Case 11 - Bilateral Dissection

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

Indication: 70 y.o. female presents to the ED with noted at noon today noted left hand weakness and left foot. Lasted 30 sec to min. history significant for fibromuscular dysplasia, BPPV, ulcerative colitis, HTN, ITP, recent atrial tachycardia (s/p recent PPM, c/b pericardial effusion) who presents with now resolved right hand and foot numbness

TECHNIQUE: CT angiographic images were performed with multiplanar reconstructions and three-dimensional reconstructions of maximum intensity projection. Study was performed after contrast.

FINDINGS:

There is 50% stenosis of the left subclavian artery from the aorta. The origin of the left vertebral artery is normal however the left vertebral artery is small in size. Its course through the neck is without stenosis.

The origin of the right vertebral artery is normal. Its course through the neck shows no evidence of stenosis. There is minimal kinking of the vessel at the C1-C2 level as it leaves the vertebral column seen best on series 7 image 324. At this level there is a line at the luminal center seen best on series 7 image 323 which may represent a small area of vascular dissection.

The origin of the left common carotid artery is normal. Its course through the neck is unremarkable. The carotid bifurcation shows no evidence of stenosis. The left internal carotid artery has variable caliber to 8 with irregularity at the C1 level and possible dissection with pseudoaneurysm. There is irregularity as the cervical left internal carotid artery is just below its petrous portion. Within the petrous portion there is a flap of a dissection seen best on series 7 image 255. The left cavernous carotid artery shows a portion of the left cavernous sinus seen best on series 7 image 239 which is early in its venous phase. The significance of this is unclear.

The origin of the right common carotid artery is normal. Its course through the neck is unremarkable. The carotid bifurcation shows no areas of stenosis. The caliber of the right internal carotid artery varies and there is an area at the C1 level seen best on series 7 image 320 where the vessel has irregular contour and narrowing followed by dilatation. The distal cervical right internal carotid artery is more dilated than its proximal portion. The petrous portion shows no abnormalities. The cavernous portion shows minimal irregularity.

The left M1 segment appears to be stenotic and there are collateral vessels in a moyamoya pattern at the M1 segment seen best on series 7 image 193.

The soft tissues of the neck are unremarkable. The patient has bilateral pleural thickening and bilateral apical pulmonary infiltrates with a fibrotic pattern.

The maximum intensity projection three-dimensional reconstructions of the intracranial circulation show the M1 segment stenosis on the left side seen best on series 11 image 36. Nonetheless distal branches are well seen.

Impression:

Dissection of the left petrous internal carotid artery, new since the MRA from January 9, 2020, with new high-grade stenosis of the left M1 segment of the middle cerebral artery with associated moyamoya syndrome lenticulostriate collaterals reconstituting the distal left M1 and M2 segments.

Early filling of the left cavernous internal carotid artery associated with the left dissection raising the possibility of a cavernous carotid fistula. Clinical correlation is recommended and confirmation with conventional arteriography may be useful.

Probable dissection of the right V3 distal segment of the vertebral artery proximal to its dural entry.

Bilateral fibromuscular dysplasia dilatations and beaded appearance to the cervical internal carotid arteries. Milder changes are present in the cervical portion of the right vertebral artery.