Extracranial vertebral artery dissection following tonic clonic seizure

Vertebral artery dissection associated with generalized convulsive seizures: a case report

A 46-year-old male with juvenile myoclonic epilepsy was admitted to the neurological department for convulsive seizures just after lamotrigine was discontinued. On admission he was awake but had a right-sided hemiparesis with Babinski sign and ataxic finger-nose test on the left side. An MR scan showed a left-sided pontine infarction, an infarct in the left cerebellar hemisphere and a right vertebral artery dissection (VAD). The patient was treated with heparin and an oral anticoagulant for 6 months. Recovery of neurologic function was excellent. In patients with symptoms of disturbances of posterior circulation after epileptic seizures, VAD should be considered.

Traumatic dissection of the vertebral artery in a toddler following a short fall

Spontaneous subarachnoid haemorrhage (SAH) in children is uncommon, but is sometimes seen after rupture of aneurysms, and in different disorders. Traumatic SAH is common after serious accidental head injury, but is also reported after child abuse with vigorous shaking. To avoid unnecessary accusations of innocent care givers, it is important not to misinterpret the findings as abusive head trauma in small children with SAH. In the presented case, a nearly two-year-old girl was brought to the hospital after a fall witnessed by her father. The girl was unconscious, with elevated intracranial pressure, SAH and bilateral retinal haemorrhage (RH). She was pronounced dead after 9h. Premortem angiography revealed a dissection of the right vertebral artery, and postmortem examination revealed a traumatic lesion deep in the neck, at the base of the skull. Cerebral edema, in combination with SAH and RH, is highly suggestive of abusive head trauma. However, no external lesions, no skeletal lesions, especially no long bone metaphyseal lesions, or subdural haematomas occurring at the same time as SAH, were found. There was no report of previous child abuse in the family. Based on the radiological and postmortem findings, we believe that an accidental fall caused a blunt force trauma with a subsequent dissection of the right vertebral artery. To our knowledge, accidental tear of one of the vertebral arteries, leading to SAH in a toddler, has previously not been described. Child abuse is an important exclusion diagnosis with serious legal implications.

Clinically unidentified dissection of vertebral artery as a cause of cerebellar infarction

BACKGROUND AND PURPOSE

Dissection of vertebral arteries has been reported in association with minor neck movements without signs of trauma on the surface of the neck. In addition, injury of a vertebral artery can cause brain infarctions. However, few cases have been reported in which fatal brain infarction was due to nonocclusive, clinically undetected, traumatic thrombus formation in a vertebral artery.

CASE DESCRIPTION

A 62-year-old man was hit by a car, and a right cerebellar infarction was found the day after the accident. The cause of the infarction could not be detected by angiography. Although the patient recovered favorably after surgical removal of the right lateral hemisphere of the cerebellum, he died suddenly 2 weeks after the accident. An autopsy and a microscopic study revealed pulmonary thromboembolism and organizing traumatic lesions of the right vertebral artery without occlusion or noteworthy stenosis of the artery.

CONCLUSIONS

We concluded that the patient sustained traumatic lesions of the right vertebral artery during the traffic accident 2 weeks before death and that his cerebellar infarction was due to a thrombus resulting from these traumatic lesions.

The devastating potential of blunt vertebral arterial injuries

OBJECTIVE

To formulate management guidelines for blunt vertebral arterial injury (BVI).

SUMMARY BACKGROUND DATA

Compared with carotid arterial injuries, BVIs have been considered innocuous. Although screening for BVI has been advocated, particularly in patients with cervical spine injuries, the appropriate therapy of lesions is controversial.

METHODS

In 1996 an aggressive arteriographic screening protocol for blunt cerebrovascular injuries was initiated. A prospective database of all screened patients has been maintained. Analysis of injury mechanisms and patterns, BVI grades, treatment, and outcomes was performed.

