Imaging characteristics of symptomatic vertebral artery dissection: a systematic review

Imaging of vertigo and dizziness: a site-based approach part 3 (Brainstem, cerebellum and miscellaneous)

Dizziness and vertigo, frequently associated with cerebrovascular origins, pose a substantial challenge in emergency medical settings due to their potential to be associated with severe underlying conditions. Sudden-onset dizziness, in particular, may be an early indicator of critical events such as stroke or transient ischemic attack (TIA). This comprehensive review encompasses the differential diagnosis of central causes of dizziness and vertigo, emphasizing the crucial role of imaging modalities in the accurate detection and assessment, including cerebrovascular diseases, inflammatory disorders, infections, and other conditions such as vestibular migraine and cervical spondylosis. It highlights the significance of advanced imaging techniques, particularly magnetic resonance imaging (MRI) and computed tomography (CT) in identifying and distinguishing these conditions.

Anatomy of vertebral artery hypoplasia and its relationship with clinical implications: a systematic review and meta-analysis of prevalence

PURPOSE

The vertebral artery (VA) is a vital branch of the subclavian artery, coursing through the transverse foramina of the cervical vertebrae, and playing a crucial role in irrigating the posterior region of the arterial cerebral circle, also known as the Polygon of Willis. Among the various possible alterations that can affect the VA, vertebral artery hypoplasia (HAV) emerges as a significant variant. This study aims to discern the anatomical features of HAV and its correlation with the clinical conditions of the posterior cerebral circulation.

METHODS

The databases Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS were searched until January 2024. Two authors independently performed the search, study selection, and data extraction. Methodological quality was evaluated with an assurance tool for anatomical studies (AQUA). Pooled prevalence was estimated using a random effects model.

RESULTS

A total of 24 studies met the established selection criteria, with a total of 8847 subjects. In this study, 6 articles were included for the meta-analysis with a total of subjects. The average prevalence of VAH reported in each study was 11% (95% CI 10-12%); the studies had a heterogeneity of 41% based on the funnel plot and a low risk of bias.

CONCLUSION

The prevalence of VAH is low, but in the presence of this condition, the changes are mainly in diameter rather than morphological. If it is present, some clinical safeguards must be taken to avoid complications such as stroke.

ACR Appropriateness Criteria® Dizziness and Ataxia: 2023 Update

Diagnostic evaluation of a patient with dizziness or vertigo is complicated by a lack of standardized nomenclature, significant overlap in symptom descriptions, and the subjective nature of the patient's symptoms. Although dizziness is an imprecise term often used by patients to describe a feeling of being off-balance, in many cases dizziness can be subcategorized based on symptomatology as vertigo (false sense of motion or spinning), disequilibrium (imbalance with gait instability), presyncope (nearly fainting or blacking out), or lightheadedness (nonspecific). As such, current diagnostic paradigms focus on timing, triggers, and associated symptoms rather than subjective descriptions of dizziness type. Regardless, these factors complicate the selection of appropriate diagnostic imaging in patients presenting with dizziness or vertigo. This document serves to aid providers in this selection by using a framework of definable clinical variants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Spontaneous intracranial vertebral artery dissections presenting with subarachnoid hemorrhage

BACKGROUND

Vertebral artery dissection (VAD) is an infrequent source of subarachnoid hemorrhage (SAH), with a high mortality rate, primarily due to the risk of rebleeding both before and after medical intervention. This paper provides a comprehensive analysis of the anatomy, pathophysiology, clinical presentation, treatment strategies, and outcomes of intracranial vertebral artery dissections that result in subarachnoid hemorrhage.

METHODS

Comprehensive five-year literature review (2018-2022) and a retrospective analysis of patient records from our institution between 2016 and 2022. We included studies with a minimum of 5 patients.

