Vertebral Artery Dissection


Article Author:
Todd Britt


Article Editor:
Shashank Agarwal


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
3/16/2019 1:27:00 PM

Introduction

Vertebral artery dissection (VAD) is a rare cause of stroke in the general population; however, represents one of the more common causes of stroke in patients younger than 45 years of age. Its signs and symptoms can be vague, and diagnosis can be elusive. [1][2][3] Spontaneous dissections have been reported. However, incidental minor trauma often precipitates this potentially dangerous condition. Often some neck distortion such as chiropractic manipulation, bending of the neck or blunt trauma causes the dissection. The dissection of the artery may ultimately lead to a stroke which often can be delayed for days following the acute dissection.

Etiology

Patients typically report minor, rather innocuous precipitating events before the onset of symptoms. Coughing, vomiting, chiropractic procedures, and blunt trauma are likely initiating events. It is estimated that 1 in 20,000 cervical spine manipulations causes a stroke. [4][5][6]Blunt trauma to the neck is the most common reported precipitating event. Patients with connective tissue disorders are also at increased risk. Ehlers-Danlos syndrome is the most the most common connective tissue disorder that can cause vertebral artery dissection. When patients with serious cervical cord injury or spine fractures are screened for vertebral artery injury approximately 20% to 40% will demonstrate traumatic occlusion. Interestingly, this occlusion tends to be asymptomatic, as opposed to dissection, and its management is controversial.

Epidemiology

It is estimated that vertebral artery dissection is the cause of approximately 2% of all ischemic strokes. However, in middle-aged and younger patients (30 to 45 years of age) it is believed to be as high as 10% to 25%, representing a significant population affected by this condition. The combined incidence of both vertebral artery and carotid artery dissections is estimated to be 2.6 per 100,000. Carotid artery dissections are more three to five times more common than vertebral artery dissections. It should be noted that chiropractors dismiss the association between manipulation and vertebral artery dissection on the grounds that the dissection is the cause of the neck pain and the reason why the patients seek out chiropractic care. There is no conclusive evidence linking the two leading some medical associations only to suggest a causative link.

Pathophysiology

The arterial anatomy consists of three layers named the intimal (innermost), the media (middle), and the adventitia (outermost layer). Dissection occurs when the structural integrity of the arterial wall is compromised. Intimal tears lead to arterial blood dissecting between the layers of the arterial wall. The blood within the arterial wall precipitates hematoma and clot formation. [7]The subsequent compromise in arterial blood flow secondary to the stenosis then leads to the symptoms of vertebral artery dissection and ultimately, stroke. Vertebral artery dissection can be either extracranial or intracranial.  Extracranial dissections usually involve the distal extracranial segment near the atlas and axis. Intracranial dissections are often associated with subarachnoid hemorrhage and carry a much worse prognosis. Neurological sequalae of both extracranial and intracranial dissections may result from cerebral ischemia due to thromboembolism, hypoperfusion, or a combination of both. However, thromboembolism rather than hypoperfusion is considered the major cause of ischemic symptoms.

History and Physical

Clinical presentation is typically acute and severe unilateral neck pain and/or a headache. Minor neck trauma often precipitates the pain. The pain is typically in the occipital-cervical area of the neck or head. Neurological symptoms are often delayed and may not be present at all. Lateral medullary syndromes (Wallenberg Syndrome) and cerebellar infarctions are the most common location for strokes. Wallenberg Syndrome is defined by sensory deficits affecting the trunk and extremities on the opposite side of the infarction and sensory deficits affecting the face and cranial nerves on the same side as the infarction. When neurological symptoms are present, dizziness, ataxia, dysarthria, diplopia, and vertigo are the predominant symptoms. Extracranial dissections often have a bruit present. The bruit has even been reported on the contralateral side secondary to increased collateral blood flow. What often distinguishes this type of patient from those with cerebellar infarctions secondary to atherosclerotic disease is the age of the patient and the presence of pain. When the dissection is intracranial, a subarachnoid hemorrhage is present 50% of the time. This group of patients has severe neurological symptoms a much worse prognosis than those with extracranial dissections.

