Non-traumatic rupture of the intracranial vertebral artery of a man found dead in a severe car accident – Histopathological differentiation by step-serial sections

Ro, Ayako; Kageyama, Norimasa; Hayashi, Kino; Shigeta, Akio; Fukunaga, Tetsuo

doi:10.1016/j.legalmed.2007.08.002

Cited by 18 publications

(5 citation statements)

References 13 publications

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“…Reported methods for diagnosing SAM. (A) A total of 121 cases were identified from the 66 case reports 4,5,8–10,13,22–81 with unique diagnostic strategies. For publications detailing multiple patients, a case was counted as unique if the diagnostic strategy was specifically based on that patient’s presentation and was considered redundant and only recorded once if the same strategy was applied to multiple patients in the report.…”

Section: Discussionmentioning

confidence: 99%

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Segmental arterial mediolysis (SAM): Systematic review and analysis of 143 cases

et al. 2019

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Segmental arterial mediolysis (SAM) is a rare but serious nonatherosclerotic, noninflammatory vasculopathy of unknown etiology that often results in dissection, aneurysm, occlusion, or stenosis of, primarily, the abdominal arteries. Current literature lacks consensus on diagnostic criteria and management options for SAM. This review summarizes 143 cases and aims to advance appropriate recognition and management of SAM. Literature review of all relevant SAM case studies from 2005 to 2018 yielded 126 individual SAM cases from 66 reports. We identified 17 additional SAM cases from our center, bringing our analysis to 143 patients. Patients with SAM were most commonly men (68%) in their 60s. Hypertension (43%), tobacco use (12%), and hyperlipidemia (12%) were common comorbidities. Abdominal pain (80%) and intraabdominal bleeding (50%) were the most common presenting symptoms. Computed tomography was the most frequently used imaging method (78%), and histology was available in 44% of cases. The most commonly affected vessels were the superior mesenteric (53%), hepatic (45%), celiac (36%), renal (26%), and splenic (25%) arteries with aneurysm (76%), dissection (61%), and arterial rupture (46%). Treatments included coil embolization (28%), abdominal organ surgery (24%), open arterial repair (21%), and medical management (20%). Case-specific treatment modalities yielded symptom relief in the vast majority (91%) of patients, with a mortality rate of 7%.

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Section: Discussionmentioning

confidence: 99%

“…A total of 126 unique cases were identified from 66 different case reports and case studies (Supplementary Table 1). 4,5,8–10,13,22–81…”

Section: Methodsmentioning

confidence: 99%

Segmental arterial mediolysis (SAM): Systematic review and analysis of 143 cases

et al. 2019

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“…We speculated that medial defects, which resemble the vascular lesions found in patients with segmental arterial mediolysis, play a key role in the occurrence of intracranial VA dissections. 11,12 Segmental arterial mediolysis is usually found in abdominal arteries; 14 however, recently, segmental arterial mediolysis has been reported in intracranial arterial dissections with and without small arterial dissections in abdominal arteries. 4,13,18 We reported on cases of segmental arterial mediolysis affecting both the intraabdominal and intracranial VAs.…”

Section: Significance Of Medial Defects As a Possible Culprit Lesion mentioning

confidence: 99%

Pathomorphometry of ruptured intracranial vertebral arterial dissection: adventitial rupture, dilated lesion, intimal tear, and medial defect