RESULTS

The study incorporated ten series from the literature and 22 cases from CHUM. Key anatomical factors increasing the risk of VAD include the vertebral artery's origin from the aortic arch, asymmetry of the vertebral artery, and its tortuosity. Patients may display specific collagen and genetic abnormalities. The occurrence of VAD appears to be more prevalent in men. Those with a ruptured intracranial VAD typically show prodromal symptoms and present with severe SAH. Rebleeding within the first 24 h is frequent. While standard imaging methods are usually adequate for VAD diagnosis, they may not provide detailed information about the perforator anatomy. Treatment approaches include both deconstructive and reconstructive methods.

CONCLUSION

Ruptured VAD is a critical, life-threatening condition. Many patients have a poor neurological status at presentation, and rebleeding prior to treatment is a significant concern. Deconstructive techniques are most effective in preventing rebleeding, whereas the efficacy of reconstructive techniques needs more investigation.

High risk and low prevalence diseases: Spontaneous cervical artery dissection

INTRODUCTION

Spontaneous cervical artery dissection (sCAD) is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of sCAD, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

sCAD is a condition affecting the carotid or vertebral arteries and occurs as a result of injury and compromise to the arterial wall layers. The dissection most commonly affects the extracranial vessels but may extend intracranially, resulting in subarachnoid hemorrhage. Patients typically present with symptoms due to compression of local structures, and the presentation depends on the vessel affected. The most common symptom is headache and/or neck pain. Signs and symptoms of ischemia may occur, including transient ischemic attack and stroke. There are a variety of risk factors for sCAD, including underlying connective tissue or vascular disorders, and there may be an inciting event involving minimal trauma to the head or neck. Diagnosis includes imaging, most commonly computed tomography angiography of the head and neck. Ultrasound can diagnose sCAD but should not be used to exclude the condition. Treatment includes specialist consultation (neurology and vascular specialist), consideration of thrombolysis in appropriate patients, symptomatic management, and administration of antithrombotic medications.

CONCLUSIONS

An understanding of sCAD can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Atypical Presentation and Diagnosis of Multiple Myeloma: A Case Report

Chronic neck pain is a common, seemingly benign condition that typically does not warrant an urgent workup, in contrast to acute onset neck pain. Vertebral artery dissection (VAD) is a relatively rare presentation of acute onset neck pain and often presents in the context of blunt trauma. Due to the risk of subsequent clot formation and stroke, patients who present with symptoms suggestive of VAD must be promptly screened, most often first with computed tomography angiography (CTA) followed by magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) for further evaluation. We present a case of a 69-year-old male with a history of chronic neck pain who was seen in the emergency department due to acute, severe neck pain with initial CTA imaging that suggested left VAD. However, follow-up MRI of his cervical spine identified that what seemed to be a left VAD was instead multiple myeloma. This case demonstrates the utility of using multiple imaging modalities, including CT, CTA, MRI, and MRA, in diagnosing an atypical presentation of multiple myeloma and the consequences of physician implicit biases that are often involved when treating patients with chronic pain.

Work-up and Management of Asymptomatic Extracranial Traumatic Vertebral Artery Injury

BACKGROUND

Non-penetrating head and neck trauma is associated with extracranial traumatic vertebral artery injury (eTVAI) in approximately 1-2% of cases. Most patients are initially asymptomatic but have an increased risk for delayed stroke and mortality. Limited evidence is available to guide the management of asymptomatic eTVAI. As such, we sought to investigate national practice patterns regarding screening, treatment, and follow-up domains.

METHODS

A cross-sectional, electronic survey was distributed to members of the Canadian Neurosurgical Society and Canadian Spine Society. We presented two cases of asymptomatic eTVAI, stratified by injury mechanism, fracture type, and angiographic findings. Screening questions were answered prior to presentation of angiographic findings. Survey responses were analyzed using descriptive statistics.