Evaluation

MRI rivals angiography for establishing the diagnosis but is not readily available to most. CT and CTA are often the first investigations obtained. CT scan can demonstrate posterior fossa ischemia or subarachnoid hemorrhage. It may also identify an occluded vertebral artery or mural thrombus. CTA, however, is superior to CT scan and should be performed. CTA more easily identifies irregularity of the vascular lumen or thickening of the arterial wall. CTA is the initial test of choice. Vascular Duplex scanning demonstrates abnormal flow in 95% of patients. However, it shows evidence specific to dissection in only 20% of patients.[8]

Treatment / Management

For those patients that survive the initial dissection, the prognosis is usually good. Approximately 10% of patients die initially. In one clinical follow-up study, 80% achieved a full recovery. Death is typically secondary to extensive intracranial dissection, brainstem infarction, or subarachnoid hemorrhage. The goal of management is to prevent stroke, which is the complication of vertebral artery dissection. Management is done with anticoagulation, typically heparin. Most dissections will resolve over time with no neurological deficits. Be advised however that when the dissection is intracranial or extends intracranially, the risk of subarachnoid hemorrhage increases significantly and anticoagulation is contraindicated. [9][10][11]Endovascular or surgical treatments are reserved for patients with concomitant complications or those whose maximal medical therapy has been unsuccessful.

Pearls and Other Issues

A headache or neck pain associated with vertebral artery dissection may precede the development of neurological symptoms by as long as 14 days. Patients may report vague neurological symptoms associated with the pain that may be transient. The problem for the emergency department physician is that when the workup is initiated for a severe headache or neck pain, the CT scan and lumbar puncture may be negative. These patients are often diagnosed with a headache or even transient ischemic attack (TIA), delaying diagnosis and treatment. The severe pain remains the hallmark and cannot be ignored. Further neurologic imaging with CTA or MRI must be performed if clinical suspicion is high. Patients with vertebral artery dissection must be admitted to the hospital for close neurological monitoring and if indicated, anticoagulation. Surgery is very rarely indicated.

Enhancing Healthcare Team Outcomes

The diagnosis and treatment of vertebral artery dissection is not simple and best managed by a multidisciplinary team that includes a radiologist, emergency department physician, nurse practitioner, neurologist, and vascular surgeon. Once imaging has made the diagnosis, the treatment depends on patient symptoms.

For those patients that survive the initial dissection, the prognosis is usually good. Approximately 10% of patients die initially. In one clinical follow-up study, 80% achieved a full recovery. Death is typically secondary to extensive intracranial dissection, brainstem infarction, or subarachnoid hemorrhage. The goal of management is to prevent stroke, which is the complication of vertebral artery dissection. Management is done with anticoagulation, typically heparin. Endovascular or surgical treatments are reserved for patients with concomitant complications or those whose maximal medical therapy has been unsuccessful. Most dissections will resolve over time with no neurological deficits.

The recovery can be prolonged and full recovery is often not possible.[3][12]

 


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Vertebral Artery Dissection - Questions

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A 17-year-old female came to the emergency room after a motor vehicle accident. On the exam, she has nausea and nystagmus. On MRI brain she was diagnosed with arterial dissection. Which artery is most commonly involved?



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A man in his mid-30s develops left tongue deviation, left fascial numbness, ataxia, and right body weakness. He indicates this developed acutely while he was painting his roof. What is the most likely diagnosis?



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A 70-year-old man with a history of atherosclerosis, hypercholesterolemia, hypertension, and diabetes mellitus presents with headache, left-sided neck pain, and tinnitus after a chiropractor appointment. On physical exam, there is a right-sided neck bruit. CT angiogram reveals a “double lumen” sign of a cervical vessel. At what level does the artery in question combine with its contralateral counterpart?



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A 42-year-old male is diagnosed with dissection of his vertebral artery. His neurologic symptoms are disequilibrium and dysarthria lasting for nearly 12 hours. CT angiogram identifies a dissection with no evidence of intracranial extension or hemorrhage. He has no prior history of a vertebral artery dissection. Which treatment would you recommend?



