Multi-modal imaging for the diagnosis of spontaneous visceral artery dissection:A case report

BACKGROUND Spontaneous visceral artery dissection(SVAD)is a rare condition that affects the visceral arteries,such as the celiac,superior mesenteric,and inferior mesenteric arteries,without involving the aorta.Organ ischemia or hemorrhage from vessel rupture can occur in SVAD;therefore,prompt detection and management is essential.Contrast-enhanced computed tomography(CECT)has been used to diagnose most of the previous cases,but few studies have explored the potential of contrast-enhanced ultrasound(CEUS)for early detection of this disease.CASE SUMMARY A 53-year-old male presented with complaints of poor appetite and abnormal liver function for the past 6 months.He had previously undergone transabdominal splenectomy,esophagogastric devascularization,and cholecystectomy for gallstones and severe portal hypertension.Liver ultrasound was performed in our department to assess liver status.An abnormal hepatic artery spectrum was observed,and dissection involving both the celiac artery and the common hepatic artery was observed.A CEUS was then performed and clearly showed the entry site of the intimal tear and the false lumen,and dissection was subsequently confirmed by CECT.The patient was asymptomatic;therefore,treatment to control the blood pressure was provided,and follow-up was recommended.After 6 months of follow-up,the celiac artery was found to be dilated with an adherent thrombus visible in the wall,and the common hepatic artery was occluded with the presence of collateralization.Despite these findings,no significant changes in liver function were observed.CONCLUSION Multi-modal imaging is effective in diagnosing SVAD,and conservative treatment is a choice for asymptomatic patients.

Intravascular photoacoustic and optical coherence tomography imaging dual-mode system for detecting spontaneous coronary artery dissection: A feasibility study

In this work,we present an intravascular dual-mode endoscopic system capable of both intravascular photoacoustic imaging(IVPAI)and intravascular optical coherence tomography(IVOCT)for recognizing spontaneous coronary artery dissection(SCAD)phantoms.IVPAI provides high-resolution and high-penetration images of intramural hematoma(IMH)at different depths,so it is especially useful for imaging deep blood clots associated with imaging phantoms.IVOCT can readily visualize the double-lumen morphology of blood vessel walls to identify intimal tears.We also demonstrate the capability of this dual-mode endoscopic system using mimicking phantoms and biological samples of blood clots in ex vivo porcine arteries.The results of the experiments indicate that the combined IVPAI and IVOCT technique has the potential to provide a more accurate SCAD assessment method for clinical applications.

Vertebral Artery Stenting for Acute Multiple Cerebral Infarctions Caused by Vertebral Artery Dissection After Massage:A Case Report

Vertebral artery dissection is a rare pathology that can cause ischemic stroke in young people.Cervical massage,especially improper pulling manipulation,is a cause of vertebral artery dissection.We present a case of 32-year old woman who developed acute multiple posterior circulation ischemic cerebral infarctions as a result of left vertebral artery V4 segment dissection after receiving neck massage.She underwent emergency vertebral artery stent implantation at the site of the dissection.Symptoms were relieved the day after treatment.The patient recovered without adverse complications or endovascular restenosis in the following year.

High-resolution magnetic resonance imaging in the diagnosis and management of vertebral artery dissection:A case report

BACKGROUND Vertebral artery dissection(VAD)is a rare but life-threatening condition characterized by tearing of the intimal layer of the vertebral artery,leading to stenosis,occlusion or rupture.The clinical presentation of VAD can be heterogeneous,with common symptoms including headache,dizziness and balance problems.Timely diagnosis and treatment are crucial for favorable outcomes;however,VAD is often missed due to its variable clinical presentation and lack of robust diagnostic guidelines.High-resolution magnetic resonance imaging(HRMRI)has emerged as a reliable diagnostic tool for VAD,providing detailed visualization of vessel wall abnormalities.CASE SUMMARY A young male patient presented with an acute onset of severe headache,vomiting,and seizures,followed by altered consciousness.Imaging studies revealed bilateral VAD,basilar artery thrombosis,multiple brainstem and cerebellar infarcts,and subarachnoid hemorrhage.Digital subtraction angiography(DSA)revealed vertebral artery stenosis but failed to detect the dissection,potentially because intramural thrombosis obscured the VAD.In contrast,HRMRI confirmed the diagnosis by revealing specific signs of dissection.The patient was managed conservatively with antiplatelet therapy and other supportive measures,such as blood pressure control and pain management.After 5 mo of rehabilitation,the patient showed significant improvement in swallowing and limb strength.CONCLUSION HR-MRI can provide precise evidence for the identification of VAD.