RESULTS

One hundred-eight of 232 (46%) participants, representing 20 academic institutions, completed the survey. Case 1: 78% of respondents would screen for eTVAI with computed topography angiography (CTA) (97%), immediately (88%). The majority of respondents (97%) would treat with aspirin (89%) for 3-6 months (46%). Respondents would follow up clinically (89%) or radiographically (75%), every 1-3 months. Case 2: 73% of respondents would screen with CTA (96%), immediately (88%). Most respondents (94%) would treat with aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy. Respondents would follow up clinically (97%) or radiographically (89%), every 1-3 months.

CONCLUSION

This survey of Canadian practice patterns highlights consistency in the approach to screening, treatment, and follow-up of asymptomatic eTVAI. These findings are relevant to neurosurgeons, spinal surgeons, stroke neurologists, and neuro-interventionalists.

Cervical Artery Dissection

OBJECTIVE

Cervical artery dissection is a common cause of stroke in young adults. This article reviews the pathophysiology, etiology and risk factors, evaluation, management, and outcomes of spontaneous cervical artery dissection.

LATEST DEVELOPMENTS

Cervical artery dissection is believed to be a multifactorial disease, with environmental factors serving as possible triggers in patients who have a genetic predisposition to dissection formation. Cervical artery dissection can cause local symptoms or ischemic events, such as ischemic stroke or transient ischemic attack. Neuroimaging is used to confirm the diagnosis; classic findings include a long tapered arterial stenosis or occlusion, dissecting aneurysm, intimal flap, double lumen, or intramural hematoma. Patients with cervical artery dissection who present with an acute ischemic stroke should be evaluated for IV thrombolysis, endovascular therapy eligibility, or both. Antithrombotic therapy with either anticoagulation or antiplatelet treatment is used to prevent stroke from cervical artery dissection. The risk of recurrent ischemia appears low and is mostly limited to the first two weeks after symptom onset.

ESSENTIAL POINTS

Cervical artery dissection is a known cause of ischemic strokes. Current data show no difference between the benefits and risks of anticoagulation versus antiplatelet therapy in the acute phase of symptomatic extracranial cervical artery dissection, thereby supporting the recommendation that clinicians can prescribe either treatment. Further research is warranted to better understand the pathophysiology and long-term outcomes of cervical artery dissection.

Review article: Non-penetrating neck artery dissection in young adults: Not to be missed!

Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front-line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi-disciplinary team management of this condition. In general, guideline-based recommendation for the management of neck artery dissection involving an intimal flap is by anti-platelet therapy while treatment of neck artery dissection that results in a pseudo-aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.

Intramural Hematoma in Vertebrobasilar Dolichoectasia-Related Stroke: A Retrospective Analysis of Six Consecutive Patients

BACKGROUND

The pathophysiology underlying vertebrobasilar dolichoectasia (VBD) is largely unknown. However, a few reports have demonstrated that acute intramural hematoma (IMH) in VBD is associated with stroke. We aimed to investigate the clinical and radiological features of IMH in VBD and the role of IMH in predicting rupture and patient outcomes.

METHODS

We retrospectively reviewed the medical records of patients treated in 2 stroke centers between January 2012 and December 2021. Patients presenting with VBD and stroke were eligible for study inclusion. We excluded patients with stroke caused by arterial dissection or artery-to-artery embolism. IMH was defined as a crescent-shaped area of high signal density in the vessel wall on axial computed tomography in the absence of an intimal flap, double lumen, and pearl-and-string sign.

RESULTS

Six patients were analyzed. All presented with symptoms of brainstem/cerebellar infarction without headache. Interobserver agreement for the presence or absence of IMH was excellent (100%). IMH was detected in 5 patients. The positive predictive value of IMH for rupture was 80% (95% confidence interval, 28%-99.5%). The median time from symptom onset to rupture was 2.5 days (range, 1.5-4). Median computed tomography values were significantly higher within the IMH than those in the lumen of the basilar artery (70 vs. 44.5 Hounsfield units; P = 0.008). The modified Rankin scale score on day 30 after onset was 5 in 1 patient and 6 in the remaining 5.

CONCLUSIONS

IMH in patients with VBD presenting with brainstem/cerebellar infarction should be regarded as a sign associated with a high risk of rupture.

