Postoperative, Focal, Nonseptic Necrosis of Vertebral and Cerebellar Arteries

Abstract

Subarachnoid hemorrhage caused by focal, nonseptic necrosis of the vertebral artery or of its branch, the posterior inferior cerebellar artery, is an unusual occurrence.We here record our observations made on 4 elderly, generally slightly hypertensive patients who showed no evidence of endocarditis or of a general or local infectious process, who died of this condition within a few days of uncomplicated abdominal operations. Only the apparently relevant features of the histories and examinations are given.There is a voluminous literature on the subject of subarachnoid hemorrhage ; however, much of this is in reference to ruptured congenital aneurysms. Sands,1 in a recent study of subarachnoid hemorrhage, reported 120 cases and pointed out that it "is caused by (1) trauma, (2) arteriosclerotic degeneration of vessel walls, (3) septic or infectious emboli, (4) ruptured intracranial aneurysms, (5) massive cerebral hemorrhage invading the subarachnoid space, (6) intraventricular hemorrhage, (7) blood dyscrasias and (8) ruptured vascular neoplasm." In addition to the foregoing there is a relatively large group which Sands listed as of "unknown or undetermined cause."Necrosis of the arteries of the brain is a well known phenomenon in large infarcts and we have also seen extensive necrosis of meningeal blood vessels in many cases of tuberculous meningitis or septic meningitis as well as in cases of "periarteritis nodosa," septic endo¬ carditis and other conditions, but we have not seen any of these that had vessels ruptured and produced exten¬ sive subarachnoid hemorrhage. As a rule in such cases the entire wall of a small artery becomes necrotic and not a small segment of the circumference, leaving the remaining portion of the wall normal. Winternitz and LeCompte 2 produced varying degrees of inflammation and proliferation of the walls of arteries by injecting organisms of different degrees of virulence into the walls of arteries but did not produce areas of focal necrosis.We have been unable to find any record in the available literature of a case of subarachnoid hemorrhage due to rupture of a noninflammatory necrotic focus in the wall of a cerebral artery. REPORT OF CASESCase 1.-An educator aged 62 was registered at the Mayo Clinic on Feb. 2, 1942 for a general examination and considera¬ tion of a right inguinal hernia. Examination disclosed a systolic blood pressure of 160 mm. of mercury and a diastolic pressure of 100 mm. There were slight hypertensive sclerosis of the retinal arterioles and slight sclerosis of the choroidal vessels.An apparently old retinal detachment was noted in the lower temporal sector on the right. Bilateral direct inguinal hernias were present. Numerous leukocytes were noted in the prostatic secretion. An occasional erythrocyte was found in the urine. Cystoscopic examination gave negative results.On February 24, with the patient under spinal anesthesia, both inguinal hernias were repaired. On February 28 he com¬ plained of an occipital headache, vomited, became confused, had a convulsion and...

Segmental Arterial Mediolysis With Accompanying Venous Angiopathy: A Clinical Pathologic Review, Report of 3 New Cases, and Comments on the Role of Endothelin-1 in Its Pathogenesis

“…37 The first published cases of cerebral SAM involved the posterior basilar cerebral arteries. 38 The number of reported cases of cerebral SAM is small, and some are questionable. 5,6 Unrecognized cases of SAM involving the cerebral arteries have been recently published, including a small series dealing with DAs of either the posterior circulation 39 or involving the middle cerebral and vertebral arteries.…”

Segmental Arterial Mediolysis in Pigs Presenting With Renal Infarcts

“…9 However, the disease was initially described in 1943 involving the vertebral and posterior inferior cerebellar arteries and in 1949 targeting the coronary arteries of newborns. 2,5 This entity is a disease of muscular arteries involving the large-and moderate-sized abdominal and retroperitoneal arteries, the extramural coronary arteries, and the arteries at the brain base. It most often presents with catastrophic abdominal hemorrhages, but it may also be introduced as an ischemic disorder caused by the sequelae of repair or transformation to fibromuscular dysplasia.…”

Segmental Arterial Mediolysis: A Review of a Proposed Vascular Disease of the Peripheral Sympathetic Nervous System – A Density Disorder of the Alpha-1 Adrenergic Receptor?

“…SAM in the heart involves the epicardial coronary arteries and they're large penetrating branches. Targeted in the brain base are the vertebral and posterior inferior cerebellar arteries, those in the Circle of Willis and the internal carotid [2,7]. The most frequently involved cerebral arteries have yet to be tallied because the histologic diagnosis-the gold standard for the diagnosis of SAM-in some reported cases either couldn't be accurately assessed, was questionable or even incorrect [7].…”

“…Calamitous abdominal hemorrhage is the hallmark presentation of segmental arterial mediolysis (SAM) an uncommon arteriopathy of the large and medium sized muscular arteries distributed in the abdomen, retroperitoneum, heart, and brain base. Slavin and Gonzalez first described it as a distinct clinical entity involving the abdominal arteries in elderly patients in 1976 but the disease was appreciated earlier in the vertebral and posterior inferior cerebellar arteries in immediate postoperative patients and in the epicardial coronary arteries in newborns [1][2][3]. As new cases were uncovered, it became apparent that this entity had other presentations.…”