Extracranial vertebral and carotid dissection occurring in the course of subarachnoid hemorrhage Abstract—The pathogenesis of both intracranial aneurysms and spontaneous cervical artery dissection may be related to an underlying vasculopathy. Seven cases of spontaneous cervical artery dissection in the course of ruptured berry aneurysms are reported here. NEUROLOGY 2005;65:1471–1473 Mikae ¨l Mazighi, MD; Jean-Pierre Saint Maurice, MD; Andre ´ Rogopoulos, MD; and Emmanuel Houdart, MD Dissections of the extracranial (EC) vertebral artery (VA) and internal carotid artery (ICA) can be related to various factors, including inherited connective tis- sue disorders, traumatic causes, minor precipitating events such as neck movements, and even some trig- gers like respiratory tract infection. 1 The reported association of spontaneous dissections with intracra- nial aneurysms likely reflects the presence of an un- derlying vasculopathy. 1 In 2000, we were surprised to find EC dissection in patients admitted for rup- tured aneurysms, and since then, we look systemati- cally for the association of these vascular lesions. We report seven cases of EC ICA and VA dissections that occurred in the course of a subarachnoid hemor- rhage (SAH) related to the rupture of berry intracra- nial aneurysms. Methods. Between January 2000 and January 2004, we pro- spectively collected cases in which an arterial dissection was doc- umented in patients admitted to our institution for aneurysmal SAH. In all patients, the diagnosis was established by selective four-vessel cerebral angiography. In the presented cases, the SAH was considered to be related to the rupture of berry aneurysms after the expertise of a staff neurosurgeon and neuroradiologist. The SAH was attributed to the aneurysm, if the latter had angio- graphic features of rupture or if the bleeding shown on the CT scan was consistent with location of the aneurysm. Patients pre- senting with other types of aneurysms such as giant, dissecting, mycotic, and fusiform were excluded. All angiograms were re- viewed by two neuroradiologists, who analyzed EC and intracra- nial anterior and posterior circulation. Results. Of 133 patients admitted for an aneurysmal SAH, seven consecutive patients (three men and four women) with EC ICA and VA dissection were identified (table). The mean age was 46.7 years (range 25 to 66 years). Ruptured aneurysms were located in the anterior circulation in five patients and in the posterior circulation in two patients. EC arterial dissections were observed in the ICA (subpetrous segment) in five patients (bilateral, one; left, two; right, two) and in the distal segment of the VA in three patients (on left side in all). One patient had dissections in both ICA (bilateral) and VA (left). There were no bilateral VA dissections. The dissections appeared with in aneurysmal form in six patients and as an intimal flap in one. In the angiographic studies, no changes com- patible with fibromuscular dysplasia were documented. Case report. In July 2000, a 52-year-old man had a sudden headache with a right transient hemiparesis. The CT scan revealed a diffuse SAH. Cerebral angiography demonstrated two small-necked aneurysms, one of the left posterior communicating artery (with angiographic fea- tures of rupture) and one of the left carotid termination, both of 4 mm. The aneurysms were treated successfully with Guglielmi detachable coils. A dissection of the left VA was also observed during the initial angiography and be- fore the endovascular treatment (figure 1). In November 2000, cerebral angiography showed a dis- section of the right and left ICA in the subpetrous seg- ment. The dissection of the left VA increased significantly since the previously obtained angiogram. In June 2001, magnetic resonance angiography demonstrated a decrease in size of the dissections of the three arterial dissections located in the right and left ICA and left VA (figure 2). Discussion. We report seven cases of EC ICA and VA dissections occurring in the course of a SAH re- lated to the rupture of berry aneurysms (table). None of these cases presented environmental factors for cer- vical artery dissections, such as head or neck trauma and chiropractic manipulation, events frequently elic- ited in patients with spontaneous dissections. 1 We excluded a dissection related to endovascular maneu- vers due to the unchanged aspect of the angiography before and after treatment on the artery supplying the aneurysm. Except for one patient who had bilat- eral ICA and left VA dissections, the arterial lesions affected arteries on which no endovascular manipu- lation have been performed. Since the EC dissections were located close to the skull base, an intracranial extension could be the mechanism of the SAH. 2 How- ever, in our cases, the documented berry aneurysms had angiographic features of rupture and the blood location on the CT scan was consistent with the site of the aneurysm. For each case, the cause of the SAH was discussed with a staff neurosurgeon and neuroradiologist and assumed to be related to the rupture of the berry aneurysm documented during angiography. During the course of an SAH, intense stimulation of the sympathetic nervous system occurs, with an increase in circulating catecholamines, resulting in From the Department of Neuroradiology, Ho ˆpital Lariboisie `re, Paris, France. Disclosure: The authors report no conflicts of interest. Received January 3, 2005. Accepted in final form July 19, 2005. Address correspondence and reprint requests to Dr. Emmanuel Houdart, Service de Neuroradiologie, Ho ˆpital Lariboisie `re, 2 rue Ambroise Pare ´, 75010 Paris, France; e-mail: emmanuel.houdart@lrb.ap-hop-paris.fr Copyright © 2005 by AAN Enterprises, Inc. 1471