Posterior Circulation Ischemia in the Endovascular Era

BACKGROUND AND OBJECTIVES

To perform literature review of clinical, radiographic, and anatomical features of posterior circulation ischemia (PCI) and systematic review of the literature on the management of basilar artery occlusion (BAO) and associated outcomes.

METHODS

Review of literature was conducted to identify publications describing the risk factors, etiology, clinical presentation, and imaging for PCI. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed and Ovid MEDLINE were searched from 2009 to 2020 for articles relating to management of BAO. A synthesis was compiled summarizing current evidence on management of BAO.

RESULTS

PCI accounts for 15%-20% of strokes. Risk factors are similar to anterior circulation strokes. Dizziness (47%), unilateral limb weakness (41%), and dysarthria (31%) are the most common presenting symptoms. A noncontrast head CT will identify PCI in 21% of cases; diffusion-weighted MRI or CT perfusion increase sensitivity to 85%. Recent trials have shown endovascular therapy can achieve >80% recanalization of BAO. In select patients, 30%-60% who receive endovascular treatment can achieve favorable outcome vs without. A total of 13% achieve good outcome and there is an 86% mortality rate.

DISCUSSION

PCI can present with waxing and waning symptoms or clinical findings that overlap with stroke mimics and anterior circulation ischemia, making diagnosis more heavily dependent on imaging. Recanalization is an important predictor of improved functional outcome and survival. In this endovascular era, trials of BAO are fraught with deterrents to enrollment. Despite limitations, endovascular treatment has shown improved outcome in select patients.

Acute Vestibular Syndrome and ER Presentations of Dizziness

Acute vestibular syndrome (AVS) describes sudden onset, severe, continuous dizziness that persists for more than 24 hours. Its wide differential presents a diagnostic challenge. Vestibular neuritis is the most common cause, but stroke, trauma, medication effects, infectious, and inflammatory causes all present similarly. The TiTrATE model (Timing, Triggers, And Targeted Exam) is systematic way to evaluate these patients, and the HINTS Plus exam (Head Impulse, Nystagmus, Test of Skew, plus hearing loss) is critical in differentiating central and peripheral causes. The importance of recognizing risk factors for stroke and the role of imaging is also discussed.

Vertebral Artery Dissection in a Woman Due to Golf: An Under Recognized Etiology

INTRODUCTION

Traditionally, spontaneous cervical artery dissections have been associated with violent, sudden neck movements. These events are a significant cause of stroke related morbidity, particularly in young people. Only a handful of cases of golf-induced vertebral artery dissection (VAD) have been described, and the discussion has primarily focused on middle-aged men. Despite the discussion focused on this demographic, women are participating in golf at higher rates than ever before, and have a higher risk for developing VAD.

CASE REPORT

A 41-year-old woman presented to our hospital with sharp neck pain, dizziness, and ptosis after swinging a driver during a morning round of golf. Imaging demonstrated a right V3/V4 VAD and subsequent ischemic infarction. After administration of tissue plasminogen activator she had abrupt change in mental status with seizure-like activity. She underwent angiogram and mechanical thrombectomy, and was started in heparin 24 hours post-tissue plasminogen activator. This was subsequently changed to low-dose aspirin following thalamic petechial hemorrhage. She was discharged from the hospital after a few days with only minor deficits. We will discuss mechanism, treatment, and outcomes of VAD in context of this case.

CONCLUSION

This patient is the first woman in the literature to suffer from VAD as a result of playing golf. The twisting motion of the head and neck in a golf swing may be a risk factor for dissection and subsequent development of stroke. As a result of increased female participation in golf, we expect to see increased incidence of women presenting with "golfer's stroke" in coming years.