Spontaneous coronary artery dissection-associated takotsubo syndrome: A systematic review of case reports

BACKGROUND Spontaneous coronary artery dissection(SCAD)is underdiagnosed and requires comprehensive angiographic findings.Few SCAD occurrences have a comparable clinical appearance as takotsubo syndrome(TTS)or exist simultaneously,making it challenging for clinicians to treat and manage.Case reports lack consolidated AIM To conduct a systematic review of available case reports on SCAD in order to investigate its potential association with TTS.METHODS SCAD-associated TTS case reports were reviewed after thoroughly screening PubMed,EMBASE,Scopus,and Google Scholar databases till January 2023.Case reports described demographics,comorbidities,imaging,management,and results.RESULTS Twelve articles about 20 female patients were analyzed.30%of patients(n=6,>60 years)were elderly(mean age 56.2±9.07 years,range 36-70 years).Canada has 9 cases,United States 3,Australia 3,Sweden 2,Japan,Denmark,and France 1.Only 5 reports identified emotional stressors in these cases while 4 reports showed physical triggers for TTS.Nine had hypertension,2 had hyperlipidemia,and 1 had prediabetes.5 patients(25%)smoked.10(50%)troponin-positive myocardial infarction patients reported chest discomfort.11(55%)of 20 instances had TTS/SCAD.12(60%)of 20 patients exhibited ST elevation and 3(15%)had T wave inversion on electrocardiogram.19/20 patients had elevated troponin.9(45%)of 20 people had apical akinesis with TTS ballooning on cardiac imaging.All 20 exhibited echocardiographic wall motion abnormalities.19(95%)of 20 coronary angiography cases had SCAD.10 of 19 SCAD patients had left anterior descending,2 diagonal,and 2 left circumflex coronary artery involvement.7 of 20 patients had left ventricular ejection fraction(LVEF)data.LVEF averaged 38.78±7.35%.5(25%)of the 20 cases underwent dual antiplatelet therapy.Three(15%)of 20 cases experienced occasional ectopic ventricular complexes,Mobitz ll AV block,and paroxysmal atrial fibrillation.All 20 cases recovered and survived.CONCLUSION Given the clinical similarities and challenges in detecting TTS and SCAD,this subset needs more research to raise awareness and reduce morbidity.

Initial clinical experience with Xpert-Pro peripheral self-expanding stent system for internal carotid artery dissection:Two case reports

Background:The standard treatment for internal carotid artery(ICA)dissection is obscure.Current therapeutic strategies include the use of antiplatelet drugs,anticoagulant drugs,intravenous thrombolysis,and endovascular treatment.Endovascular treatment is important in acute internal carotid artery dissection.This study reports two acute internal carotid artery dissection cases that were treated successfully using the Xpert-Pro peripheral selfexpanding stent system.Case summary:The first case was of a 38-year-old male patient with transient speechlessness and paralysis of the right limb in July 2021.Cervical computed tomographic angiography(CTA)showed ICA occlusion on the left side.Digital subtraction angiography(DSA)showed severe stenosis of the C1 segment of the left internal carotid artery with intermural hematoma.The patient subsequently underwent Xpert-Pro peripheral self-expanding stent implantation,and his condition stabilized.The second case was of a 56-year-old male patient with speechlessness and paralysis of the right limb.Cervical CTA showed a dissected left ICA,and DSA showed an occluded left ICA and middle cerebral artery.The patient subsequently underwent stent implantation,and his condition stabilized.

Spontaneous Coronary Artery Dissection with Iliac Artery Dissection: A Case Report and Literature Review

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome or sudden cardiac death.It often occurs in females with no conventional cardiovascular risk factors.Bilateral iliac artery dissection is also a rare disease.This case report describes a patient with spontaneous coronary artery dissection and iliac artery dissection.The authors believe that a conservative approach could be used as an effective therapy for a clinically stable patient.