RESULTS

Thirty-eight patients (0.53% of blunt trauma admissions) were diagnosed with 47 BVIs during a 3.5-year period. Motor vehicle crash was the most common mechanism, and associated injuries were common. Cervical spine injuries were present in 71% of patients, but there was no predilection for cervical vertebral level or fracture pattern. The incidence of posterior circulation stroke was 24%, and the BVI-attributable death rate was 8%. Stroke incidence and neurologic outcome were independent of BVI injury grade. In patients treated with systemic heparin, fewer overall had a poor neurologic outcome, and fewer had a poor outcome after stroke. Trends associated with heparin therapy included fewer injuries progressing to a higher injury grade, fewer patients in whom stroke developed, and fewer patients deteriorating neurologically from diagnosis to discharge.

CONCLUSIONS

Blunt vertebral arterial injuries are more common than previously reported. Screening patients based on injury mechanisms and patterns will diagnose asymptomatic injuries, allowing the institution of therapy before stroke. Systemic anticoagulation appears to be effective therapy: it is associated with improved neurologic outcome in patients with and without stroke, and it appears to prevent progression to a higher injury grade, stroke, and deterioration in neurologic status.

Vertebral artery occlusion after acute cervical spine trauma

STUDY DESIGN

A retrospective study of vertebral artery injury diagnosed during the last 6 years in our institution.

OBJECTIVES

To determine the clinical and radiologic features of vertebral artery injury.

SUMMARY OF BACKGROUND DATA

Extracranial occlusion of the vertebral artery associated with cervical spine fracture is uncommon and can cause serious and even fatal neurologic deficit due to back lifting and cerebellar infarction. Magnetic resonance imaging and magnetic resonance angiography are extremely helpful in the examination of acute injuries of the cervical spine.

METHODS

Magnetic resonance imaging and magnetic resonance angiography were performed at the time of injury.

RESULTS

The authors reviewed six patients with cervical spine fractures who were diagnosed with a unilateral occlusion of the vertebral artery by means of magnetic resonance imaging/magnetic resonance angiography. One patient had signs of vertebrobasilar insufficiency and another with complete cord lesion had cerebellar and back lifting infarctions. Surgical anterior spinal fusion was performed in five patients, and one was treated by traction and orthosis. At the time of discharge, five patients had no vertebrobasilar symptoms, and the patient who experienced vertebrobasilar territory infarctions showed no progression of the neurologic damage.

CONCLUSIONS

Vertebral artery injury should be suspected in cervical trauma patients with facet joint dislocation or transverse foramen fracture. Magnetic resonance imaging/magnetic resonance angiography is a helpful test to rule out vascular injury. Vertebral artery injury affects the extracranial segment at the same level as the cervical fracture. This is a retrospective review that did not permit drawing conclusions about the effects of early surgical stabilization in the treatment of cervical spine injuries with associated vertebral artery injury; however, surgical stabilization may avoid propagation and embolization of the clot located at the site of the lesion.

Blunt cerebrovascular injuries

On the basis of our experience and the available literature, we submit that aggressive screening for BCI based on injury patterns is warranted. However, several important clinical issues remain unresolved. The precise injury patterns and relative cerebrovascular risks remain to be defined. Furthermore, the optimal diagnostic screening test remains to be identified, with consideration of the relative risk-benefit profile. Finally, we must determine the best methods for the treatment of BCI. Although the definitive study has yet to be completed, the use of heparin was associated with a trend toward improved outcomes in symptomatic patients. In addition, no asymptomatic patient experienced the development of new neurologic deficits during heparin therapy. Therefore we believe that the early institution of heparin therapy is indicated. The role of endovascular stenting, however, remains unclear.

Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation

STUDY DESIGN

Potential precipitating events and risk factors for vertebrobasilar artery dissection were reviewed in an analysis of the English language literature published before 1993.

OBJECTIVES

To assess the literature pertaining to precipitating neck movements and risk factors for vertebrobasilar artery dissection in an attempt to determine whether the incidence of these complications can be minimized.

