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ARTICLES: Fernando Pico, Julien Labreuche, Pierre-Jean Touboul, and Pierre Amarenco Intracranial arterial dolichoectasia and its relation with atherosclerosis and stroke subtype Neurology 2003; 61: 1736-1742 [Abstract] [Full text] [PDF]

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Intracranial arterial dolichoectasia and its relation with atherosclerosis and stroke subtype

Catalina C Ionita, Andrew R Xavier, Jeffrey Farkas, Patrick Pullicino   (28 January 2004)

Reply to Ionita et al

Pierre Amarenco, Fernando Pico, MD   (28 January 2004)

Intracranial arterial dolichoectasia and its relation with atherosclerosis and stroke subtype 28 January 2004
Catalina C Ionita, UMDNJ 185 South Orange Avenue, H 506, Newark NJ, 07103, Andrew R Xavier, Jeffrey Farkas, Patrick Pullicino Send Correspondence to journal: Re: Intracranial arterial dolichoectasia and its relation with atherosclerosis and stroke subtype ccionita{at}yahoo.com Catalina C Ionita, et al.	We found the association of intracranial arterial dolichoectasia (IADE) and coronary artery disease interesting in Pico et al's article. [1] The lack of correlation between carotid intima-media thickness and ectasia suggests that ectasia is not a variant of atherosclerosis. This is supported by increased ectasia in sickle cell anemia [2] and Marfan’s syndrome[3], both non-atheroclerotic diseases. We have certain concerns regarding the diagnostic methods for IADE, used in Pico et al's study: 1. MRI is widely available for investigation and diagnosing IADE using the proposed MRI methods seems convenient. However, this is not the most accurate method in diagnosing IADE, because the diameter as well as the length assessment based on T2WI axial cuts can be biased. A vessel with normal diameter caught in an oblique view by the axial cut may seem ectatic, and the 3-5 mm axial MRI axial cuts can miss lengthy parts of a vessel with tortuous course. The optical method used was more of a quantification of the visual method and not a real validation. 2. More accurate vascular measurements could be obtained using quantitative MRA. [2] Volumetric analysis of basilar artery appears to be more sensitive to subtle vasculopathic changes that can be missed by qualitative analysis.[2] 3. A method such as conventional cerebral angiogram with 3D reconstruction could also provide more accurate information, but it is an invasive procedure and may not be applicable in most of the individuals. 4. In our institution, we have utilized multi-slice CT angiography which is a rapid and non-invasive investigation. The additional advantage is the ability to perform 3-D reconstruction of the cerebral vasculature; accurate measurements of vessel length and diameter at multiple points could be readily performed using computerized methods. The vascular volume of basilar artery could also be calculated using computer-aided analysis with markers placed at its origin from the vertebral arteries and its termination into the posterior cerebral arteries. (Fig 1) Figure 1: 3D reconstruction of a multi-slice CT angiogram in a patient with IADE. Maximum diameter of ectasia - 13.4mm; Length - 12.4cm; Volume - 7.384 ±.915cc. References 1. Pico F, Labreuche J, Touboul PJ, Amarenco P. Intracranial arterial dolichoectasia and its relation with atherosclerosis and stroke subtype. Neurology. 2003 Dec 23;61:1736-42. 2. Grant Steen R, Langston JW, Ogg RJ, Manci E, Mulhern RK, Wang W. Ectasia of the basilar artery in children with sickle cell disease: relationship to hematocrit and psychometric measures. J Stroke and Cerebrovasc Dis 1998;7:32-43. 3. Silverman IE, Berman DM, Dike GL, Sung GY, Litt B, Wityk RJ. Vertebrobasilar dolichoectasia associated with Marfan syndrome. J Stroke and Cerebrovasc Dis 2000; 9:196-198.
Reply to Ionita et al 28 January 2004
Pierre Amarenco, Department of Neurology and Stroke Centre, Bichat University Hospital and Medical School 46 rue Henri Huchard, 75018 Paris, France, Fernando Pico, MD Send Correspondence to journal: Re: Reply to Ionita et al pierre.amarenco{at}bch.ap-hop-paris.fr Pierre Amarenco, et al.	We thank Ionita et al for their interest in our work. The GENIC study was designed to investigate the genetic susceptibility for brain infarction. As brain MRI is more sensitive and specific for brain infarction than CT scan [1], MRI was required by protocol to include the 510 consecutive cases as explained in our Methods. [2] We used the available method for the diagnosis of IADE. In addition, MRI is more sensitive than CT scan for the diagnosis of this intracranial arterial disease. [3] The aim of our study was not to evaluate and validate axial slices MRI for IADE diagnosis but to investigate the relationship between IADE and carotid atherosclerosis and stroke subtype. The systematic and quantitative reading with direct measurement of seven intracranial arteries diameters and rating of basilar artery transverse position and height of bifurcation in four point scales validates our method because these two readings were independent. Furthermore, 94% of IADE(+) patients --as defined by the consensus method--had at least one intracranial artery diameter in the highest quartile. We note that a normal vessel caught in an oblique view in axial slices can appear ectatic, but can be explained because a normal vessel with no tortuous course has no reason to be cut in an oblique view in axial slices. This is frequently seen in the dolicho artery. We agree that the 3-5 mm axial MRI cuts can miss lengthy parts of a vessel with tortuous course but in this case we think that it would be a very focal and minor form of dolicho artery. The figure of the CT angiogram is demonstrative but illustrates a single case. Although there is a need to develop new imaging techniques in addition to axial slices brain MRI, no study has yet compared the yield and complication rate of multislice CT angiography and CT scan and Magnetic resonance angiogram plus brain MRI for the diagnosis of IADE. References 1. Mullins ME, Schaefer PW, Sorensen AG et al. CT and conventional and diffusion weighted MR imaging in acute stroke : study in 691 patients at presentation to the emergency department. Radiology 2002; 224 : 353-360. 2. Pico F, Labreuche J, Touboul PJ, Amarenco P. Intracranial arterial dolichoectasia and its relation with atherosclerosis and stroke subtype. Neurology 2003;61:1736-1742. 3. Giang DW, Perlin SJ, Monajati A, Kido DJ, Hollander J. Vertebrobasilar dolichoectasia: assessment using MR. Neuroradiology 30:518-523.