a right lateral suboccipital craniotomy. After adequate cerebrospinal fluid drainage from the cerebellopontine angle cistern, the superolateral surface of the cerebellum was gently retracted, and the SPV was easily identified.
* Corresponding author. Tel.: +81 952 34 2346; fax: +81 952 34 2066. E-mail address: [email protected] (J. Masuoka).
The SPV complex was composed of four tributaries: the superior hemispheric vein, the vein of the cerebellopontine fissure, the pontotrigeminal vein and the vein of the middle cerebellar peduncle (Fig. 1). The former three tributaries joined to form a common stem, and the vein of the middle cerebellar peduncle drained directly into the superior petrosal sinus. During MVD, the common stem of the three tributaries was sacrificed to obtain a satisfactory view of the trigeminal nerve. A bifurcation of the superior cerebellar artery (SCA) compressed the trigeminal nerve at the medial side of the root entry zone (Fig. 2). The SCA was transposed and fixed to the tentorium in order to free the compressed trigeminal nerve. The surgical procedure was uneventful and the cerebellum remained slack until the dura mater was closed. Soon after the operation, the patient regained normal consciousness, and the neuralgia resolved completely; however, she developed a headache and vomiting, and her consciousness deteriorated to drowsiness on postoperative day 1. Fluid-attenuated inversion recovery MRI revealed a heterogeneously hyperintense area in the right cerebellum, suggesting haemorrhagic infarction (Fig. 3). The patient was treated conservatively and gradually improved until being discharged with mild cerebellar ataxia 4 months later.
3. Discussion The mechanism responsible for cerebellar edema in our patient is not clear, but we think that it was caused by the sacrifice of the SPV because: (i) the edema was most prominent in the deep part of the cerebellum, but was mild on the surface of the cerebellum where it was in direct contact with the retractor spatula; (ii) the
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1342–1344
Fig. 1. Intraoperative photograph showing the upper portion of the right cerebellopontine angle and the superior petrosal vein complex.
Fig. 2. Intraoperative photograph after sectioning the common stem of the three tributaries of the superior petrosal vein. The middle cerebellar peduncle vein (black arrows) drains directly into the superior petrosal sinus. The superior cerebellar artery (white arrows) compresses the trigeminal nerve. CN = cranial nerve.
Fig. 3. Axial fluid-attenuated inversion recovery MRI showing a heterogeneously hyperintense area in the right cerebellum, representing haemorrhagic infarction.
1343
lesion contained a haemorrhagic component believed to be caused by venous hypertension, which is an indirect sign of venous infarction and; (iii) the topography of the lesion was not consistent with a known arterial territory, but was compatible with the drainage territory of the SPV. SPV is an important venous drainage system in the posterior fossa. This venous complex drains the anterior aspect of the brainstem and cerebellum, and empties into the superior petrosal sinus. The most common tributaries of the SPV are the vein of the cerebellopontine fissure, the vein of the middle cerebellar peduncle, the transverse pontine vein, the pontotrigeminal vein and the veins draining the lateral cerebellar hemisphere (Fig. 4).3,4 In MVD for TN, SPV is a major obstacle as well as an anatomical landmark. The management of SPV during surgery is controversial. Some authors report that SPV can be sectioned without related complications: Samii et al. reported that SPV can be transected safely in patients with petrous apex tumours because the vein is markedly displaced and/or compressed by the tumour, and the collateral veins are already developed.5 In a large series of MVD procedures reported by McLaughlin et al., the SPV was frequently sacrificed without any significant morbidity.1 They reported that the frequency of cerebellar damage was not a result of the SPV sacrifice, but was related to cerebellar retraction.6 Conversely, there have been several reports describing complications arising from coagulation of the SPV.7–12 Sacrifice of the SPV may not cause problems in most patients; however, major complications can occur in a few individuals. The complication rate may depend on individual variations in the anatomy of the SPV and on the degree of compensation by venous collaterals. In addition to sacrifice of the vein, brain retraction that is too long or too strong may promote serious brain damage; however, predicting the patients at high risk of venous complications is difficult. In our series of 170 patients treated with MVD for TN who were operated on by the same neurosurgeon (TM), two patients, including the patient described here, suffered complications resulting from the sacrifice of the SPV. The other patient has already been described in detail.12 In brief, a 63-year-old woman with TN underwent MVD. When a venous haemorrhage occurred during surgery, the SPV was sacrificed. Postoperatively, the patient developed visual and auditory hallucinations, which continued until postoperative day 5 and subsided gradually. In both patients, sectioning of the SPV might have been avoided by a wide dissection of the arachnoid membrane around the vein. Sufficient dissection of the arachnoidal sleeve over the SPV is an important procedure to increase the flexibility of the vein. Fujimaki et al. reported a com-
Fig. 4. Cadaveric specimen showing the veins in the left cerebellopontine angle. Cer. = cerebellar, Cer. Med = cerebellomedullary, Cer. Pon. = cerebellopontine, Fiss. = fissure, Hem. = hemispheric, Mid. = middle, Ped. = peduncle, Pon. = pontine, Pon. Trig. = pontotrigeminal, Sup. = superior, Trans. = transverse, V. = vein.