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A patient who has a serious allergy to contrast dye is suspected of having a vertebral artery dissection. The value of using duplex ultrasound as part of the evaluation is being considered. What findings would expect on ultrasound in a patient with a diagnosis of vertebral artery dissection?



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A 22-year-old male athlete presents today with new-onset severe head and neck pain. Physical exam elicits abnormal gait with the patient leaning to the right side and requiring assistance. He is a college basketball player and goes to his chiropractor twice a week but has not suffered any physical trauma recently. Also, he is noted to have nystagmus and decreased pain and temperature sensation on the right side of his face and left upper and lower extremity. Pupils are 4 mm, equal reactive to light with no ptosis noted. Which of the following locations is most likely injured in this patient?



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A 25-year-old female professional volleyball player with a past medical history for hypertension and smoking complains about sudden onset headache and severe neck pain 2 hours ago. She has not had any trauma but saw her chiropractor 3 days ago. Physical exam shows a slender female with long fingers heavily leaning to the left side and nystagmus with decreased sensation to pain and temperature on the left face and right upper and lower extremities. 20 minutes into the encounter the patient is able to walk and can now feel pain sensation in the areas where she could previously not. Which additional test would show evidence for the underlying cause of the patient's current symptoms?



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Vertebral Artery Dissection - References

References

Zhou Y,Wang L,Zhang JR,Zhou K,Shuai J,Gong ZL,Liu Y,Wei F,Han YF,Shen L,Yang QW, Angioplasty and stenting for severe symptomatic atherosclerotic stenosis of intracranial vertebrobasilar artery. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2019 Mar 5;     [PubMed]
Kim MK,Lim YC, Conservative Management of Unruptured Spontaneous Intracranial Vertebral Artery Dissection. World neurosurgery. 2019 Feb 26;     [PubMed]
Markus HS,Levi C,King A,Madigan J,Norris J, Antiplatelet Therapy vs Anticoagulation Therapy in Cervical Artery Dissection: The Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA neurology. 2019 Feb 25;     [PubMed]
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Walsh BA,Gregorie WD,Whittle JS, Deconstructing Dissections: A Case Report and Review of Blunt Cerebrovascular Injury of the Neck. Case reports in emergency medicine. 2018;     [PubMed]
Hu Y,Du J,Liu Z,Wu H,Ding J,Jian F, Vertebral artery dissection caused by atlantoaxial dislocation: a case report and review of literature. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2019 Jan;     [PubMed]
Yun SY,Heo YJ,Jeong HW,Baek JW,Choo HJ,Seo JH,Kim ST,Lee JY,Jin SC, Spontaneous intracranial vertebral artery dissection with acute ischemic stroke: High-resolution magnetic resonance imaging findings. The neuroradiology journal. 2018 Jun;     [PubMed]
McNally JS,Hinckley PJ,Sakata A,Eisenmenger LB,Kim SE,De Havenon AH,Quigley EP,Iacob E,Treiman GS,Parker DL, Magnetic Resonance Imaging and Clinical Factors Associated With Ischemic Stroke in Patients Suspected of Cervical Artery Dissection. Stroke. 2018 Oct;     [PubMed]
Turner RC,Lucke-Wold BP,Boo S,Rosen CL,Sedney CL, The potential dangers of neck manipulation     [PubMed]
Brukner P,Gara TJ,Fortington LV, Traumatic cricket-related fatalities in Australia: a historical review of media reports. The Medical journal of Australia. 2018 Mar 26;     [PubMed]
Urasyanandana K,Songsang D,Aurboonyawat T,Chankaew E,Withayasuk P,Churojana A, Treatment outcomes in cerebral artery dissection and literature review. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences. 2018 Jun;     [PubMed]
Takahara M,Ogata T,Abe H,Higashi T,Morishita T,Takano K,Inoue T, The Comparison of Clinical Findings and Treatment Between Unilateral and Bilateral Vertebral Artery Dissection. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2019 Jan 30;     [PubMed]

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