―Case Reports― Anterior Cerebral Artery Dissection Presenting Subarachnoid Hemorrhage and Cerebral Infarction Kentaro Suzuki, Masahiro Mishina, Seiji Okubo, Arata Abe, Satoshi Suda, Masayuki Ueda and Yasuo Katayama Department of Neurological, Nephrological and Rheumatological Science, Graduate School of Medicine, Nippon Medical School Divisions of Neurology, Nephrology and Rheumatology, Department of Internal Medicine, Nippon Medical School Hospital Abstract A 35-year-old man presented with simultaneous occurrence of subarachnoid hemorrhage (SAH) and cerebral infarction (CI) caused by anterior cerebral artery (ACA) dissection. He complained of sudden onset of left frontal headache and his symptoms progressed to consciousness disturbance and right hemiparesis. Computed tomography and magnetic resonance imaging demonstrated SAH localized in the left interhemispheric fissure and CI in the territory of the left ACA. Right carotid angiography demonstrated a long double lumen sign at the left A2 to A4 segment of the left ACA, leading to a diagnosis of the combined type of CI and SAH caused by ACA dissection. Although many surgeons have previously tried to perform endovascular treatment, we selected only medication in this case, and his neurological findings gradually improved. Only 9 cases including the present case presented with simultaneous occurrence of SAH and CI caused by ACA dissection. Many of these patients showed stenosis with dilatation of ACA on carotid angiography. The prognoses of these patients were good. However, many SAH patients with dissecting aneurysm had poor prognoses. To improve the strategy for managing ACA dissection, we need to accumulate a greater number of such cases in the future. We also recommend that angiography should be performed in the patients with ACA dissection. (J Nippon Med Sch 2012; 79: 153―158) Key words: anterior cerebral artery, dissection, simultaneous, cerebral infarction, subarachnoid hemorrhage imaging (MRI) have investigated the etiologies and clinical features. Cerebral infarcts localized in the Introduction ACA territory are reported to comprise 0.5―3% of all Infarction in the anterior cerebral artery (ACA) th ischemic strokes2,3. Spontaneous dissecting territory was first described in the early 20 century aneurysms of the internal carotid circulation occur based on autopsy results1. Recent studies using frequently less than those of the vertebrobasilar computed tomography (CT) and magnetic resonance circulation, with more than 90% of dissecting Correspondence to Kentaro Suzuki, MD, Divisions of Neurology, Nephrology and Rheumatology, Department of Internal Medicine, Nippon Medical School, 1―1―5 Sendagi, Bunkyo-ku, Tokyo 113―8603, Japan E-mail: kentarow@nms.ac.jp Journal Website (http:! ! www.nms.ac.jp! jnms! ) J Nippon Med Sch 2012; 79 (2) 153 K. Suzuki, et al Fig. 1 Computed tomography on admission. It is a computed tomography on admission at 9 hours after onset. High density areas were observed in the left interhemispheric fissure, and a low density area is observed in the territory of the left anterior cerebral artery. vertebrobasilar facial palsy, hemiparesis and sensory disturbance. circulation4. ACA dissection is reported to comprise The National Institute of Health Stroke Scale aneurysms occurring in the 5 Spontaneous (NIHSS) was 20. Systolic blood pressure was 148 intracranial dissection often develops in young mmHg and diastolic blood pressure was 100 mmHg. healthy people and is associated with severe General symptom. We report a case of simultaneous cerebral computed tomography at 9 hours after onset infarction and subarachnoid demonstrated 36.7% of intracranial dissections . hemorrhage (SAH) laboratory SAH data were normal. localized in the Initial left caused by dissection of the ACA. It was a rare case, interhemispheric fissure, and cerebral infarction in but the territory of the left ACA (Fig. 1). In MRI fluid was an important case considering the attenuation inversion recovery (FLAIR) image also management of younger stroke. showed high intensity signals, and T2*-weighted Case Report image showed low intensity signals in the left interhemispheric fissure (Fig. 2). FLAIR, T2- A 35-year-old male patient complained of sudden weighted and diffusion-weighted image (DWI) MRI onset of left frontal headache during work. The showed cerebral infarct in the territory of the left headache worsened gradually, and he was admitted ACA (Fig. 2). Left carotid angiography (CAG) to a hospital. After seven hours, however, his demonstrated a long double lumen sign at the left symptoms progressed to consciousness disturbance A2 to A4 segment one day after onset (Fig. 3). We and right hemiparesis. Then he was referred to our diagnosed the combined type of cerebral infarction hospital. He had a habit of smoking 30 cigarettes a and SAH caused by ACA dissection. day, and a history of hypertension without medication. He did not have a history of head injury. On admission, he demonstrated aphasia, right 154 We administered nicardipine, glycerol and edaravone for the treatment of cerebral infarction6―8. The patientʼs neurological findings gradually J Nippon Med Sch 2012; 79 (2) ACA Dissection Presenting SAH and CI Fig. 2 Magnetic resonance imaging. In the left interhemispheric fissure, we detected high intensity signals on fluid attenuation inversion recovery (FLAIR) image (upper left) and low intensity signals on T2*-weighted image (lower right). FLAIR, T2-weighted (lower left) and diffusionweighted images (upper right) showed a high intensity area in the territory of left anterior cerebral artery. improved on day 5. We could not find any new unlikely because the diameter of the A1 segment is lesion on MRI, and right CAG did not show approximately half that of the M1 segment and enlargement of ACA dissection on day 10. Then