- Division of Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
Correspondence Address:
Fahad Alkherayf
Division of Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
DOI:10.4103/2152-7806.122397
Copyright: © 2013 Yuh S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Yuh S, Alkherayf F, Lesiuk H. Dolichoectasia of the vertebral basilar and internal carotid arteries: A case report and literature review. Surg Neurol Int 29-Nov-2013;4:153
How to cite this URL: Yuh S, Alkherayf F, Lesiuk H. Dolichoectasia of the vertebral basilar and internal carotid arteries: A case report and literature review. Surg Neurol Int 29-Nov-2013;4:153. Available from: http://sni.wpengine.com/surgicalint_articles/dolichoectasia-of-the-vertebral-basilar-and-internal-carotid-arteries-a-case-report-and-literature-review/
Abstract
Background:Dolichoectasia is a rare disorder of the cerebral vasculature consisting of vascular elongation, widening, and tortuosity, usually involving the vertebral and basilar arteries. Its neurological symptoms and signs are highly variable.
Case Description:We present a case of dolichoectasia of the vertebrobasilar system in a patient with a long standing history of multiple falls. Repeat neuroimaging revealed an increase in size of the dolichoectatic segment. In addition, a new fusiform dilatation of the contralateral petrous segment of the internal carotid artery and isolated ventriculomegaly had developed.
Conclusion:Vertebrobasilar dolichoectasia can cause multiple clinical manifestations, with hydrocephalus being less common. In addition, having dolichoectasia of both posterior and anterior circulation is extremely rare.
Keywords: Carotid artery, hydrocephalus, vertebrobasilar dolichoectasia
INTRODUCTION
Vertebrobasilar dolichoectasia (VBD) is an uncommon but well recognized vascular anomaly. It is asymptomatic in 90%.[
A review of the literature revealed only six other cases of VBD as a cause of hydrocephalus,[
CASE REPORT
A 67-year-old male with a known dolichoectasia of his vertebrobasilar artery, presented with a history of increasing falls over the past 3 months. A computed tomography (CT) scan of the head [
A magnetic resonance (MR) angiogram [
His past medical history included: Hypertension, dyslipidemia, long time smoker, chronic obstructive pulmonary disease, previous transient ischemic attack, depression, and prostate cancer treated with radiotherapy and NSTEMI treated with PCI (two bare metal stents).
Additional investigation
The presence of new ventriculomegaly on imaging raised the possibility of symptomatic hydrocephalus. A radionuclide cerebrospinal fluid (CSF) flow study was undertaken. It revealed normal migration of the radio tracer from the subarachnoid lumbar space to the basal cisterns and sylvian fissures, with no activity within the lateral ventricles in the 24 and 48 hour images. However, the patient also underwent a trial of lumbar drainage, during which his gait was assessed by the medical allied health team documenting an objective improvement in his gait. Consequently, the patient had a ventriculoperitoneal (VP) shunt inserted with no complications.
