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Detection of Basilar Artery Dissection by Ultrasound
Case Report
Detection of Basilar Artery Dissection by Ultrasound Evguenia Vassileva, MD, PhD,* Plamen Getsov, MD,† Evgenii Vavrek, MD,* and Marin Daskalov, MD, PhD, DSc*
We report a case of a 45-year-old woman with unusual headache 1 week before admission. After cerebrovascular ultrasound, a basilar artery dissection was supposed despite the normal neurologic, cerebrospinal fluid, and computed tomography findings. On a follow-up color-coded duplex sonography (1 month after the onset), reperfusion was detected in the vertebral and basilar arteries, but residual high-grade stenosis of the basilar artery was also present. Key Words: Basilar artery dissection—stroke—cerebrovascular ultrasound—young adults. Ó 2015 by National Stroke Association
Basilar artery dissection (BAD) is an extremely rare cause of stroke in young adults1-4 and probably underdiagnosed due to its atypical presentation in some of cases.5 A 45-year-old woman with unusual headache, 1 week before admission, but without neurologic deficit, was admitted to our hospital. Computed tomography (CT) did not reveal pathologic signs. Blood and cerebrospinal fluid tests were normal. Color-coded duplex sonography (CCDS) detected high-resistance flow pattern in both vertebral arteries (Fig 1, A,B) and reduced flow velocity with decreased pulsatility index in both posterior cerebral arteries (Fig 1, C,D). Microembolic signals were detected in the distal part of the basilar artery (BA; Fig 1, E). BAD was supposed, and she was referred for CT angiog-
From the *Department of Neurology, University Hospital ‘‘Tsaritsa Yoanna–ISUL’’, Sofia; and †Department of Radiology, University Hospital ‘‘Tsaritsa Yoanna–ISUL’’, Sofia, Bulgaria. Received July 19, 2014; revision received December 11, 2014; accepted January 30, 2015. The authors have no conflict of interest or any financial disclosures to report. Address correspondence to Evguenia Vassileva, MD, PhD, University Hospital ‘‘Tsaritsa Yoanna–ISUL,’’ Clinic of Neurology, 8 ‘‘Bialo more’’ Str., Sofia 1527, Bulgaria. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.01.035
raphy. Treatment with anticoagulant was introduced. CT angiography on the next day confirmed BAD (Fig 1, G,H). On the third day, the patient developed ischemic stroke–nistagmus, gaze paresis, dysarthria, ataxia, right central facial, and hemiparesis (National Institutes of Health Stroke Scale score, 15). Magnetic resonance imaging revealed ischemia in the cerebellum and brainstem (Fig 1, F). During the hospital stay, an improvement was observed, and on discharge, moderate trunk ataxia was persistent. On a follow-up CCDS (1 month later), reperfusion in both vertebral arteries (Fig 1, I,J) and residual highgrade stenosis of the BA were detected.
Discussion Headache is not a common symptom at the onset of acute ischemic cerebrovascular disease, but it is one of the nonspecific prodromal symptoms of BA occlusion.6,7 At admission, when our patient was without neurologic deficit and normal CT, CCDS was the first method to detect the arterial lesion. After the ultrasound examination, anticoagulant treatment was introduced, and neuroradiologic examinations were performed. Diagnosis of BAD is always based on clinical and radiologic signs.8,9 The diagnostic value of CCDS in BAD is unknown because of its very rare incidence. Ultrasound findings are highly dependent on the type of the dissection. There are very few reports concerning sonographic
Journal of Stroke and Cerebrovascular Diseases, Vol. 24, No. 5 (May), 2015: pp e127-e128
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Figure 1. (A, B) Extracranial CCDS–high-resistance flow pattern in both vertebral arteries; (C, D) transcranial CCDS–low velocities and pulsatility index in the posterior cerebral arteries; (E) transcranial CCDS–microembolic signals in BA; (F) MRI–left cerebellar and brainstem ischemia; (G, H) CT angiography– basilar dissection with pseudoaneurysm formation; and (I, J) extracranial CCDS (30th day)–recanalization of both vertebral arteries. Abbreviations: BA, basilar artery; CCDS, color-coded duplex sonography; CT, computed tomography; MRI, magnetic resonance imaging.
findings in this condition.1,10 Ruecker et al1 reported abnormal transcranial Doppler results suggestive of BA stenosis in 4 of 9 patients with BAD, examined with ultrasound. The detection of high-resistance flow pattern in both vertebral arteries reflects downstream resistance irrespective of the cause of the occlusion of the BA. But the association of these findings in both vertebral arteries with the absence of carotid atherosclerotic plaques, and of cardioembolic source, is highly suggestive for basilar dissection. Registration of microembolic signals in the distal part of the BA showed the underlying mechanism of the subsequent stroke and confirmed the proximal BA’s origin of microemboli. CCDS is also a powerful method for monitoring the follow-up of the arterial lesion and determined the duration of antithrombotic treatment.