SUMMARY OF BACKGROUND DATA

Vertebrobasilar artery dissection and occlusion leading to brain stem and cerebellar ischemia and infarction are rare but often devastating complications of cervical, manipulation and neck trauma. Although various investigators have suggested potential risk factors and precipitating events, the basis for these suggestions remains unclear.

METHODS

A detailed search of the literature using three computerized bibliographic databases was performed to identify English language articles from 1966 to 1993. Literature before 1966 was identified through a hand search of Index Medicus. References of articles obtained by database search were reviewed to identify additional relevant articles. Data presented in all articles meeting the inclusion criteria were summarized.

RESULTS

The 367 case reports included in this study describe 160 cases of spontaneous onset, 115 cases of onset after spinal manipulation, 58 cases associated with trivial trauma, and 37 cases caused by major trauma (3 cases were classified in two categories). The nature of the precipitating trauma, neck movement, or type of manipulation that was performed was poorly defined in the literature, and it was not possible to identify a specific neck movement or trauma that would be considered the offending activity in the majority of cases. There were 208 (57%) men and 158 (43%) women (gender data not reported in one case) with an average age of 39.3 +/- 12.9 years. There was an overall prevalence of 13.4% hypertension, 6.5% migraines, 18% use of oral contraception (percent of female patients), and 4.9% smoking. In only isolated cases was specific vascular disease such as fibromuscular hyperplasia noted.

CONCLUSIONS

The literature does not assist in the identification of the offending mechanical trauma, neck movement, or type of manipulation precipitating vertebrobasilar artery dissection or the identification of the patient at risk. Thus, given the current status of the literature, it is impossible to advise patients or physicians about how to avoid vertebrobasilar artery dissection when considering cervical manipulation or about specific sports or exercises that result in neck movement or trauma.

Detection of vertebral artery injury after cervical spine trauma using magnetic resonance angiography

BACKGROUND

We prospectively describe the incidence, magnetic resonance-based diagnosis, and treatment of vertebral artery (VA) injury resulting from closed cervical spine trauma.

METHODS

Patients with fracture or dislocation on plain radiographic studies underwent computed tomography. Among these patients, the subset with computed tomographic evidence of foramen transversarium (FT) fracture underwent magnetic resonance angiography as early as possible.

RESULTS

During a 16-month period, 38 patients with closed cervical trauma were treated. Twelve patients demonstrated fracture extension through at least one FT by computed tomography. Among these patients, four showed unilateral VA injury by magnetic resonance angiography, all ipsilateral to the fractured FT. Three cases of VA occlusion and one of focal narrowing were demonstrated. All four patients were initially treated with aspirin, and two were systemically anticoagulated. None developed irreversible neurologic deficits from the VA compromise.

CONCLUSION

Our data suggest that the incidence of VA injury in closed cervical spine trauma is significant and that FT fractures warrant flow-sensitive magnetic resonance imaging.

Case of intracranial vertebral artery dissection in young age

Stroke in childhood is rare and has its own characteristic findings. Vertebrobasilar ischemia due to trauma in this age group has been described, but its specific features have not yet been clearly defined. Dissection of vertebral artery is one of the causes of vertebrobasilar ischemia that is very uncommonly detected in the intracranial portion of the posterior circulation in childhood. We report a 14-year-old boy with a history of neck trauma and transient vertigo attacks who presented with brainstem and cerebellar ischemic findings. Due to the large left cerebellar infarct size compressing the fourth ventricle, we performed emergent posterior fossa decompression. Digital cerebral subtraction angiography revealed left vertebral artery dissection beginning at the V1 portion to the level of V4 and distal thrombosis of basilar artery. After 2 months, he was discharged from the hospital with minor neurologic deficit with anticoagulation therapy. Due to better outcome in childhood, early investigation for intracranial dissection should be included in the evaluation of posterior circulation infarcts in this age group.

Dissection of the vertebral arteries: case report and discussion

Vertebral artery dissection is an unusual condition with potentially protean neurologic presentations. It may occur spontaneously or follow apparently minor neck trauma. Ischemic symptoms related to the posterior circulation ensue and may be due to obstruction or embolization. The ensuing stroke is ischemic, although subarachnoid hemorrhage may be a complication as well. A case of vertebral artery dissection in a young woman who developed symptoms approximately one week after mild neck injury is reported, and the topic is reviewed.