Mild trauma causing cervical fracture through transverse foramen leading to a vertebral arteriovenous fistula

Vertebral arteriovenous fistula (vAVF) is an uncommon vascular disease defined as abnormal connections between the vertebral artery or its branches extracranially with nearby venous structures. This case report outlines the case of a man in his late 70s presenting with C1-C3 fractures after a mild trauma falling down a small staircase. CT angiogram (CTA) gave suspicion of vertebral artery dissection and pseudoaneurysm; however, digital subtraction angiography revealed a fracture-induced vAVF successfully treated endovascularly with coils. In conclusion, cervical fractures involving the transverse foramen regardless of trauma mechanism should result in a CTA. Endovascular treatment with ipsilateral vertebral artery closure is preferred due to its feasibility and safety.

[Imaging diagnosis of intracranial artery dissections: visualization of the vessel walls on high-resolution vessel wall imaging]

MRI is a non-invasive imaging modality with a high contrast resolution useful in diagnosing intracranial artery dissections. However, conventional MRI techniques, including time-of-flight MR angiography or basi-parallel anatomical scanning provide only limited information because they focus on imaging findings rather than the vessel walls. A newly devised MRI technique, high-resolution vessel wall imaging (HRVWI), enables direct visualization of vessel wall and therefore more accurate diagnosis. With increasing use of HRVWI, physicians need to understand the clinical indications, MR sequences for assessment, optimization of acquisition parameters, and limitations in the interpretation of images. For precise interpretation of images, physicians should be aware of the pathological condition of intracranial artery dissection and its radiological findings. In this review, we provide an overview and principles of MRI assessment used for intracranial artery dissection paying special attention to its pathological findings and radiological presentations on HRVWI.

Intracranial vessel wall MR imaging of an intradural vertebral artery dissection

Diagnosis of intracranial arterial dissections can be challenging due to the wide spectrum of imaging presentations. High-resolution vessel wall MR imaging can be a useful adjunct to conventional lumen-based imaging techniques for diagnosing arterial dissections. We present a case of a 37-year-old male with a history of a Wolff-Parkinson-White syndrome presenting with acute onset of nausea, vertigo, and left body hemisensory loss of pain and temperature. A conventional brain MRI identified an acute infarct in the right lateral medulla, concordant with clinical symptoms of Wallenberg syndrome. CT angiogram of the head and neck showed lack of opacification of the right intradural vertebral artery. Intracranial vessel wall MR imaging showed findings suggestive of an intimal dissection flap with both intramural and intraluminal thrombus. Intracranial vessel wall MR imaging can provide complementary information to conventional lumen-based imaging to diagnose a vertebral dissection.

A case of multiple Vertebrobasilar artery fenestration misdiagnosed as vertebral artery dissection

Background

Fenestration of vertebra-basilar artery is an uncommon congenital vascular anomaly, which is identified by incidental findings on imaging in patients presented without related symptoms or in patients with intracerebral hemorrhage secondary to concomitant artery aneurysm or arteriovenous malformations. Yet, cases of fenestration being misdiagnosed as cerebral artery dissection have never been reported.

Case presentation

We present a patient of 66-year-old female with acute onset of dizziness after chiropractic manipulation of the neck. Neck computed tomography angiography (CTA) showed ‘double lumen’ sign and ‘intimal flap’ of the V1 segment of the vertebral artery, which led to the initial diagnosis of vertebral artery dissection (VAD). However, vertebral artery fenestration at V1 segment was eventually identified by multi-directional digital subtraction angiography (DSA). Interestingly, concomitant vertebral fenestration at V3 segment, basilar fenestration and basilar artery tip aneurysm was also revealed by DSA.

Conclusion

The triple fenestration at vertebrobasilar artery with basilar tip artery aneurysm is extremely rare, and the fenestration at the V1 segment of vertebral artery was easily misdiagnosed as VAD due to the similar imaging morphology.