Conclusion CCDS has diagnostic value in cases of high-grade basilar obstruction due to BAD. The most typical ultrasound findings included: high-resistant pattern in both vertebral and low pulsatile in both posterior cerebral arteries, absence of atherosclerotic plaques on cervical vessels, and microembolic signals in BA.
References 1. Ruecker M, Furtner M, Knoflach M, et al. Basilar artery dissection: series of 12 consecutive cases and review of the literature. Cerebrovasc Dis 2010;30:267-276. 2. Yoshimoto Y, Hoya K, Tanaka Y, et al. Basilar artery dissection. J Neurosurg 2005;102:476-481. 3. Thomas ZH, Wynnie WL, Yannie L, et al. Spontaneous basilar artery dissection. Hong Kong Med J 2007;13: 144-146. 4. Li C, Li Y, Jiang C, et al. Stent alone treatment for dissections and dissecting aneurysms involving the basilar artery. J Neurointerv Surg 2013; http://dx.doi.org/ 10.1136/neurintsurg-2013-010967. 5. Berkovic SF, Spokes RL, Anderson RM, et al. Basilar artery dissection. J Neurol Neurosurg Psychiatry 1983; 46:126-129. 6. Gazioglu S, Boz C, Ozmenoglu M. Basilar artery occlusion in migraine-like headache: a possible triggering effect of sumatriptan. Neurol Sci 2012;33:125-128. 7. Mattle HP, Arnold M, Lindsberg PJ, et al. Basilar artery occlusion. Lancet Neurol 2011;10:1002-1014. 8. Kim BM, Suhd SH, Parke SI, et al. Management and clinical outcome of acute basilar artery dissection. AJNR Am J Neuroradiol November 2008;29:1937-1941. 9. Masson C, Krespy Y, Masson M, et al. Magnetic resonance imaging in basilar artery dissection. Stroke 1993; 24:1264-1266. 10. de Bray JM, Penisson-Besnier I, Dubas F, et al. Extracranial and intracranial vertebrobasilar dissections: diagnosis and prognosis. J Neurol Neurosurg Psychiatry 1997;63:46-51.
Detection of Basilar Artery Dissection by Ultrasound Evguenia Vassileva, MD, PhD,* Plamen Getsov, MD,† Evgenii Vavrek, MD,* and Marin Daskalov, MD, PhD, DSc*
We report a case of a 45-year-old woman with unusual headache 1 week before admission. After cerebrovascular ultrasound, a basilar artery dissection was supposed despite the normal neurologic, cerebrospinal fluid, and computed tomography findings. On a follow-up color-coded duplex sonography (1 month after the onset), reperfusion was detected in the vertebral and basilar arteries, but residual high-grade stenosis of the basilar artery was also present. Key Words: Basilar artery dissection—stroke—cerebrovascular ultrasound—young adults. Ó 2015 by National Stroke Association
Basilar artery dissection (BAD) is an extremely rare cause of stroke in young adults1-4 and probably underdiagnosed due to its atypical presentation in some of cases.5 A 45-year-old woman with unusual headache, 1 week before admission, but without neurologic deficit, was admitted to our hospital. Computed tomography (CT) did not reveal pathologic signs. Blood and cerebrospinal fluid tests were normal. Color-coded duplex sonography (CCDS) detected high-resistance flow pattern in both vertebral arteries (Fig 1, A,B) and reduced flow velocity with decreased pulsatility index in both posterior cerebral arteries (Fig 1, C,D). Microembolic signals were detected in the distal part of the basilar artery (BA; Fig 1, E). BAD was supposed, and she was referred for CT angiog-
From the *Department of Neurology, University Hospital ‘‘Tsaritsa Yoanna–ISUL’’, Sofia; and †Department of Radiology, University Hospital ‘‘Tsaritsa Yoanna–ISUL’’, Sofia, Bulgaria. Received July 19, 2014; revision received December 11, 2014; accepted January 30, 2015. The authors have no conflict of interest or any financial disclosures to report. Address correspondence to Evguenia Vassileva, MD, PhD, University Hospital ‘‘Tsaritsa Yoanna–ISUL,’’ Clinic of Neurology, 8 ‘‘Bialo more’’ Str., Sofia 1527, Bulgaria. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.01.035
raphy. Treatment with anticoagulant was introduced. CT angiography on the next day confirmed BAD (Fig 1, G,H). On the third day, the patient developed ischemic stroke–nistagmus, gaze paresis, dysarthria, ataxia, right central facial, and hemiparesis (National Institutes of Health Stroke Scale score, 15). Magnetic resonance imaging revealed ischemia in the cerebellum and brainstem (Fig 1, F). During the hospital stay, an improvement was observed, and on discharge, moderate trunk ataxia was persistent. On a follow-up CCDS (1 month later), reperfusion in both vertebral arteries (Fig 1, I,J) and residual highgrade stenosis of the BA were detected.
