Vertebral artery dissection with left PICA infarct

Case contributed by Dr Namita Sinha

Presentation

History of neck pain for one week followed by sudden onset of giddiness and swaying.

Patient Data

Age: 30 years
Gender: Male
On the pre contrast T1W images of the neck, there is a curvilinear T1 hyperintense lesion seen parallel
to the extra-foraminal course of the left vertebral artery at the level of C1-2, measuring 18 x 5mm.
There is moderate mural thickening with eccentric mural enhancement seen on the post contrast
images in this segment of the vertebral artery.
This lesion is suggestive of a dissection with hematoma in the false lumen.

The true lumen in this segment of the vertebral artery is thinned out, however is still patent.

On the 3D TOF images, the hematoma is seen as bright lesion parallel to the curved course of the left vertebral artery due to the inherent T1 shortening effect seen with subacute hematoma in TOF sequences. This necessitates the use of T1 sequences and Post contrast MRA.

Case Discussion

Vertebral artery dissection is one of the common causes of posterior territory stroke in young. Recognition of the dissection depends on choosing the ideal imaging modality. MR with 3D TOF MRA is usually the initial imaging modality for stroke in young. Care must be taken to assess for T1 shortening along the course of the vertebral artery walls, which should not be mistaken for normal flow (as flow signal and signal of meth-hemoglobin is identical on TOF). Once such an abnormality is identified, it is essential to confirm these findings with a fat Sat T1W sequence in the affected segment of the vertebral artery, followed by contrast enhanced MRA. 

This was especially essential in our case, in view of the fact that the dissection had not caused complete occlusion of the artery and small patent true lumen was seen even beyond the segment of dissection.

The lack of flow in one vertebral artery with mural thickening are other signs of vertebral artery dissection. 

CT angiography may not be helpful in cases like ours, in view of the fact that the hematoma was only segmental, subacute (hence may be isodense and missed) and did not cause complete obstruction.

The study of vertebral arteries is challenging, especially when dissection is suspected and appropriately designed examinations are needed. A multiparametric approach, with T1WI, T2WI, and TOF MRA followed by CE-MRA may be useful to identify the vessel pathology and differentiate hematomas and venous structures (1).

This case was contributed by Dr. Anisha Sawkar, Radiologist at St Johns Hospital.

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Case information

rID: 23706
Case created: 4th Jul 2013
Last edited: 21st Sep 2015
Inclusion in quiz mode: Included

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