Cerebral infarct secondary to traumatic internal carotid artery dissection

BACKGROUND Traumatic internal carotid artery dissection(TICAD)is rare and can result in severe neurological disability and even death.No consensus regarding its diagnostic screening and management has been established.AIM To investigate the clinical presentation,imaging features,diagnostic workup,and treatment of TICAD.METHODS In this retrospective case series,emergency admissions for TICAD due to closed head injury were analyzed.The demographic,clinical,and radiographic data were retrieved from patient charts and the picture archiving and communication system.RESULTS Six patients(five males and one female,age range of 43-62 years,mean age of 52.67 years)presented with TICAD.Traffic accidents(4/6)were the most frequent cause of TICAD.The clinical presentation was always related to brain hypoperfusion.Imaging examination revealed dissection of the affected artery and corresponding brain infarction.All the patients were definitively diagnosed with TICAD.One patient was treated conservatively,one patient underwent anticoagulant therapy,two patients were given both antiplatelet and anticoagulant drugs,and two patients underwent decompressive craniectomy.One patient fully recovered,while three patients were disabled at follow-up.Two patients died of refractory brain infarction.CONCLUSION TICAD can cause catastrophic outcomes and even refractory brain hernia.Early and efficient diagnosis of TICAD is essential for initiating appropriate treatment.The treatment of TICAD is challenging and variable and is based on clinician discretion on a case-by-case basis.

Spontaneous coronary artery dissection as a cause of myocardial infarction

Spontaneous coronary artery dissection(SCAD) is a rare disease that is usually seen in young women in left descending coronary artery and result in events like sudden cardiac death and acute myocardial infarction. A 70-year-old man was admitted to the emergency department with chest pain which started 1 h ago during a relative's funeral. The initial electrocardiography demonstrated 2 mm ST-segment depression in leads V1-V3 and the patient underwent emergent coronary angiography. SCAD simultaneously in two different coronary arteries [left anterior descending(LAD) artery and left circumflex(LCx)] artery was detected and SCAD in LCx artery was causing total occlusion which resulted in acute myocardial infarction. Successful stenting was performed thereafter for both lesions. In addition to the existence of SCAD simultaneously in two different coronary arteries, the presence of muscular bridge and SCAD together at the same site of the LAD artery was another interesting point which made us report this case.

The ratio of superior mesenteric artery diameter to superior mesenteric vein diameter based on non-enhanced computed tomography in the early diagnosis of spontaneous isolated superior mesenteric artery dissection

BACKGROUND:Spontaneous isolated superior mesenteric artery(SMA)dissection(SISMAD)is a rare cause of abdominal pain.The aim of the study is to investigate the role of a new parameter,the ratio of the SMA diameter to the superior mesenteric vein(SMV)diameter(SMA/SMV)based on non-enhanced computed tomography(CT),in the early diagnosis of SISMAD.METHODS:In a registry study from December 2013 to June 2021,97 abdominal pain SISMAD patients(SISMAD group)admitted to our hospital were enrolled.Meanwhile,the matched sex and age abdominal pain non-SISMAD patients at 1:2 were collected in reverse chronological order as the control group.Student’s t-test,Wilcoxon rank-sum test,and Chi-square test were used to compare differences between the SISMAD and control groups.Med Calc was used to generate receiver operating characteristic(ROC)curve.RESULTS:A total of 291 abdominal pain patients,including 97 SISMAD patients and 194 nonSISMAD patients,were included in the current study.The maximum SMA diameter,perivascular exudation,and SMA/SMV based on non-enhanced CT were significant between the two groups(all P<0.05).ROC curves showed that for the maximum SMA diameter,the area under the curve(AUC),cut-off,sensitivity,and specificity were 0.926,9.80,93.8%,and 79.4%,respectively.For SMA/SMV,its AUC,cut-off,sensitivity,and specificity were 0.956,0.83,88.7%,and 92.3%,respectively.The diagnostic efficiency of SMA/SMV was better than that of the maximum SMA diameter(P<0.05).The combined parameters of SMA/SMV and maximum SMA diameter had the best diagnostic efficiency(AUC=0.970).CONCLUSION:SMA/SMV may be a potential marker for SISMAD.