DISCUSSION
VBD is a rare dilatative arteriopathy that is defined as elongation or widening of the intracranial vertebral and or basilar arteries. The prevalence ranges from 0.06% to 5.8%.[
Pathogenesis
The pathogenesis of intracranial arterial dolichoectasia is unclear. Multiple pathophysiological processes might contribute to the development of such arterial ectasia vessels such as systemic arterial hypertension associated with atherosclerosis.[
Symptoms
Most cases are asymptomatic. However, the tortuous dolichoectatic vertebrobasilar artery can produce pulsatile compression on the brainstem that may produce the syndromes of obstructive hydrocephalus, cerebellar dysfunction, or even trigeminal neuralgia.[
Diagnosis
Some suggest the diagnosis of VBD as a clinical one of posterior circulation dysfunction.[
Radiographic criteria for VBD are vertebral or basilar artery (1) diameter > 4.5 mm in any location along its course, (2) lateral deviation > 10 mm perpendicular to a straight line joining its origin to its bifurcation, (3) origin at the level of the pontomedullary junction, (4) bifurcation above the suprasellar cistern, (5) lateral to the margin of the clivus or dorsum sellae, and (6) basilar length > 29.5 mm or intracranial vertebral artery length > 23.5mm.[
Prognosis and treatment
The long-term prognosis of VBD is mostly associated with the severity of the condition at diagnosis and on its evolution characteristics, which was associated with a higher mortality and morbidity.[
The first surgical treatment reported in the literature for VBD is that of occlusion of vertebral artery.[
Recently treatment with the use of coil-assisted stent reconstruction has been explored to determine the feasibility and long-term effectiveness in preventing ischemic/infarction events. There have been numerous reports of trials with different kinds of stents and coils with good results.[
In addition, medical therapies used to treat this condition have not been systematically evaluated.[
Since the greatest mortality of VBDE is associated with ischemic events, it would be wise to consider anticoagulation as a primary treatment. However, there are a few dilemmas regarding anticoagulation that one must consider before. Cerebral infarction associated with VBDE is caused by luminal thrombi that obstruct arterial branches, and this is different from the pathophysiology associated with atherosclerosis and cerebral aneurysm. In addition, there is a clear difference in prevalence and prognosis when comparing intracranial dolichoectasia to atherosclerosis and aneurysm.[
Dolichoectasia most frequently involves the vertebrobasilar arteries, and or basilar arteries.[
References
1. Aiba T, Nakazawa T. Non-communicating hydrocephalus due to megadolichobasilar artery-case report. Neurol Med Chir (Tokyo). 1995. 35: 104-6
2. Anson JA, Lawton MT, Spetzler RF. Characteristics and surgical treatment of dolichoectatic and fusiform aneurysms. J Neurosurg. 1996. 84: 185-93
3. Bain M, Hussain MS, Spiotta A, Gonugunta V, Moskowitz S, Gupta R. “Double-barrel” stent reconstruction of a symptomatic fusiform basilar artery aneurysm: Case report. Neurosurgery. 2011. 68: E1491-6
4. Borota L, Jonasson P. Basilar and bilateral carotid dolichoectasia with spontaneous dissection of C2 segment of the internal carotid artery. AJNR Am J Neuroradiol. 2006. 27: 1241-4
5. Branco G, Goulao A, Ferro JM. MRI in aqueduct compression and obstructive hydrocephalus due to an ecstatic basilar artery. Neuroradiology. 1993. 35: 447-8
6. D’Andrea F, Maiuri F, Gangemi M, Iaconetta G. Megadolichobasilar anomaly. Clinical and diagnostic considerations on 30 cases. Acta Neurol (Napoli). 1992. 14: 611-9
