What is the role of 4-vessel cerebral angiography in the workup of vertebral artery dissection (VAD)?

Updated: Feb 21, 2019
  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Prior to the development of noninvasive techniques such as magnetic resonance imaging (MRI) and Doppler ultrasonography, cerebral angiography was the criterion standard in diagnosing vertebral artery dissection (VAD). These noninvasive techniques are supplanting angiography as the imaging techniques of choice for patients in whom VAD is suspected. [7]

A French retrospective study that evaluated clinical and imaging features with outcomes in 20 pediatric patients with extracranial VAD over 14 years indicated that the initial imaging studies should include the posterior fossa vessels and the craniocervical region with V2-V3 segments. [38] In the presence of inconclusive findings on nonivasive imaging studies, the investigators suggested use of conventional angiography for definitive diagnosis. [38]

The characteristic angiographic finding in a dissected vertebral artery is the string or "string and pearl" appearance of the stenotic vessel lumen. [10] Angiograms are shown in the images below.

A, Dissection of the left vertebral artery seconda A, Dissection of the left vertebral artery secondary to guidewire injury. B, Complete resolution occurred in 6 months with only aspirin and clopidogrel (Plavix) therapy.
Gunshot wound to the right side of the neck. A, Th Gunshot wound to the right side of the neck. A, The angiogram shows transections of the right vertebral artery (RVA) and the right internal maxillary artery (RIMAX), with partial transection and pseudoaneurysm formation of the midcervical right internal carotid artery (RICA). The transected segments of the RVA and RIMAX were embolized with coils. B and C, The RICA pseudoaneurysm was successfully treated with a 7 x 40-mm covered stent (Wallgraft).

Because of the high incidence (up to 40% in some series) of multiple extracranial cervical artery dissections occurring simultaneously in the same patient, 4-vessel angiography is the angiographic technique of choice in all patients with potential carotid artery dissection (CAD) or VAD. [10]

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