Kageyama

2013

JNS

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Object Subarachnoid hemorrhage (SAH) due to ruptured intracranial vertebral artery (VA) dissection is a life-threatening disease. Angiographic and symptomatic prognostic factors for rupture and rerupture have been investigated, but the pathological characteristics have not been fully investigated. The authors aimed to investigate these features by performing a pathomorphometic study of ruptured intracranial VA dissections. Methods This study included 50 administrative autopsy cases of fatal SAH due to ruptured intracranial VA dissection among 517 fatal nontraumatic cases of SAH occurring between March 2003 and May 2011. Pathomorphometry was performed using serial 5-μm histological cross-sections with elastica van Gieson staining from each 0.2-mm segment around the ruptured intracranial VA. The longitudinal lengths of 4 types of vascular lesions—adventitial ruptures, dilated lesions where the internal elastic lamina (IEL) was ruptured with adventitial extension, intimal tears where the IEL was ruptured, and medial defects—were calculated based on the numbers of the slides in which these lesions were continuously detected (minimum 2 adjoining slides). The distance from the vertebrobasilar junction to the center of adventitial rupture was also calculated in 37 cases. Results All cases showed one adventitial rupture with a mean length of about 1.9 ± 1.1 mm. The center of the adventitial rupture was located 5.0–26.8 mm (mean 14.6 ± 5.5 mm) from the intracranial VA bifurcation. Adventitial ruptures existed in the centers of dilated lesions, where the adventitia was highly extended. Other vascular lesions were serially observed surrounding the adventitial rupture. The mean lengths of dilated lesions, intimal tears, and medial defects were 9.4 ± 4.8 mm, 13.2 ± 6.3 mm, and 15.6 ± 7.2 mm, respectively. The lengths between proximal lesions and distal lesions from the center of the adventitial rupture for both medial defects and intimal tears were significantly longer at proximal lesions than at distal ones (chi-square test, p < 0.01). Conclusions Every ruptured intracranial VA dissection has a single point of adventitial rupture where the adventitia was maximally extended, so dilation appears to be a valuable predictive factor for hemorrhagic intracranial VA dissections. The adventitial ruptures were as small as 2 mm in length, and clinically detectable dilated lesions were about 9 mm in length. However, vascular vulnerability caused by IEL ruptures and medial defects existed more widely across a length of VA of 1.3–1.5 cm. Comparatively broader protection of the intracranial VA than the clinically detected area of dissection might be desirable to prevent rebleeding. Broader protection of proximal lesions than distal lesions might be effective from the viewpoint of site distribution of vascular lesions and blood flow alteration to the pseudolumen caused by the dissecting hematoma. Medial defects are the most widely seen lesions among the 4 types of vascular lesions studied. Medial degenerative disease, known as segmental arterial mediolysis, is suspected in the pathogenesis of intracranial VA dissections.

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“…3) SAM affects multiple arteries. [3][4][5][6][7][8][9][10] We previously reported a patient who died of SAMrelated subarachnoid hemorrhage, with new/old multiple intracranial artery dissection, 11) and a patient who died of SAM-related intraperitoneal hemorrhage, with old IVA dissection. 12) However, there has been only one case report in which the SAM-related rupture of both intracranial and -peritoneal arteries led to subarachnoid and intraperitoneal hemorrhage.…”

Section: Discussionmentioning

confidence: 99%

Pathomorphological Examination of Patients with the Simultaneous Rupture of Dissecting Intracranial Vertebral and Intraperitoneal Arteries: Involvement of Segmental Arterial Mediolysis in Intracranial Artery Dissection

Kageyama

Mukai

2018

JNET

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Objective: To examine the involvement of segmental arterial mediolysis (SAM) in intracranial artery dissection. Methods:In four autopsy cases of subarachnoid hemorrhage related to the rupture of the intracranial vertebral artery (IVA) with intraperitoneal hemorrhage, we calculated the extent of arterial dissection using elastica van Gieson staining from the tissue sections of the left/right IVAs and intraperitoneal arteries (IPAs), and examined the properties of the vascular smooth muscle and responses of mesenchymal cells using immunostaining with anti-α smooth muscle antibody (SMA) and anti-S100A4 antibodies. Results:The length of the adventitia at the site of IVA rupture was ≤2.4 mm, and that of disruptions of the internal elastic lamina was 5.4-11 mm. The IVA/IPA rupture sites showed acute arterial dissection. In the blood vessels at the sites of dissection, defect/necrosis of the vascular smooth muscle, which are characteristic of SAM, were noted. In three cases, the topical infiltration of mesenchymal cells was observed in the adventitia at the dissected site of the ruptured IVA. In all cases, dissection of unruptured intracranial or -peritoneal arteries was also present. Its pathological properties vary from acute to old dissection. Conclusion:Autopsy revealed SAM-related systemic multiple arterial dissection in all cases, suggesting the involvement of SAM in the development of intracranial artery dissection.

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Non-traumatic rupture of the intracranial vertebral artery of a man found dead in a severe car accident – Histopathological differentiation by step-serial sections

Cited by 18 publications

References 13 publications

Segmental arterial mediolysis (SAM): Systematic review and analysis of 143 cases

Segmental arterial mediolysis (SAM): Systematic review and analysis of 143 cases

Pathomorphometry of ruptured intracranial vertebral arterial dissection: adventitial rupture, dilated lesion, intimal tear, and medial defect

Pathomorphological Examination of Patients with the Simultaneous Rupture of Dissecting Intracranial Vertebral and Intraperitoneal Arteries: Involvement of Segmental Arterial Mediolysis in Intracranial Artery Dissection

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