1344
Case Reports / Journal of Clinical Neuroscience 16 (2009) 1344–1346
bined transhorizontal-supracerebellar approach to MVD for TN.13 In addition to a supracerebellar approach, arachnoid dissection of the cerebellar horizontal fissure and the vein of the great horizontal fissure allowed easy observation of the whole surface of the trigeminal nerve. Nonetheless, sectioning of the SPV is sometimes necessary to obtain adequate exposure of the trigeminal nerve. In such situations, sectioning of the vein should be restricted to small-calibre tributaries, and the vein of the cerebellopontine fissure, which is the largest vein among the tributaries of the SPV and drains most of the petrosal surface of the cerebellum and much of the lower brainstem,3,4 must be preserved. Sacrifice of the vein of the cerebellopontine fissure may lead to extensive venous infarction of the posterior fossa. TN is not a life-threatening disorder, and steps should be taken to minimize the morbidity and mortality resulting from MVD. The SPV should be closely monitored to reduce the risk of venous complications, even though they occur rarely. References 1. McLaughlin MR, Jannetta PJ, Clyde BL, et al. Microvascular decompression of cranial nerves: lessons learned after 4400 operations. J Neurosurg 1999;90:1–8. 2. Choudhari KA. Superior petrosal vein in trigeminal neuralgia. Br J Neurosurg 2007;21:288–92.
3. Matsushima T, Rhoton Jr AL, de Oliveira E, et al. Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 1983;59:63–105. 4. Rhoton Jr AL. The posterior fossa veins. Neurosurgery 2000;47(Suppl.):S69–92. 5. Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprameatal approach to Meckel’s cave and the middle fossa: surgical technique and outcome. J Neurosurg 2000;92:235–41. 6. McLaughlin MR, Jannetta PJ, Subach BR, et al. Coagulation of the petrosal vein for MVD (Letter). J Neurosurg 1999;90:1148. 7. Chen HJ, Lui CC. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: report of a case. J Formos Med Assoc 1995;94:503–5. 8. Daljit S, Anita J, Sanjiv S. Brain stem infarction: a complication of microvascular decompression for trigeminal neuralgia. Neurol India 2006;54:325–6. 9. Koerbel A, Wolf SA, Kiss A. Peduncular hallucinosis after sacrifice of veins of the petrosal venous complex for trigeminal neuralgia. Acta Neurochir (Wien) 2007;149:831–2. 10. Ryu H, Yamamoto S, Sugiyama K, et al. Neurovascular decompression for trigeminal neuralgia in elderly patients. Neurol Med Chir (Tokyo) 1999;39:226–30. 11. Strauss C, Naraghi R, Bischoff B, et al. Contralateral hearing loss as an effect of venous congestion at the ipsilateral inferior colliculus after microvascular decompression: report of a case. J Neurol Neurosurg Psychiatry 2000;69:679–82. 12. Tsukamoto H, Matsushima T, Fujiwara S, et al. Peduncular hallucinosis following microvascular decompression for trigeminal neuralgia: case report. Surg Neurol 1993;40:31–4. 13. Fujimaki T, Kirino T. Combined transhorizontal-supracerebellar approach for microvascular decompression of trigeminal neuralgia. Br J Neurosurg 2000;14:531–4.
doi:10.1016/j.jocn.2008.12.024
Dolichoectasia involving the vertebrobasilar and carotid artery systems Satoru Takeuchi *, Yoshio Takasato, Hiroyuki Masaoka, Takanori Hayakawa, Naoki Otani, Yoshikazu Yoshino, Hiroshi Yatsushige, Takashi Sugawara Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa-shi, Tokyo 190-0014, Japan
a r t i c l e
i n f o
Article history: Received 8 September 2008 Accepted 14 December 2008
Keywords: Carotid artery Cerebral infarction Dolichoectasia Vertebrobasilar artery
a b s t r a c t Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries. It most frequently involves the vertebral and basilar arteries; involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems. Ó 2009 Elsevier Ltd. All rights reserved.
1. Introduction
2. Case report
Dolichoectasia is an angiopathy characterized by dilatation, elongation, and tortuosity of the brain arteries.1 The prevalence of dolichoectasia is estimated to be 0.05% to 0.06%.1–3 Dolichoectasia most frequently involves the vertebral and basilar arteries.1 Involvement of both the vertebrobasilar and carotid systems is rare. We present a patient with fatal dolichoectasia involving both the vertebrobasilar and carotid artery systems.
A 67-year-old male presented with a reduced level of consciousness. On admission, physical examination revealed a conscious level of 5 on the Glasgow Coma Scale, a blood pressure of 189/124 mmHg and pulse rate of 117 beats per minute. Neurologic examination revealed tetraplegia. A brain CT scan showed remarkable dilatation of the vertebrobasilar and bilateral carotid artery systems (Fig. 1). A brain MRI revealed left-sided vertebral artery (VA) dolichoectasia compressing the left side of the medulla with deviation to the right. Cerebral infarcts of the right occipital lobe and the brainstem were also demonstrated (Fig. 2). Magnetic resonance angiography (MRA) of the brain and threedimensional CT angiography (3D-CTA) demonstrated dilatation that involved bilateral VAs, the basilar artery (BA), bilateral internal
* Corresponding author. Tel.: +81 42 526 5511; fax: +81 42 526 5548. E-mail address: [email protected] (S. Takeuchi).