7. Doran SE, Deveikis JP, Chandler WF. Dolichoectasia of the anterior cerebral arteries in an adolescent. AJNR Am J Neuroradiol. 1995. 16: 1548-50
8. Dziewasa R, Freund M, Ludemann P, Muller M, Ritter M, Droste DW. Treatment options in vertebrobasilar dolichoectasia--case report and review of the literature. Eur Neurol. 2003. 49: 245-7
9. Ekbom K, Greitz T, Kugelberg E. Hydrocephalus due to ectasia of the basilar artery. J Neurol Sci. 1969. 8: 465-77
10. Fiorella D, Albuquerque FC, Han P, McDougall CG. Preliminary experience using the Neuroform stent for the treatment of cerebral aneurysms. Neurosurgery. 2004. 54: 6-16
11. Flemming KD, Wiebers DO, Brown RD, Link MJ, Nakatomi H, Huston J. Prospective risk of hemorrhage in patients with vertebrobasilar nonsaccular intracranial aneurysm. J Neurosurg. 2004. 101: 82-7
12. Gautier JC, Hauw JJ, Awada A, Loron P, Gray F, Juillard JB. Dolichoectatic intracranial arteries. Association with aneurysms of the abdominal aorta. Rev Neurol. 1988. 144: 437-46
13. Greitz T, Lofstedt S. The relationship between the third ventricle and the basilar artery. Acta Radiol. 1954. 42: 85-100
14. Gutierrez J, Sacco RL, Wright CB. Dolichoectasia-an evolving arterial disease. Nat Rev Neurol. 2011. 7: 41-50
15. Hegedus K. Ectasia of the basilar artery with special reference to possible pathogenesis. Surg Neurol. 1985. 24: 463-9
16. Higashida RT, Smith W, Gress D, Urwin R, Dowd CF, Balousek PA. Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature. J Neurosurg. 1997. 87: 944-9
17. Ikeda K, Nakamura Y, Hirayama T, Sekine T, Nagata R, Kano O. Cardiovascular risk and neuroradiological profiles in asymptomatic vertebrobasilar dolichoectasia. Cerebrovasc Dis. 2010. 30: 23-8
18. Ince B, Petty GW, Brown RD, Chu CP, Sicks JD, Whisnant JP. Dolichoectasia of the intracranial arteries in patients with first ischemic stroke: A population-based study. Neurology. 1998. 50: 1694-8
19. Iwama T, Andoh T, Sakai N, Iwata T, Hirata T, Yamada H. Dissecting and fusiform aneurysms of vertebro-basilar systems. MR imaging. Neuroradiology. 1990. 32: 272-9
20. Kansal R, Mahore A, Dange N, Kukreja S. Dolichoectasia of vertebrobasilar arteries as a cause of hydrocephalus. J Neurosci Rural Pract. 2011. 2: 62-4
21. Lou M, Caplan LR. Vertebrobasilar dilatative arteriopathy (dolichoectasia). Ann N Y Acad Sci. 2010. 1184: 121-33
22. Mangrum WI, Huston J, Link MJ, Wiebers DO, McClelland RL, Christianson TJ. Enlarging vertebrobasilar nonsaccular intracranial aneurysms: Frequency, predictors, and clinical outcome of growth. J Neurosurg. 2005. 102: 72-9
23. Matsumoto K, Yamada K, Hayakawa T, Kataoka K, Yamamoto K, Onishi T. Dolichoectatic basilar artery treated by reducing hemodynamic stress--report of two cases. Neurol Med Chir (Tokyo). 1990. 3: 691-4
24. Milandre L, Bonnefoi B, Pestre P, Pellissier JF, Grisoli F, Khalil R. Vertebrobasilar arterial dolichoectasia. Complications and prognosis. Rev Neurol. 1991. 147: 714-22
25. Moseley IF, Holland IM. Ectasia of the basilar artery: The breadth of the clinical spectrum and the diagnostic value of computed tomography. Neuroradiology. 1979. 18: 83-91
26. Mount LA, Taveras JM. Ligation of basilar artery in treatment of an aneurysm at the basilar-artery bifurcation. J Neurosurg. 1962. 19: 167-70
27. Nagaseki Y, Horikoshi T, Omata T, Ueno T, Uchida M, Nukui H. Oblique sagittal magnetic resonance imaging visualizing vascular compression of the trigeminal or facial nerve. J Neurosurg. 1992. 77: 379-86
28. Nijensohn DE, Saez RJ, Reagan TJ. Clinical significance of basilar artery aneurysms. Neurology. 1974. 24: 301-5
29. Passero S, Filosomi G. Posterior circulation infarcts in patients with vertebrobasilar dolichoectasia. Stroke. 1998. 29: 653-9
