Spontaneous Intracranial Dissection in the Anterior Circulation

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Abstract
A patient with spontaneous intracranial dissection in the carotid system and fatal outcome is presented. A review of 59 patients reported in the literature shows that this condition has different epidemiological, clinical, pathological and prognostic features compared to other craniocerebral dissections. The disorder usually affects healthy subjects below 30 years with no underlying vasculopathy. The middle cerebral artery is most commonly involved, often in combination with the intracranial carotid artery. The plane of dissection is subintimal in 80% of the cases, leading to stenosis or occlusion of the vessel. These patients present with sudden headache, focal neurologic deficits, syncope, seizures and early alterations of consciousness. Twenty percent of the patients have a subadventitial dissection and present with subarachnoid bleeding. Angiography is rarely pathognomonic, showing usually a nonspecific intracranial arterial stenosis or occlusion. Diagnosis in vivo is difficult and must be based on both clinical and radiological features. No treatment has proved its efficacy: anticoagulation and surgery should be proposed only on an individual basis. Prognosis is usually poor with a fatal outcome in three quarters of the patients and neurologic sequelae in half of the survivors. However, recent reports suggest the possibility of intracranial dissections of the carotid system with less dramatic presentations and more favorable outcomes. The use of MRI studies may lead to earlier and better recognition of this condition, improving so its management and prognosis.

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