Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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January 24, 2019
LENTICULOSTRIATE ARTERY DISSECTING ANEURYSM
- Background
- Aneurysms arising along the lenticulostriate artery (LSA) are rare, but thought to be a cause of ischemic or hemorrhagic stroke.
- The majority of these aneurysms are likely to be dissecting aneurysms.
- In histopathological examination of surgical specimens, the lack of internal elastic lamina is a significant feature.
- Because of the small size of aneurysms and the parent vessels, non-invasive studies may be normal or initially read as normal.
- Clinical Presentation
- LSA dissection may result in lacunar infarction and/or basal ganglia hemorrhage depending on whether it results in luminal occlusion or arterial rupture respectively.
- Even though ruptured LSA aneurysms have a high rebleeding risk they can heal spontaneously.
- Key Diagnostic Features
- Repeated examinations with multiple modalities are considered necessary. Catheter angiography is the gold standard for detection, characterization and follow-up.
- In addition, features of synchronic or metachronic infarction and hemorrhage could be more suggestive for dissection.
- Differential Diagnosis
- Moyamoya disease: Steno-occlusive disease in distal ICA, which evolves with LSA hypertrophy (puff of smoke sign). They can develop small aneurysms along the hypertrophied arteries.
- Arteriovenous malformation: Has enlarged feeding arteries, nidus, and draining veins.
- Systemic vasculitis: Rarely can cause penetrating artery aneurysms, and are usually associated with an autoimmune disease.
- Mycotic aneurysms: Usually patients with infective endocarditis, and are more common in distal cortical branches, rather than perforating vessels.
- Treatment
- Conservative treatment with close follow-up examinations and strict blood pressure control could be an effective treatment.
- For rupture cases, surgery with clipping or resection of aneurysms and endovascular intervention with parent vessel occlusion can be considered.
- The management of LSA dissecting aneurysms remains controversial, due to uncertainty of its natural history and the risk associated with endovascular or surgical treatment. A multi-disciplinary team is needed for therapeutic strategies in a case-by-case basis.
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