Simultaneous Occurrence of Subarachnoid Hemorrhage and Cerebral Infarction Caused by Anterior Cerebral Artery Dissection Treated by Endovascular Trapping -Case Report-

Abstract

A 48-year-old man presented with a rare dissection of the anterior cerebral artery (ACA) causing simultaneous subarachnoid hemorrhage (SAH) and cerebral infarction manifesting as sudden onset of headache and left hemiparesis. Computed tomography and magnetic resonance imaging showed SAH localized in the interhemispheric fissure and cerebral infarction in the territory of the right ACA. Digital subtraction angiography (DSA) demonstrated segmental narrowing and dilatation at the right A 1 and A 2 portions of the ACA, leading to a diagnosis of ACA dissection. Fourteen days after the onset, DSA confirmed the enlarged fusiform dilatation of the right A 2 portion with distal narrowing, suggesting the risk of rerupture of the dissection. Endovascular obliteration of the aneurysm with parent artery occlusion was performed without anastomosis on day 16. The aneurysm was catheterized and obliterated with detachable coils. Postoperative DSA revealed complete obliteration of the dissection and parent artery. The patient was doing well without recurrence of the dissection 8 months after the intervention. The simultaneous occurrence of SAH and cerebral infarction in patients with ACA dissection is extremely rare, and the optimal treatment has not yet been established. Endovascular treatment is safe and effective for the treatment of ACA dissection.

Two Cases of Subarachnoid Hemorrhage from Spontaneous Anterior Cerebral Artery Dissection : A Case of Simultaneous Hemorrhage and Ischemia Without Aneurysmal Formation and Another Case of Hemorrhage with Aneurysmal Formation

“…Intracranial arterial dissection is rare, and approximately 90% of arterial dissections occur in the posterior circulation 7)12)18)19)20). Arterial dissections in the posterior circulation usually present with SAH because of their elongated subarachnoid course 1)6).…”

“…Subintimal dissection between the internal elastic lamina and media usually results in stenosis or occlusion with thrombosis of the true lumen of the parent artery, which causes ischemia 2)7)14)16)21). It generally shows good recovery from neurological symptoms.…”

“…It generally shows good recovery from neurological symptoms. On the other hand, subadventitial dissection between the media and adventitia usually results in formation of aneurysmal dilatation and rupture of the dissected wall, which causes hemorrhage 1)7)14)18)21). The outcome is variable or worse than the ischemic presentation.…”

“…Spontaneous intracranial arterial dissection usually occurs in the posterior circulation and is relatively rare in the anterior circulation, particularly the anterior cerebral artery (ACA) 4)7)8)17)20). It tends to develop in young healthy people, and is often associated with severe morbidity and mortality 13)17).…”

“…Isolated ACA territory infarction is very rare, representing 0.5-3% of all cases of ischemic stroke, and 47% of cases are angiographically proven dissection confined to the ACA 8)10)14)15)18). The number of patients diagnosed with spontaneous ACA dissection has recently shown a marked increase due to advancement of diagnostic devices, such as multi-channel 3-dimensional computed tomography angiography (3D-CTA), high Tesler magnetic resonance angiography (MRA), and high quality digital subtraction angiography (DSA) 7)13). In addition to the aid of advanced diagnostic tools, a high level of suspicion should be maintained in order to prevent misdiagnosis.…”