Diagnosis of spontaneous isolated superior mesenteric artery dissection with ultrasound:A case report

BACKGROUND Spontaneous isolated superior mesenteric artery dissection(SISMAD)is a rare disease that originates from the superior mesenteric artery,without the presence of aortic and other arterial dissections.Most cases are diagnosed using contrastenhanced computed tomography(CECT),whereas the application of ultrasound is less common.CASE SUMMARY Here,we report a case of SISMAD with sudden epigastric pain that worsened as the main symptom after eating.The patient had a long history of hypertension with unknown blood pressure control but no history of smoking or alcohol consumption.This case was initially diagnosed using ultrasound and the results were later confirmed by CECT.After admission,the patient fasted,followed by parenteral nutrition support and fluid supplementation to maintain electrolyte and acid–base balance.Metoprolol succinate sustained-release tablets and aspirin were given as nonoperative treatments.After 1 wk,the symptoms improved,and the patient was discharged.During telephone follow-up,the patient did not develop similar symptoms.CONCLUSION Whether ultrasound can be used as a routine and noninvasive imaging method for the diagnosis of SISMAD needs further exploration.

Pregnancy associated spontaneous coronary artery dissection:A case report and review of literature

BACKGROUND Pregnancy-associated spontaneous coronary artery dissection(PSCAD)is an important cause of chest pain and acute myocardial infarction in pregnant and postpartum women.Pregnancy is considered an isolated risk factor for spontaneous coronary artery dissection.The etiology,pathogenesis,and incidence of PSCAD are not known.CASE SUMMARY We present a case of a 33-year-old postpartum female who presented with sudden onset chest pain and was diagnosed with spontaneous coronary artery dissection and needed urgent catheterization revealing left anterior descending coronary artery dissection.She underwent emergent coronary artery bypass graft surgery with good post-operative recovery.CONCLUSION Most patients with PSCAD can be managed conservatively with medical management and have good outcomes.Patients with high-risk presentations benefit from the invasive approach.Coronary artery bypass graft may be required in select few patients based on angiography findings.Due to the risk of recurrent spontaneous coronary artery dissection,subsequent pregnancies are discouraged.

Spontaneous coronary artery dissection:A review of diagnostic methods and management strategies

Spontaneous coronary artery dissection(SCAD)is a rare non-atherosclerotic cause of acute coronary syndromes defined as non-iatrogenic,non-traumatic separation of the coronary artery wall.The most common profile is a middle-aged woman between 44 and 53 years with few cardiovascular risk factors.SCAD is frequently linked with predisposing factors,such as postpartum,fibromuscular dysplasia or other vasculopathies,connective tissue disease and hormonal therapy,and it is often triggered by intense physical or emotional stress,sympathomimetic drugs,childbirth and activities increasing shear stress of the coronary artery walls.Patients with SCAD usually present at the emergency department with chest discomfort,chest pain,and rapid heartbeat or fluttery.During the last decades,the most common problem of SCAD was the lack of awareness about this condition which has led to significant underdiagnosis and misdiagnosis.However,modern imaging techniques such as optical coherence tomography,intravascular ultrasound,coronary angiography or magnetic resonance imaging have contributed to the early diagnosis of the disease.Treatment of SCAD remains controversial,especially during the last years,where invasive techniques are being used more often and in more emergent cardiac syndromes.Although conservative treatment combining aspirin and betablocker remains the recommended strategy in most cases,revascularization could also be suggested as a method of treatment in specific indications,but with a higher risk of complications.The prognosis of SCAD is usually good and long-term mortality seems to be low in these patients.Follow-up should be performed on a regular basis.

Vocal Cord Paralysis Secondary to Carotid Artery Dissection: A Case Report

Background and Objective: Vocal cord paralysis results in impairment of breathing and/or speech. One of the causes of vocal cord paralysis is the disruption of vagus nerve innervation to the vocal cords by the mass effect of a neighbouring structure. We report a rare case of vocal cord paralysis secondary to internal carotid artery dissection. Method: The diagnosis was based on clinical history, physical examination and imaging studies. Literature review was done. Case Report: This was a 53-year-old female with a history of unremitting, progressive hoarseness and mild dysphagia to liquid, who was clinically found to have impaired left vocal cord mobility, a left-sided pulsatile neck mass and left carotid artery dissection based on imaging studies. Symptoms abated after conservative treatment with Aspirin and she has remained symptom free since two years of follow-up. Conclusion: Vocal cord paralysis can be a consequence of carotid artery dissection causing mass effect on the vagus nerve. Thus, carotid artery dissection should not be forgotten as a possible cause of vocal cord paralysis in some cases of vocal cord paralysis of uncertain etiology. Treatment with anti-platelet drug can bring about resolution of symptoms and return of vocal cord mobility.