Discussion Headache is not a common symptom at the onset of acute ischemic cerebrovascular disease, but it is one of the nonspecific prodromal symptoms of BA occlusion.6,7 At admission, when our patient was without neurologic deficit and normal CT, CCDS was the first method to detect the arterial lesion. After the ultrasound examination, anticoagulant treatment was introduced, and neuroradiologic examinations were performed. Diagnosis of BAD is always based on clinical and radiologic signs.8,9 The diagnostic value of CCDS in BAD is unknown because of its very rare incidence. Ultrasound findings are highly dependent on the type of the dissection. There are very few reports concerning sonographic
Journal of Stroke and Cerebrovascular Diseases, Vol. 24, No. 5 (May), 2015: pp e127-e128
e127
E. VASSILEVA ET AL.
e128
Figure 1. (A, B) Extracranial CCDS–high-resistance flow pattern in both vertebral arteries; (C, D) transcranial CCDS–low velocities and pulsatility index in the posterior cerebral arteries; (E) transcranial CCDS–microembolic signals in BA; (F) MRI–left cerebellar and brainstem ischemia; (G, H) CT angiography– basilar dissection with pseudoaneurysm formation; and (I, J) extracranial CCDS (30th day)–recanalization of both vertebral arteries. Abbreviations: BA, basilar artery; CCDS, color-coded duplex sonography; CT, computed tomography; MRI, magnetic resonance imaging.
findings in this condition.1,10 Ruecker et al1 reported abnormal transcranial Doppler results suggestive of BA stenosis in 4 of 9 patients with BAD, examined with ultrasound. The detection of high-resistance flow pattern in both vertebral arteries reflects downstream resistance irrespective of the cause of the occlusion of the BA. But the association of these findings in both vertebral arteries with the absence of carotid atherosclerotic plaques, and of cardioembolic source, is highly suggestive for basilar dissection. Registration of microembolic signals in the distal part of the BA showed the underlying mechanism of the subsequent stroke and confirmed the proximal BA’s origin of microemboli. CCDS is also a powerful method for monitoring the follow-up of the arterial lesion and determined the duration of antithrombotic treatment.
Conclusion CCDS has diagnostic value in cases of high-grade basilar obstruction due to BAD. The most typical ultrasound findings included: high-resistant pattern in both vertebral and low pulsatile in both posterior cerebral arteries, absence of atherosclerotic plaques on cervical vessels, and microembolic signals in BA.
References 1. Ruecker M, Furtner M, Knoflach M, et al. Basilar artery dissection: series of 12 consecutive cases and review of the literature. Cerebrovasc Dis 2010;30:267-276. 2. Yoshimoto Y, Hoya K, Tanaka Y, et al. Basilar artery dissection. J Neurosurg 2005;102:476-481. 3. Thomas ZH, Wynnie WL, Yannie L, et al. Spontaneous basilar artery dissection. Hong Kong Med J 2007;13: 144-146. 4. Li C, Li Y, Jiang C, et al. Stent alone treatment for dissections and dissecting aneurysms involving the basilar artery. J Neurointerv Surg 2013; http://dx.doi.org/ 10.1136/neurintsurg-2013-010967. 5. Berkovic SF, Spokes RL, Anderson RM, et al. Basilar artery dissection. J Neurol Neurosurg Psychiatry 1983; 46:126-129. 6. Gazioglu S, Boz C, Ozmenoglu M. Basilar artery occlusion in migraine-like headache: a possible triggering effect of sumatriptan. Neurol Sci 2012;33:125-128. 7. Mattle HP, Arnold M, Lindsberg PJ, et al. Basilar artery occlusion. Lancet Neurol 2011;10:1002-1014. 8. Kim BM, Suhd SH, Parke SI, et al. Management and clinical outcome of acute basilar artery dissection. AJNR Am J Neuroradiol November 2008;29:1937-1941. 9. Masson C, Krespy Y, Masson M, et al. Magnetic resonance imaging in basilar artery dissection. Stroke 1993; 24:1264-1266. 10. de Bray JM, Penisson-Besnier I, Dubas F, et al. Extracranial and intracranial vertebrobasilar dissections: diagnosis and prognosis. J Neurol Neurosurg Psychiatry 1997;63:46-51.