A Case of Intracranial Vertebral Artery Dissection Undetected by CT, MRI, and MRA at the Onset of Headache That Caused Subarachnoid Hemorrhage Seven Days Later

Abstract

We report a patient with normal imaging findings at the onset of preceding headache who developed subarachnoid hemorrhage (SAH) due to intracranial vertebral artery dissection 7 days later.Case Presentation: A 51-year-old woman with a history of chronic headache visited our emergency outpatient department with a complaint of mild to moderate right nuchal pain. CT, MRA, and MRI (diffusion-weighted image, T2-weighted image, FLAIR, MR cisternography, and basi-parallel anatomical scanning) were normal. Seven days later, she was admitted to our hospital with sudden disturbance of consciousness. CT revealed SAH and CTA demonstrated dilatation of the right vertebral artery (VA). The dilated lesion with an intimal flap on the right VA proximal to the posterior inferior cerebellar artery was confirmed on DSA. The dilated lesion and the proximal VA were occluded endovascularly using coils. The condition of the patient improved gradually, and she was transferred to the rehabilitation hospital on day 45 with a modified Rankin Scale score of 2. Conclusion:The clinical course of the presented case, although rare, should be kept in mind in daily clinical practice.

Acute morphological changes of impending rupture of vertebral artery dissection: clinical management of symptomatic but unruptured vertebral artery dissection. Illustrative case

“… 14 Initial imaging findings in VAD often reveal fusiform dilatation or the "pearl-and-string" sign, yet the absence of an intramural hematoma, intimal flap, or double lumen can complicate the identification of dissection. 4 Detection of an intramural hematoma can take 48–72 hours after its onset, and these hematomas manifest as a high signal on T1-weighted MRI scans. 6 Many patients with VAD are typically diagnosed 5.8–9.8 days after symptom onset; therefore, the critical 3-day window of high bleeding risk is missed.…”

“…There are few reports regarding the dynamic morphological changes in imaging findings of impending rupture of an IAD. 4 , 5 We report the case of a vertebral artery dissection (VAD) that ruptured 2 days following the onset of headache. Initial imaging findings did not reveal typical imaging signs; however, the dissection site dilated rapidly within several hours after the dissection occurred, causing SAH.…”