Clinical characteristics of fibromuscular dysplasia with severe headache misdiagnosed as cerebral artery dissection: a case report

Fibromuscular dysplasia(FMD)is a rare disease with a typical clinical manifestations.This article will describe the clinical features of a FMD case with severe headache misdiagnosed as cerebral artery dissection(CAD).Treatment remedies:we collected the clinical data of a patient with severe headache and performed brain MRI(magnetic resonance imaging)and cerebral arteriovenous MRA(magnetic resonance angiography).The preliminary diagnosis was considered as right vertebral artery dissection,and then cerebral DSA(digital subtraction angiography)was performed for further diagnosis.Post treatment evaluating:cerebral angiography showed that the vessel wall was stiff,with multiple(insect phagocytic)-like changes,and severe stenosis of local long segments.Some vessels showed“double lumen sign”,which was consistent with the performance of FMD.After anticoagulant treatment,the patient’s condition was improved.Conclusions:for severe headache,in addition to common diseases,the possibility of FMD should also be paid great attention.Early cerebrovascular screening is conducive to early diagnosis and timely treatment.

Spontaneous Coronary Artery Dissection as a Cause of Acute Myocardial Infarction in Young Female Population： A Single-center Study

Background： Spontaneous coronary artery dissection （SCAD） is a nonatherosclerotic but a rare and extremely dangerous clinical entity, it has a high prevalence in young female population with acute myocardial infarction （AMI）. The previous reports were restricted to other countries＇ population, but rare in China. Hence, this study aimed to focus on the characteristics of SCAD as a cause of young female AMI population in Jiangsu, China. Methods： This study enrolled young female AMI patients aged ≤50 years who underwent coronary angiography （CAG） and intracoronary imaging in our center between January 2013 and December 2016. Their clinical presentations, risk factors, and CAG characteristics were analyzed. Results： A total of 60 young l＇emale AMI （〈7 days） patients were enrolled. From their CAG and intracoronary imaging results, the prevalence of SCAD in young female AMI population was 35% （21/60）, the prevalence of coronary atherosclerostic heart disease was 65% （39/60）. In the SCAD group, 43% （9/21） presented with non-ST-elevation myocardial infarction （NSTEM1） and the remainder presenting as STEMI. SCAD usually occurred in a single vessel （20/21, 95%）, especially in left anterior descending artery （14/21, 67%）. Eighteen patients （18/21, 86%） underwent conservative treatment, whereas the remaining three patients （3/21, 14%） underwent percutaneous coronary intervention. Regarding the angiographic results of SCAD lesions, intramural hematoma was discriminated in 95% （20/21）, and Type I imaging was observed in 5% （1/21）, Type l I was observed in 67% （14/21）, and Type Ⅲ was 29% （6/21）. The average stenosis in the group was 76.9% - 20.6%, and the mean lesion length was 36.6 ± 8.6 ±m. Conclusions： SCAD has a high prevalence in young female AMI population in Jiangsu, China. Discriminating the cause of AMI in young female population is very important.

Acute occlusion of the left subclavian artery with artery dissection

Subclavian steal syndrome is cerebral or brain Istem ischemia resulting from diversion of bloodflow from the basilar artery to the subclavian artery, which is caused by occlusive disease of either the subclavian artery or the innominate artery before they branch off at the vertebral artery. In the patients with subclavian steal syndrome the subclavian artery is fed by retrograde flow from the vertebral artery via the carotids and the circle of Willis.

