Vertebral Artery Dissection

1

• Vertebral Artery Dissection
• Evaluation and Management
• William Barsan, M.D.
• University of Michigan

2
History

• 29 y.o. female with hx of migraine. Had sudden
  onset of falling and vertigo for 1 minute in the
  morning - resolved. Felt light headed and
  noticed left neck pain radiating to left temporal
  area (dull ache - not migrainous).
• Past History migraine
• Meds BCP, Imitrex prn

3
Evaluation

• BP 137/88 P 80 Afebrile
• Eyes normal w/o nystagmus
• Neuro no focal deficits
• MRI/MRA left vertebral artery dissection

4
Management

• Admission to Neurology service
• IV Heparin, d/c on Warfarin
• Evaluation for Ehler-Danlos IV

5
References

• Silbert et al Headache and Neck Pain in
  Spontaneous Carotid and Vertebral Artery
  Dissections, Neurology 451517-1522, 1995.
• Documents signs and symptoms in 161 patients with
  dissection.
• Biousse et al Head Pain in Non-Traumatic
  Carotid Artery Dissection, Cephalgia 1433-36,
  1994.
• Discusses presenting signs and symptoms of
  carotid artery dissection.
• Schierink et al Heritable Connective Tissue
  Disorders in Cervical Artery Dissections,
  Neurology 501166-1169, 1998.
• Documents that connective tissue disorders are
  common in dissection patients although they dont
  meet the classic criteria for diagnosis.
• Wityk Stroke in a Healthy 46 year old man,
  JAMA 285(21)2757-2762, 2001
• Case presentation of spontaneous carotid
  dissection with a literature review.

6
Outcome

• MRI/MRA 6 months later
• Normalization of vertebral artery appearance
• Workup for connective tissue disorder negative
• Coumadin d/c
• Remains well one year later

7
Summary

• Etiology
• History
• Physical exam
• Diagnostic workup
• Treatment

8
Etiology

• Peak incidence 40s
• 2.5 of first strokes
• Carotid - males females
• Vertebral - females gt males
• Association with arteriopathy/trauma

9
Arteriopathies

• Fibromuscular dysplasia
• Ehlers-Danlos type IV
• Marfans

10
Etiology

• Trauma - may be mild
• Spontaneous
• Cervical manipulation
• Association with migraine
• Respiratory infections (?)

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Stroke Mechanism

• Occlusion of lumen
• Thrombosis/embolus

12
History

• Precedent trauma
• Associated neurological symptoms
• Migraine (25-50)
• Headache, neck pain
• Amaurosis fugax
• Pulsatile tinnitus
• Cranial nerve paresis

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Carotid vs. Vertebral

• Neck pain - 26 vs. 46
• Headache - 68 vs. 69
• Symptom development - 4 days vs. 14 hours
• Carotid - eye, facial, ear pain

14
Physical Exam

• Horners syndrome (carotid)
• Cranial nerve palsies
• II, IV, V, VI, VII, IX, X, XII
• Stroke syndrome

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Diagnostic Workup

• Ultrasound
• MRA
• Angiography

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Location of Dissection

• Carotid - C1 - C2 level
• Vertebral - C1 - C2 level

17
Treatment

• Acute stroke - thrombolysis
• IV heparin
• Admission
• Warfarin for 3-6 months
• Re-imaging