A Case of Spontaneous Dissection of the Cervical Internal Carotid Artery Presented with Progressing Stroke Hiroharu KATAOKA, M.D. and Osamu HIRAI, M.D

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1 A Case of Spontaneous Dissection of the Cervical Internal Carotid Artery Presented with Progressing Stroke Hiroharu KATAOKA, M.D. and Osamu HIRAI, M.D. Department of Neurosurgery, Shinko Hospital, Kobe, Japan Summary: A 21-year-old man presented with several episodes of ischemic attack involving the right extremities and speech. The first left carotid arteriogram revealed an embolic occlusion of the anterior ascending branch of the middle cerebral artery, although the left cervical internal carotid artery (ICA) appeared intact. Even after medical treatment, his neurological symptoms continued to deteriorate. At the second angiography carried out immediately after an episode of right hemiplegia and an amourosis of the left eye about one month later, a tapering occlusion of the left ICA was demonstrated, which was compatible with the findings of carotid arterial dissection. Hypervolemia and induced hypertension were started, and an occipital artery-middle cerebral artery anastomosis was performed 2 weeks after the final episode. Thereafter, he has been free of symptoms except for a mild expressive aphasia. Control angiography 8 months postoperatively demonstrated a complete occlusion of the left cervical ICA while the left hemisphere was well perfused through the bypass. Spontaneous internal carotid arterial dissection has become increasingly recongnized as a cause of cerebral ischemia, primarily in young patients. Although the benign nautre of the disease may indicate the use of noninvasive diagnositc tools and anticoagulant therapy, intensive care and surgical treatment will be mandatory for patients with progressive neurological deterioration, which is refractory to medical treatment as shown in this report. Key words: Surg Cereb Stroke (Jpn) 27: 54-58, 1999

2 Fig. 1 The first left carotid arteriogram demonstrated that the ICA appeared normal at the cervical portion (A) through the intracranial part, however an embolic occlusion of the anterior ascending branch of the left MCA (B). Fig. 2 CT scan at the final episode of ischemia revealed low density areas at the left corona radiata and posterior temporal cortex. Surgery for Cerebral Stroke 27 :

3 Fig. 3 The second arteriogram demonstrated a severe tapering of the left cervical ICA; early phase (A) and late phase (B), and occlusion within the petrous portion (C). Fig. 4 Collateral circulation to the left cerebral hemisphere were through the left anterior cerebral arteries (A), the left posterior cerebral arteries and the posterior communicating artery (B). どを用 い た と ころ,視 力 は急 激 に 回復 し,右 片麻 痺 も上肢 3/5,下 肢4/5位 まで 回復 し た.こ の 時 点 で 特 発 性 内 頸 動 血 行 力 学 的脳 虚 血 の状 態 と考 え られ た. 病 状 の 安 定 を待 っ て6月3日 手 術 を行 っ た.浅 側 頭 動 脈 脈 解 離 が 疑 わ れ た が,血 圧 依 存 性 の 神 経 症 状 を呈 す る ため, の発 達 が不 良 な た め,後 頭 動 脈 を用 い て 中大 脳 動 脈 のcen- 循 環 血 液 量 を維 持 す る と と もに,ド ー パ ミ ンの 点滴 に よっ tral arteryに 吻 合 した.術 後 は特 に昇 圧 を行 わ な く と も, て血 圧 を で き る だ け mmHg以 運 動 機 能 に 関 して は上 肢4/5,下 節 した.SPECTで 56 上 を保 つ よ う に調 は左 半 球 の 低 還 流 が 示 され,い 脳 卒 中 の外 科27:1999 わゆる 肢5/5位 まで 回復 した が 失語 症 の 治療 の た め6ヵ 月 間転 院 の うえ,集 中 的 に機 能 訓

4 Fig. 5 Angiograpms taken 8 months postoperatively showed a complete occlusion of the cervical ICA (A) and a patent anastomosis between the occipital and the middle cerebral artery (B). Fig. 6 MRI taken the next day of admission indicated a lim of hyperintensity around the extracranial ICA suggestive of a dissection (arrow). Surgery for Cerebral Stroke 27 :

5 2) Biousse V, D'Anglejan-Chatillon J, Touboul PJ, et al: Time course of symptoms in extracranial carotid artery dissections. A series of 80 cases. Stroke 26: , ) Ehrenfeld WK, Wylie EJ: Spontaneous dissection of the internal carotid artery. Arch Surg 111: , ) Fisher CM, Ojemann RG, Roberson GH: Spontaneous dissection of cervico-cerebral arteries. Can J Neurol Sci 5: 9-19, ) Friedman WA, Day AL, Quisling RG, et al: Cervical carotid dissecting aneurysms. Neurosurgery 7: ) Leys D, Lucas C, Gobert M, et al: Cervical artery dissections. Eur Neurol 37: 3-12, ) Pozzati E, Gaist G, Poppi M: Resolution of occlusion in spontaneously dissected carotid arteries. Report of two cases. J Neurosurg 56: , ) Provenzale JM, Barboriak DP: Brain infarction in young adult: Etiology and imaging findings. AJR 169: , ) Sturzenegger M: Spontaneous internal carotid artery dissection: Early diagnosis and management in 44 patients. J Neurol 242: , ) Treiman GS, Treiman RL, Foran RF, et al: Spontaneous dissection of the internal carotid artery: A nineteen-year clinincal experience. J Vasc Surg 24: , 1996

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