30. Passero SG, Calchetti B, Bartalini S. Intracranial bleeding in patients with vertebrobasilar dolichoectasia. Stroke. 2005. 36: 1421-5
31. Pereira-Filho A, Faria M, Bleil C, Kraemer JL. Brainstem compression syndrome caused by vertebrobasilar dolichoectasia: Microvascular repositioning technique. Arq Neuropsiquiatr. 2008. 66: 408-11
32. Pico F, Labreuche J, Cohen A, Touboul PJ, Amarenco P. Intracranial arterial dolichoectasia is associated with enlarged descending thoracic aorta. Neurology. 2004. 63: 2016-21
33. Pico F, Labreuche J, Touboul PJ, Amarenco P. Intracranial arterial dolichoectasia and its relation with atherosclerosis and stroke subtype. Neurology. 2003. 61: 1736-42
34. Pico F, Labreuche J, Touboul PJ, Leys D, Amarenco P. Intracranial arterial dolichoectasia and small-vessel disease in stroke patients. Ann Neurol. 2005. 57: 472-9
35. Rabb CH, Barnwell SL. Catastrophic subarachnoid hemorrhage resulting from ruptured vertebrobasilar dolichoectasia: Case report. Neurosurgery. 1998. 42: 379-82
36. Rautenberg W, Aulich A, Rother J, Wentz KU, Hennerici M. Stroke and dolichoectatic intracranial arteries. Neurol Res. 1992. 14: 201-3
37. Resta M, Gentile MA, Di Cuonzo F, Vinjau E, Brindicci D, Carella A. Clinical-angiographic correlations in 132 patients with megadolichovertebrobasilar anomaly. Neuroradiology. 1984. 26: 213-6
38. Ricci G, Lenzi J, Esposito V. Hydrocephalus caused by dolichoectatic basilar artery. Case report. J Neurosurg Sci. 2000. 44: 155-8
39. Romi F, Krakenes J, Thomassen L, Tysnes OB. Dolichoectasia of the intracranial arteries and stroke. Tidsskr Nor Laegeforen. 1999. 119: 3004-5
40. Schulz R, Fegbeutel C, Althoff A, Traupe H, Grimminger F, Seeger W. Central sleep apnoea and unilateral diaphragmatic paralysis associated with vertebral artery compression of the medulla oblongata. J Neurol. 2003. 250: 503-5
41. Siddiqui A, Chew NS, Miszkiel K. Vertebrobasilar dolichoectasia: A rare cause of obstructive hydrocephalus: Case report. Br J Radiol. 2008. 81: e123-6
42. Smoker WR, Corbett JJ, Gentry LR, Keyes WD, Price MJ, McKusker S. High-resolution computed tomography of the basilar artery: 2. Vertebrobasilar dolichoectasia: Clinical-pathologic correlation and review. AJNR Am J Neuroradiol. 1986. 7: 61-72
43. Svien HJ, Peserico L. Occlusion of the third ventricle by tortuous, bulbous, calcified basilar artery. Neurology. 1959. 9: 836-8
44. Takeuchi S, Takasato Y, Masaoka H, Hayakawa T, Otani N, Yoshino Y. Dolichoectasia involving the vertebrobasilar and carotid artery systems. J Clin Neurosci. 2009. 16: 1344-6
45. Tay KY, U-King-Im JM, Trivedi RA, Higgins NJ, Cross JJ, Davies JR. Imaging the vertebral artery. Eur Radiol. 2005. 15: 1329-43
46. Thiex R, Mull M. Basilar megadolicho trunk causing obstructive hydrocephalus at the foramina of Monro. Surg Neurol. 2006. 65: 199-201
47. Tomasello F, Alafaci C, Salpietro FM, Longo M. Bulbar compression by an ectatic vertebral artery: A novel neurovascular construct relieved by microsurgical decompression. Neurosurgery. 2005. 56: 117-24
48. Ubogu EE, Zaidat OO. Vertebrobasilar dolichoectasia diagnosed by magnetic resonance angiography and risk of stroke and death: A cohort study. J Neurol Neurosurg Psychiatry. 2004. 75: 22-6
49. Vieco PT, Maurin EE, Gross CE. Vertebrobasilar dolichoectasia: Evaluation with CT angiography. AJNR Am J Neuroradiol. 1997. 18: 1385-8
50. Yu YL, Moseley IF, Pullicino P, McDonald WI. The clinical picture of ectasia of the intracerebral arteries. J Neurol Neurosurg Psychiatry. 1982. 45: 29-36
51. Zenteno MA, Murillo-Bonilla LM, Guinto G, Gomez CR, Martinez SR, Higuera-Calleja J. Sole stenting bypass for the treatment of vertebral artery aneurysms: Technical case report. Neurosurgery. 2005. 57: E208-