Imaging characteristics of symptomatic vertebral artery dissection: a systematic review

Rebecca F Gottesman, Priti Sharma, Karen A Robinson, Martinson Arnan, Megan Tsui, Ali Saber-Tehrani, David E Newman-Toker, Rebecca F Gottesman, Priti Sharma, Karen A Robinson, Martinson Arnan, Megan Tsui, Ali Saber-Tehrani, David E Newman-Toker

Abstract

Background: Vertebral artery dissection (VAD) is an important cause of stroke in the young. VAD can present with a range of imaging findings. We sought to summarize the diagnostic value of various imaging findings in patients with symptomatic VAD.

Methods: We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality and imaging data were abstracted. Pooled proportions were calculated.

Results: Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. Most studies utilized conventional angiography or magnetic resonance angiography (MRA) to diagnose VAD; computed tomographic angiography (CTA) and Doppler ultrasonography were described less frequently. Imaging findings reported were vertebral artery stenosis (51%), string and pearls (48%), arterial dilation (37%), arterial occlusion (36%), and pseudoaneurysm, double lumen, and intimal flap (22% each). In cases where conventional angiography was the reference standard, CTA was more sensitive (100%) than either MRA (77%) or Doppler ultrasonography (71%) (P=0.001).

Conclusions: Imaging findings vary widely in patients with VAD, with no single radiographic sign present in the majority of VAD patients. Nonspecific radiographic signs predominate. CTA probably has greater sensitivity for dissection than MRA or ultrasound relative to conventional angiography. Higher quality studies on imaging techniques and radiographic criteria in subjects with VAD are needed. Future studies should compare imaging techniques in well-defined, undifferentiated populations of clinical VAD suspects.

Figures

Figure 1
Figure 1
CT Angiography showing left vertebral artery intimal flap (arrow) secondary to vertebral artery dissection.
Figure 2
Figure 2
MR Angiography of the neck showing right vertebral artery tapering occlusion (arrow), caused by vertebral artery dissection in the distal V2 segment. The V1 through V4 segments are indicated along the normal left vertebral artery.
Figure 3
Figure 3
Flow chart showing suggested diagnostic process in evaluating a patient with potential vertebral artery dissection. Imaging should be evaluated for “direct” findings (double lumen, intimal flap) or “indirect” findings (arterial stenosis, occlusion, dilation, aneurysm or pseudoaneurysm, string and pearl sign).

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