Ultrasound findings in spontaneous extracranial vertebral artery dissection

BACKGROUND AND PURPOSE

In this study we analyzed the value of ultrasound examination for diagnosis of vertebral artery dissection.

METHODS

The vertebrobasilar arterial system was assessed in 14 patients using transcranial and extracranial pulsed-wave Doppler and duplex sonography.

RESULTS

The dissections were verified by angiography (in 1 patient), magnetic resonance imaging (in 5), or both (in 8). The dissected segments were atlantoaxial (V-3) in 6, V-3 and intertransverse (V-2) in 3, V-3 and intracranial (V-4) in 3, and V-2 in 2 patients. Extracranial and transcranial Doppler examination of the atlas loop, involved in 12 patients, showed absent flow signal in 5, low bidirectional flow signal in 1, and poststenotic low blood flow velocities in 3 patients. Seven of these patients had high-grade stenosis or occlusion. The stenotic segment with increased flow signal could be identified directly in 2 patients. Duplex examination of the intertransverse segment confirmed absent flow in 4 patients, making technically insufficient examination unlikely. In the 2 patients with directly detected stenosis, duplex examination showed low flow velocities before the stenosis. The combined use of extracranial and transcranial Doppler and duplex sonography increases the diagnostic yield to detect vertebral artery pathology. If any abnormal sonographic finding was considered, the yield was 86%; relying only on definitively abnormal findings (absent flow signal, severely reduced vertebral artery blood flow velocities, no diastolic flow, bidirectional flow, and a stenosis signal), the yield was 64%.

CONCLUSIONS

In most cases, there is no pathognomonic ultrasound finding for vertebral artery dissection. However, if a patient presents with suggestive symptoms, ultrasound may corroborate the clinical suspicion and aid in the decision regarding early anticoagulant treatment. A definite diagnosis can be made noninvasively when magnetic resonance imaging demonstrates hematoma in the vessel wall. Angiography yields additional information such as nature of underlying vascular disease, site and extent of dissection, intracranial extension, and presence of pseudoaneurysm.

Noninvasive detection of vertebral artery dissection

BACKGROUND AND PURPOSE

We sought to identify the use of duplex and transcranial Doppler sonography in the noninvasive diagnosis of vertebral dissection.

METHODS

Ten patients with a diagnosis of symptomatic vertebral artery dissection confirmed by cerebral angiography were retrospectively analyzed.

RESULTS

Computed tomographic scanning and magnetic resonance imaging together delineated lateral medullary or cerebellar infarcts in 7 patients. Angiography documented a total of 21 vertebral artery lesions (16 stenoses and 5 occlusions), with 7 of 10 patients having multiple sites of vertebral artery dissection. Vertebral Doppler was abnormal in 8 of the 10 patients. A high resistance signal in the relevant vertebral artery was found in 6 patients, no flow in a well-imaged vertebral artery in 1, and bilateral retrograde vertebral artery flow in 1 patient. Transcranial Doppler was abnormal in only 2 patients, with reduced pulsatility index in 1 and high resistance vertebral signal in another. A hyperintense intramural signal of the affected vertebral artery by magnetic resonance imaging was documented in 1 patient in whom Doppler sonography was nondiagnostic.

CONCLUSIONS

Vertebral artery dissection can be detected and monitored by noninvasive vertebral Doppler and magnetic resonance imaging in the setting of a clinically suggestive presentation.

Unilateral upper cervical posterior spinal artery syndrome following sneezing

A 35 year old man experienced severe transitory neck pain following a violent sneeze. This was followed by neurological symptoms and signs indicating a left sided upper cervical cord lesion. MRI showed an infarct at this site in the territory of the left posterior spinal artery. This discrete infarct was probably due to partial left vertebral artery dissection secondary to sneezing.