Avoiding Misdiagnosis in Patients With Posterior Circulation Ischemia: A Narrative Review

Posterior circulation strokes represent 20% of all acute ischemic strokes. Posterior circulation stroke patients are misdiagnosed twice as often compared to those with anterior events. Misdiagnosed patients likely have worse outcomes than correctly diagnosed patients because they are at risk for complications of the initial stroke as well as recurrent events due to lack of secondary stroke prevention and failure to treat the underlying vascular pathology. Understanding important anatomic variants, the clinical presentations, relevant physical examination findings, and the limitations of acute brain imaging may help reduce misdiagnosis. We present a symptom-based review of posterior circulation ischemia focusing on the subtler presentations with a brief discussion of basilar stroke, both of which can be missed by the emergency physician. Strategies to avoid misdiagnosis include establishing an abrupt onset of symptoms, awareness of the nonspecific presentations, consideration of basilar stroke in altered patients and using a modern approach to diagnosis of the acutely dizzy patient.

Traumatic vertebral artery injury: a review of the screening criteria, imaging spectrum, mimics, and pitfalls

PURPOSE

Traumatic vertebral artery injury (TVAI) can have a varied clinical presentation and appearance on imaging. In this review, we present the screening criteria, spectrum of imaging features, grading, and imaging pitfalls of TVAI. Our review focuses on the imaging of TVAI on computed tomography angiography (CTA), magnetic resonance angiography (MRA), and cases of TVAI mimics.

IMAGING

The imaging spectrum on CTA can range from either focal or long segment luminal stenosis (the most common findings), smooth or tapered narrowing of lumen, string of pearls appearance, concentric intramural haematoma, intimal flap (the most definite sign), and double lumen of the artery. On time-of-flight MRA, the most common findings include loss of flow void within the vessel due to slow flow, thrombosis or occlusion, and hyperintense signal within the vessel wall due to intramural haematoma on T1 fat-saturated images.

CONCLUSION

The reader should be aware of the screening criteria, common and uncommon findings, variant anatomy, artifacts, and mimics of TVAI when evaluating cases of craniocervical trauma, to be competent in calling in or ruling out injury.

Clinical application of high-resolution MRI in combination with digital subtraction angiography in the diagnosis of vertebrobasilar artery dissecting aneurysm: An observational study (STROBE compliant)

Vertebrobasilar artery dissecting aneurysm (VBA-DA) is associated with serious complications and poor prognosis in patients. High-resolution magnetic resonance imaging (HR-MRI) is a noninvasive method for the diagnosis of VBA-DA.VBA-DAs were classified according to the feature of HR-MRI in combination with digital subtraction angiography (DSA), and the clinical outcomes of different types of VBA-DAs were analyzed. Thirty-nine patients with 42 VBA-DAs were included and underwent HR-MRI, including three-dimensional T1 weighted image, three-dimensional T2 weighted image (3D-T2WI), three-dimensional time of flight MRA (3D-TOF-MRA), and three-dimensional fast imaging employing steady state acquisition (3D-FIESTA), and hematoma and flaps were compared. The follow-up was 3 to 25 months. The VBA-DAs were classified based on the images of HR-MRI and DSA, and the prognosis was analyzed.VBA-DAs more frequently occurred on the vertebral artery, especially on the dominant vertebral artery. 3D-TOF-MRA showed high signal from hematoma, and 3D-FIESTA showed high signal from flaps. Based on HR-MRI images in combination with DSA, VBA-DAs were classified into 4 types: classical, stenosis, spiral, and hemorrhagic. The patients with the classical VBA-DAs had a higher improvement rate and a lower exacerbation rate. The patients with spiral and hemorrhagic VBA-DAs had poor clinical outcomes. The patients with stenosis VBA-DAs had poorer clinical outcomes than classical types and better clinical outcomes than spiral and hemorrhagic types.The detection of intramural hematoma and dissection flap using HR-MRI provides basic information for the diagnosis of VBA-DA. Individualized therapeutic strategies can be designed for the treatment of VBA-DAs with different features of DSA and HR-MRI.