the cerebral blood flow is lower in the ACA than in the patient started walk rehabilitation. NIHSS had MCA3. improved to 10 on day 14 and 2 at 3 months after frequently found in the MCA10. According to the the onset. Modified Rankin Scale was 1 at 3 months. Spontaneous Cervicocephalic Arterial Dissections Second, atherosclerotic changes are Study (SCADS), ʻDouble lumenʼ demonstrated on Discussion DSA is defined as the major criterion of 11 cervicocephalic arterial dissection . Our patient Shimoyama et al. indicated that spontaneous intra- demonstrated a long ʻdouble lumenʼ in the CAG, and cranial arterial dissection (SICAD) was found in we could diagnose the patient as having arterial 64.3% of patients with ACA infarction. SICAD is dissection. relatively infrequent among patients with middle subintimal dissection tends to result in stenosis of cerebral artery (MCA) or posterior cerebral artery the arterial lumen, leading to cerebral infarctions, 9 Regarding pathological features, a infarction . There are two reasons to explain this whereas a subadventitial dissection may cause difference. First, embolism in the ACA may be aneurysmal dilatation of the artery, resulting in J Nippon Med Sch 2012; 79 (2) 155 K. Suzuki, et al Fig. 3 Right carotid angiography showing lateral view (upper left), anteroposterior view (upper right), left anterior oblique (LAO) 30°(lower left) and magnified image of LAO (lower right). Long double lumen sign was observed in the A2 to A4 segment of the left anterior cerebral artery (from the lower arrow to the upper arrow). In the A2 segment, dilatation of the artery was also found. hemorrhagic events. Seven of 9 cases of ACA the ACA territory caused by dissection were dissection subarachnoid younger and less commonly had a history of heart hemorrhage and infarction showed stenosis with disease or previous stroke than patients without dilatation (Table 1). In these cases, we estimated to dissection13. Anterior cerebral artery dissection in 9 occur the both mechanisms. Many of the patients patients who simultaneously developed SAH and with ACA dissection accompanied by simultaneous cerebral infarction SAH and infarction showed nonperimesencephalic showed similar with simultaneous including the characteristics, present such 14―18 as case good SAH. Generally, a good outcome of nonaneurysmal outcome and middle age (Table 1) nonperimesencephalic SAH has been reported12. Inoue et al., a 48-year-old man was complained of Therefore, we consider that all cases of ACA sudden onset of headache and left hemiparesis. MRI dissection with SAH and infarction showed a and CT detected dissection from A1 to A2, and relative good outcome comparison with dissection demonstrated SAH and CI in the ACA territory. with SAH, because it is not easy to demonstrated The patient initially treated by edaravone, but perimesencephalic lesion by ACA dissection. digital subtraction angiography (DSA) confirmed the Sato et al. indicated that patients with stroke in 156 . In the case of enlarged fusiform dilatation of the right A2 with J Nippon Med Sch 2012; 79 (2) ACA Dissection Presenting SAH and CI Table 1 Cases of simultaneous subarachnoid hemorrhage and infarction caused by dissection of the anterior cerebral artery Authors Age/Sex Site of Lesion Angiographic findings outcome Yasukawa et al. (1993)14 62/M 40/F 50/M 40/M 64/F 49/F 49/M 49/M 35/M Lt. A2 Lt. A2 Rt. A2-A3 A2 A2 A2 A3 ACoA-rt. A2 Lt. A2-A3 stenosis with dilatation stenosis with dilatation stenosis with dilatation stenosis without dilatation stenosis with dilatation stenosis with dilatation stenosis without dilatation stenosis with dilatation stenosis with dilatation good recovery good recovery good recovery good recovery good recovery good recovery good recovery good recovery good recovery Kato et al. (2000)15 Miyahara et al. (2001)16 Ohkuma et al. (2003)17 Ohkuma et al. (2003)17 Ohkuma et al. (2003)17 Ohkuma et al. (2003)17 Inoue et al. (2010)18 Present case ACoA=anterior communicating artery. distal narrowing on day 14. So endvascular trapping patients was performed. The patient remained neurologically prognoses, stable after operation and got an outpatient with 25 important . To improve the strategy for managing mild monoparesis of the left lower extremity eight ACA dissection, we need to accumulate a greater month after the onset. number of ACA dissection cases in the future. We Because the prognoses are different, it is very important to distinguish ischemic or hemorrhagic with dissecting prompt and aneurysm accurate had poor diagnosis is also recommend that angiography be performed in patients with ACA dissection. disease early. The optimal treatment for ACA dissection remains controversial. The onset of References ischemia is generally indicated for conservative therapy, whereas the onset of bleeding almost always requires surgical treatment. In this case, because vasodilatation was limited, we selected conservative treatment by administration of edaravone without surgery and achieved a good outcome. A Japanese multi-center study showed that a novel free radical scavenger, edaravone, was efficacious in patients with acute ischemic stroke19,20. In vitro and in vivo studies showed that edaravone inhibited brain edema after ischemia21,22, delayed neuronal death23, and vascular endothelial cell 24 injury . Specifically, because edaravone in the membrane can promote the delivery of fat soluble vitamin E inside the membrane and water soluble vitamin C outside the membrane and effectively prevent damage to membrane lipids, which are susceptible to radical injury, we suggest that edaravone is not complicating factor for arterial dissection. Recently, we could easily diagnose such cases as ACA dissection with advanced technology such as DSA and MRI. 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