Syncope with spontaneous coronary artery dissection in an elderly woman

Diagnosis of spontaneous coronary artery dissection （SCAD） is challenging because of its rarity and uncertain etiology. It frequently occurs in young women during pregnancy and in the postpartum period, and rarely found in elder women with no history of cardiovascular disease or coronary risk factors. In this article we report a case of SCAD in a 75-year-old woman without traditional cardiovascular risk factors who presented with syncope and mild chest discomfort. There were no abnormal electrocardiographic changes and no elevated cardiac enzymes were detected. Computed tomography of brain revealed nothing abnormal. Coronary artery disease was suspected. Coronary angiogram revealed dissection in the middle left circumflex artery. The patient underwent percutaneous transluminal coronary angioplasty and was free of symptoms at 6-month follow-up. Our report suggests that emergency coronary angiography is indicated if syncope caused by coronary artery disease is suspected.

Intravascular ultrasonography assisted carotid artery stenting for treatment of carotid stenosis: Two case reports

BACKGROUND Digital subtraction angiography(DSA),the gold standard of cerebrovascular disease diagnosis,is limited in its diagnostic ability to evaluate arterial diameter.Intravascular ultrasonography(IVUS)has advantages in assessing stenosis and plaque nature and improves the evaluation and effectiveness of carotid artery sten-ting(CAS).CASE SUMMARY Case 1:A 65-year-old man presented with a five-year history of bilateral lower limb weakness due to stroke.Physical examination showed decreased strength(5-/5)in both lower limbs.Carotid artery ultrasound,magnetic resonance angiography,and computed tomography angiography(CTA)showed a right proximal internal carotid artery(ICA)stenosis(70%-99%),acute cerebral infarction,and severe right ICA stenosis,respectively.We performed IVUS-assisted CAS to measure the stenosis and detected a low-risk plaque at the site of stenosis prior to stent implantation.Post-stent balloon dilatation was performed and postoperative IVUS demonstrated successful expansion and adherence.CTA six months postoperatively showed no significant increase in in-stent stenosis.Case 2:A 36-year-old man was admitted with a right common carotid artery(CCA)dissection detected by ultrasound.Physical examination showed no positive neurological signs.Carotid ultrasound and CTA showed lumen dilation in the proximal CCA with an intima-like structure and bulging in the proximal segment of the right CCA with strip-like low-density shadow(dissection or carotid web).IVUS-assisted DSA confirmed right CCA dissection.CAS was performed and intraoperative IVUS suggested a large residual false lumen.Post-stent balloon dilatation was performed reducing the false lumen.DSA three months postoperatively indicated good stent expansion with mild stenosis.CONCLUSION IVUS aids decision-making during CAS by accurately assessing carotid artery wall lesions and plaque nature preoperatively,dissection and stenosis morphology intraoperatively,and visualizing and confirming CAS postoperatively.

Spontaneous dissection of proximal left main coronary artery in a healthy adolescent presenting with syncope:A case report

BACKGROUND Spontaneous coronary artery dissection(SCAD)is a frequent cause of acute coronary syndrome in young to middle-aged women with few or no traditional cardiovascular risk factors.Chest pain is the most frequently described presenting symptom,but syncope is extremely rare.Herein,we report on a 16-year-old girl who presented with an episode of syncope occurring during a race.Despite significantly elevated troponin level,the diagnosis of the left main coronary artery SCAD with cardiogenic shock was delayed.CASE SUMMARY A 16-year-old girl presented with an episode of syncope.Myocardial injury markers were positive.Echocardiography showed a mildly reduced left ventricular ejection fraction(50%).Although initially stable,she later experienced recurrent chest pain accompanying precordial ST segment elevation with dynamic changes and developed cardiogenic shock,necessitating emergent revascularization.Coronary angiography demonstrated almost total occlusion at the ostium and proximal segment of the left main trunk coronary artery(LMT).Intravascular ultrasound confirmed a false lumen with prominent dissection in the LMT.Percutaneous coronary intervention assisted by intra-aortic balloon pump was conducted in the LMT.A 3.5 mm×24 mm everolimus-eluting stent was deployed to the focal lesions of the LMT.A postprocedural electrocardiogram showed alleviation of the precordial ST-segment elevation.The diagnosis of SCAD was confirmed.Transthoracic echocardiography showed an improved left ventricular ejection fraction(57%).The patient was asymptomatic during the 24-mo.follow-up period.CONCLUSION SCAD should always be considered in the differential diagnosis of acute coronary syndrome presentations in low-risk patients,regardless of age.