A Posterior Circulation Stroke Presenting with Isolated Truncal Ataxia

Vertebral artery dissection is an infrequent and often misdiagnosed cause of stroke. In this case report, we describe a patient with a posterior circulation stroke caused by a vertebral artery dissection, who presented to the emergency department with isolated truncal ataxia. This case emphasizes the importance of obtaining a thorough history and physical exam for all neurologic complaints, including a careful ambulation assessment.

Non-traumatic vertebral artery dissection presenting with unilateral cervical pain, hemilateral vision problems and headache

Spontaneous vertebral artery dissection is a rare condition, mainly affecting young adults with non-specific symptoms, which are often considered not severe. We report a case of a non-traumatic vertebral artery dissection in a 30-year-old woman. Our patient presented with unilateral right-sided neck pain and frontal headache during 3 weeks and recently developed right-sided vision problems. History and clinical findings were non-specific. Neurovascular imaging showed a right-sided vertebral artery dissection from C2 to C6 with an intima flap at C5-C6. The patient was observed in the stroke unit for 1 week and antithrombotics were given during 3 months. There was a complete revascularization of the vertebral artery after 3 months. A review of literature is given concerning predisposing factors, clinical symptoms, neurovascular imaging and treatment options.

Diagnosis of Intracranial Artery Dissection

Cerebral arterial dissection is defined as a hematoma in the wall of a cervical or an intracranial artery. Cerebral arterial dissection causes arterial stenosis, occlusion, and aneurysm, resulting in acute infarction and hemorrhage. Image analysis by such methods as conventional angiography, computed tomography, magnetic resonance imaging, and so on plays an important role in diagnosing cerebral arterial dissection. In this study, we explore the methods and findings involved in the diagnosis of cerebral arterial dissection.

Vertigo and hearing loss

Symptoms referable to disorders affecting the inner ear and vestibulocochlear nerve (eighth cranial nerve) include dizziness, vertigo, tinnitus, and hearing loss, in various combinations. Similar symptoms may occur with involvement of the central nervous system, principally the brainstem and cerebellum, to which the vestibular and auditory systems are connected. Imaging choices should be tailored to patient symptoms and the clinical context. Computed tomography (CT) should be used primarily to assess bony structures. Magnetic resonance imaging (MRI) should be used primarily to assess soft-tissue structures. Vascular imaging by angiography or venography should be obtained when vascular lesions are suspected. No imaging should be obtained in patients with typical presentations of common peripheral vestibular or auditory disorders. In current clinical practice, neuroimaging is often overused, especially CT in the assessment of acute dizziness and vertigo in the emergency department. Despite low sensitivity for ischemic strokes, CT is often used to rule out neurologic causes. When ischemic stroke is the principal concern in acute vestibular presentations, imaging should almost always be by MRI with diffusion-weighted images, rather than CT. In this chapter, we describe recommended strategies for audiovestibular imaging based on patient symptoms and signs.

Diagnosis of vertebral artery dissection in childhood posterior circulation arterial ischaemic stroke

AIM

Review a series of children with posterior circulation arterial ischaemic stroke (PCAIS) to identify diagnostic modality and associations in cases of vertebral artery dissection (VAD).

METHOD

Retrospective analysis of 30 cases of childhood PCAIS identified from two tertiary centres over 11 years. Clinical and demographic details were recorded. Brain and cerebrovascular imaging were reviewed. Aetiology was classified using the Childhood Arterial Ischaemic Stroke Standardized Classification and Diagnostic Evaluation criteria. Outcome was evaluated using standardized paediatric stroke outcome scores. Logistic regression was used to explore variables associated with diagnosis.

RESULTS

Twenty-three patients were male (77%) and 7 were female (23%). VAD was the most commonly identified aetiology, in 15 cases (50%). Aetiology was undetermined in 12 (40%), probable cardioembolism in two, and reversible cerebral vasoconstriction syndrome in one. In those with VAD, diagnosis was made on initial magnetic resonance angiography (MRA) in six (40%). Further cases of VAD were diagnosed with catheter angiography (n=6), computed tomographic angiography (n=1), or follow-up MRA (n=2). Presence of multiple infarcts was associated with a diagnosis of VAD.

