Vertebral artery dissection can present weeks after minor trauma

  • Am J Emerg Med

  • Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • Vertebral artery dissection (VAD) may not be obvious.
  • Maintain high clinical suspicion amid recent trauma, even trivial.

Why this matters

  • VAD is a major cause of stroke in young people, second only to cardioembolic events.

Description

  • Case report, review of recent literature.

Key details

  • A 42-year-old woman reported acute onset:
    • Pain in left neck, face.
    • Numbness.
    • Diaphoresis.
  • No headache, dizziness, vomiting.
  • Past medical history: 
    • Rear-ended in car 1 month prior with whiplash, neck pain.
  • Exam:
    • Neck: no pain, tenderness, or external abnormalities. 
    • No diaphoresis.
    • Normal cranial nerves II-XII, normal pupils.
    • No nystagmus, focal weakness, sensory deficits.
  • CT angiogram of head and neck: 
    • Left intracranial vertebral artery (VA): stenosis, occlusion.
    • Left posterior internal carotid artery: concerning for VAD.
  • Patient course:
    • Developed dysphagia, diplopia.
    • Underwent left VA embolization for suspected acute dissection. 
    • Imaging: left lateral medullary infarction. 
    • Began rehabilitation for multiple neurological sequelae.
  • Neck (vertebral or internal carotid) artery dissection symptoms: head or neck pain (80%), stroke (67%), Horner syndrome (25%).
  • VAD etiology likely multifactorial, requiring both injury and vulnerability.
  • Association with “trivial” trauma in 1 review: OR, 3.8 (95% CI, 1.3-11).
  • Traumas have included sudden head rotation during sports, working for hours with reclined head, and chiropractic.