MRI- and MRA-guided therapy of carotid and vertebral artery dissections

A high sensitivity and specificity has been shown for magnetic resonance imaging (MRI) and angiography (MRA) in the diagnosis of internal carotid (ICAD) and vertebral (VAD) artery dissections, where arteriography has been and still is the gold standard. Five patients (three with ICAD, two with VAD; age range 42-56 years) are presented, in whom diagnosis and follow-up management were exclusively based on non-invasive measures. In all patients, MRI demonstrated a typical intramural hematoma and MRA in 3D phase contrast technique showed loss or diminished flow. After anticoagulation (heparin) for 3 to 4 weeks follow-up, MRI showed a regression of the mural hematoma and MRA revealed reperfusion or improvement of flow. Depending on the extent of MRI-/MRA-pathology, three patients were put on antiplatelet therapy and two on Coumadin until normalization of MRI and MRA findings, which are assessed in 3-months intervals. We suggest, that with, (I) a suspicious history, symptoms and signs for cervical artery dissection (CAD), (II) typical MR-findings proven to indicate CAD, (III) improving or resolving at follow-up, (IV) in unusual location for atherosclerotic involvement, (V) in the absence of coexisting atherosclerotic lesions, the diagnosis has not to be confirmed with conventional arteriography. Therefore, safe MRI- and MRA-guided anticoagulation and antiplatelet therapy during serial follow-up measurements are possible.