INTERPRETATION

Endoluminal cerebrovascular imaging increases the rate of diagnosis of VAD in childhood PCAIS and should especially be considered if there are multiple infarcts.

Vertebral artery dissection with compelling evidence on duplex ultrasound presenting only with neck pain

Vertebral artery dissection (VAD) is among the most common identifiable etiologies of stroke in young adults and poses a diagnostic challenge due to nonspecific symptoms and substantial variability of imaging results. Here, we present a case of unspecific neck pain as isolated symptom of VAD with unusually compelling evidence on duplex ultrasound. This observation has clinical relevance as the absence of any neurological symptoms in our patient highlights the necessity of considering cervical artery dissection in patients presenting with unspecific symptoms such as neck pain, even if isolated. Furthermore, our image of intramural hematoma on duplex ultrasound has been captured in an unusual, clear and distinct fashion and might therefore be a useful reference image in the clinical assessment of patients with a suspicion of cervical artery dissection.

Stroke in a Young Swimmer

Introduction:

Arterial dissections are important causes of stroke in the young population. Dissection has been reported in association with some sports. It seems that this report is among the first ones of the cervical arterial dissection in a young swimmer.

Case Presentation:

A 30-year-old male professional swimmer with no history of any major disease suddenly complained of severe ataxia, moderate headache, neck pain, unilateral left facial weakness, and feelings of tingling and paresthesia on the left side of his body and face a few minutes following head and body stretching exercises in land. There was no history of major head or neck trauma, manipulation, and practicing diving skills in the past. Acute infarction of the left cerebellum was diagnosed after performing brain computed tomography and magnetic resonance imaging (with contrast) studies. Cervical magnetic resonance angiography confirmed left vertebral artery dissection as the cause of infarction.

Conclusions:

Important differential diagnoses of cervicocephalic arterial dissection include other vascular or neurological causes of head and neck pain and/or local neurological syndromes and other causes of brain ischemia such as cardiac emboli, atherosclerosis, and vasculopathy of brain vessels. It is important that sports medicine practitioners pay attention to this less-diagnosed cause of stroke in young athletes.

Vertebral artery dissection caused by swinging a golf club: case report and literature review

Vertebral artery (VA) dissection caused by swinging a golf club is extremely rare, and the mechanism of the dissection has not been elucidated. A 39-year-old man suddenly felt sharp neck pain and dizziness when he swung a driver while playing golf and visited our clinic. Imaging studies showed acute right cerebellar infarction and complete occlusion of the right VA at the C2 (axis) level. After 1 month of 100 mg aspirin treatment, the occluded right VA was completely recanalized and the patient became totally asymptomatic. Professional golfers look at the position of the ball on the ground or tee until completion of their follow-through. However, some amateur golfers look in the direction that the ball travels at the beginning of their follow-through. It is hypothesized that this rapid disproportionate head rotation produces VA elongation and distortion, mainly at the C2 level, causing stenosis or occlusion of the artery.

Use of perfusion imaging and other imaging techniques to assess risks/benefits of acute stroke interventions

The advent of multimodal neuroimaging has provided acute stroke care providers with an armamentarium of sophisticated imaging options to utilize for guidance in clinical decision-making and management of acute ischemic stroke patients. Here, we propose a framework and potential algorithm-based methodology for imaging modality selection and utilization for the purpose of achieving optimal stroke clinical care. We first review imaging options that may best inform decision-making regarding revascularization eligibility, with a focus on the imaging modalities that best identify critical inclusion and exclusion criteria. Next, we review imaging methods that may guide the successful achievement of revascularization once it has been deemed desirable and feasible. Further, we review imaging modalities that may best assist in both the noninterventional care of acute stroke as well as the identification of stroke-mimics. Finally, we review imaging techniques under current investigation that show promise to improve future acute stroke management.