Symptomatic spontaneous vertebrobasilar dissections in children: review of 29 consecutive cases

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The purpose of this study is to analyze the clinical presentation, morphological characteristics, angio-architecture, and outcome of vertebrobasilar dissection (VBD) in the pediatric population.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors retrospectively reviewed 29 consecutive cases involving children younger than 16 years of age who were diagnosed with symptomatic VBDs. Data were gathered with respect to the patient's age, sex, clinical history, associated underlying disease, and symptoms (headache, vertigo) as well as the location of the dissection and the imaging appearance.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The patients' mean age was 8.24 years (range 2 months–15 years). There was an overall 3:1 male predominance, although among children older than 8 years, girls and boys were similarly affected. Hemorrhagic dissections occurred in 10 of 29 cases. In nonhemorrhagic dissections, stroke occurred in 16 cases, with the most common presenting symptoms being headaches and vertigo; in the other 3 cases, mass effect due to a chronic dissecting aneurysm was present. In 7 children an underlying vessel wall disease was found. The location of the dissection was extradural in 11 cases and intradural in the remainder. There was no preference with respect to side. The basilar artery was affected in 9 patients.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The imaging appearance and clinical presentation of symptomatic VBDs in the pediatric population differs from that in adults. Boys are more often affected, especially at younger ages, and hemorrhagic presentation is more common, presumably owing to the fact that the basilar artery is more commonly involved. Depending on the pathogenetic mechanism underlying the dissection, different clinical symptoms will evolve, necessitating individually tailored treatment.</jats:p></jats:sec>

The Many Faces of Intracranial Arterial Dissections

“…Perforator occlusion has to be considered if ischemia is present in the territory of local perforators at the site of the dissection 13 . If in these patients under conservative therapy a secondary stroke was to occur and imaging was to show expansion of the intramural hematoma, we would suggest parent vessel occlusion to stop the blood from entering the dissection cavity.…”

Evolution of a chronic dissecting aneurysm on magnetic resonance imaging in a pediatric patient

“…1,5,12,13,16,17,19 Based on these reports, it was suggested that some PTAs may be caused by a chronic dissecting process. 7,16,19 According to this hypothesis, an intimal tear of an intradural artery leads to an intramural hematoma that neither dissects through the adventitia to cause an acute subarachnoid hemorrhage nor reopens into the parent vessel to be the cause of repeated embolic events. Instead, the intramural hematoma may clot or even organize.…”

“…14 Multiple studies subsequently confirmed this speculation by using diagnostic imaging techniques, direct surgical inspection, or histopathological investigation. 1,5,12,13,16,17,19 It was suggested that certain PTAs arise from repeated hemorrhages of the vasa vasorum within the vessel wall, whereas other PTAs occur in relation to a chronic dissecting process with repeated intramural hemorrhages stemming from an incompletely healed acute dissection with intimal tearing. However, there has not yet been any serial imaging evidence to support the latter pathomechanism; i.e., the evolution of an acute dissecting aneurysm into a PTA, thereby rendering this pathomechanism hypothetical.…”

“…4 Giant PTAs represent a therapeutic challenge and, ideally, complete surgical removal or trapping of the aneurysm (which may necessitate bypass surgery) was deemed to be the treatment of choice. 8 Because some dissecting aneurysms initially may be asymptomatic, 8,16 it may be hypothesized that some patients with chronic dissecting aneurysms may only present with symptoms caused by mass effect after their dissecting aneurysm has evolved into a PTA. Given this presumed pathomechanism, it may be more accurate to refer to these lesions as aneurysms with intramural hematoma instead of "partially thrombosed" aneurysms.…”

Radiological Changes in Infantile Dissecting Anterior Communicating Artery Aneurysm Treated Endovascularly

“…However, long-term efficacy in children remains unclear because no studies with extended post-treatment follow-up periods have been performed thus far. To our knowledge, only seven cases of endovascular treatment of ruptured spontaneous dissecting aneurysms in infants have been reported, but without information on long-term outcomes 1,12,13,17 . We are also unaware of any case of an infant being treated endovascularly for spontaneous dissecting aneurysm located in the anterior communicating artery (ACoA).…”