Clinical characteristics of symptomatic vertebral artery dissection

Clinical Characteristics of Symptomatic Vertebral Artery dissection

1. Clinical Characteristics of Symptomatic Vertebral Artery Dissection. By Mohammed Y. El- zalouey Neurology Resident – Mansoura University

2. Vertebral artery dissection (VAD) is an important cause of stroke in the young with an estimated annual incidence between 1 and 1.5 per 100,000. Frank presentations of VAD including : stroke, TIA, or subarachnoid hemorrhage (SAH) are likely to initiate an inpatient hospitalization and complete diagnostic workup, including vascular imaging. Sometimes patients with VAD may present with nonspecific complaints such as: dizziness with neck pain, or headache with nausea and vomiting. VAD is more likely to be considered in patients with a clear history of trauma or with known underlying connective tissue disease. some cases neither of these known risk factors is present.

3. Symptoms associated with VAD: dizziness or vertigo was the most common symptom among individuals with vertebral artery dissection, in approximately 58% of VAD patients , followed by headache (51%) and neck pain (46%) . Headache or neck pain as the initial symptom was present in 67% of Cases. Fewer studies provided information on more specific neurologic symptoms such as gait problems or ataxia, nystagmus, dysphagia, and tinnitus. Cerebral ischemic events and SAH : Stroke was commonly reported in VAD subjects, occurring in 63% of cases, with a higher prevalence among those with extracranial than intracranial VAD. TIA was much less commonly reported, occurring in only 14% of VAD subjects analyzed, with a trend towards being more common among those with extracranial than intracranial VAD SAH was the least common cerebrovascular complication, occurring in 10% of cases, and exclusively among those with intracranial VAD.

4. VAD and trauma : Minor trauma was relatively uncommon in association with VAD, with even lower frequencies of sporting injuries, chiropractic manipulation, and “major trauma” (primarily motor vehicle accidents). Sports identified as possible risk factors included jogging, horseback riding, skiing, surfing, and playing tennis. Other factors associated with VAD : In the 12 studies that addressed history of connective tissue disorders (some with known diagnosis before VAD, others diagnosed after VAD), only 7.9% , had a known connective tissue disorder, including fibromuscular dysplasia. Results for history of smoking were slightly less heterogeneous, with an overall proportion of 170/496 individuals with history of smoking . Outcome after VAD : individuals with VAD appear to have relatively good outcomes when treated in routine clinical fashion.

5. CASE 1

6. This patient’s neck stiffness and headaches began 2 days after chiropractic manipulation, The patient has residual left arm weakness and headaches. Antero-posterior and lateral views on digital subtraction angiography (A, B) showed : distal left V2 and V3 dissection. Diffusion-weighted magnetic resonance imaging showed acute left cerebellar infarcts (C, D).

7. CASE 2

8. A 39-year-old woman presented with sudden loss of consciousness. Physical examination revealed altered mental status with bilateral pyramidal signs, Cranial MRI showed multiple infarcts in the bilateral thalami, occipital lobes, and the left cerebellum. She was put on aspirin and showed gradul improvement in her neurological status and muscle strength was grade 4 in the left limbs, grade 1 in the right upper limb, and grade 3 in the right lower limb.

9. DSA performed on day-19 revealed a 1.8 Χ 0.8 mm dissecting aneurysm in the V3 segment of the right VA and non-visualization of the distal end of the left postero -inferior cerebellar artery. The aneurysm was obliterated by a coated stent (4.0Χ12 mm)  At the time of discharge she was alert with normal power in the left sided limbs and power 3-4 in the right side limbs .

10. CASE 3

11. A 15-year-old boy who presented with a sudden Vertigo, unsteady gait, tinnitus of the right ear, nausea, and brief Unconsciousness without any recent head or neck trauma. Magnetic resonance imaging ( mri ) showed infarcts in the right Cerebellum and the splenium of the corpus callosum. One Hundred milligrams of aspirin per day was prescribed by the local Hospital for 11 days. His symptoms gradually improved and then The patient stopped taking aspirin. Unfortunately, symptoms Reappeared with neck stiffness 2 days later. Then, the patient Was referred to department of neurology. Neurological examination revealed ataxia of right extremities. Vision test revealed bilateral disturbance of abduction and hori - Zontal nystagmus. Cervical vascular ultrasound showed false lumens on V3 segments of bilateral vertebral arteries (vas) suggesting VAD. Three-dimensional computed tomography angiography (3D-CTA) showed occlusion of bilateral intracranial Vertebral arteries And basilar artery (BA). Then, the patient received whole cerebral digital subtraction angiography (DSA) which indicated proximal BA was occluded and the right posterior inferior cerebellar artery (PICA) was not visualized. He was treated with 150 mg warfarin per day sustaining the (INR) between 2 and 3 since admission.

12. CASE 4

13. A 57-year-old man with a history of hypertension and mechanical valve replacement, on warfarin, presented to Harbor-UCLA Medical Center after experiencing severe headache and decreasing level of consciousness; the precise time of onset was unknown. there was no history of preceding trauma, tobacco use, or known connective tissue disorders. By the time of initial evaluation, the patient was unresponsive and did not withdraw to noxious stimulation. His Glasgow Coma Scale score was 5 , the patient’s international normalized ratio was in the therapeutic range; warfarin was held, and anticoagulation was reversed using prothrombin complex concentrate and Vitamin K. His Imaging shows Noncontrast computed tomography (CT) imaging of the brain revealing diffuse hemorrhage in the subarachnoid cisterns and fourth ventricular hemorrhage , with secondary mild obstructive hydrocephalus. CT angiography showed a focal vascular lesion arising from the distal right VA.

14. Digital subtraction angiography further revealed a dissection of the distal aspect of the vessel and a broad-based, 5  mm aneurysm that involved the origin of a large PICA [Figure 2b and Figure  3]. The right posterior communicating artery (posterior communicating artery (PCOM)) was not visualized. Injection of the left VA did not demonstrate any appreciable collateral flow to the right PICA territory, although a balloon occlusion test was not performed. there was a normal variant short segment partial duplication of the right VA at the V2-V3 junction that was not involved by the dissection.

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