Vertebral artery injury and cerebellar stroke while swimming: case report

Vertebral Artery Dissection in Sport: A Systematic Review

BACKGROUND

Vertebral artery dissection (VAD) is a potentially catastrophic injury that may occur during sports participation. A comprehensive review is needed to collate documented cases to improve understanding and inform future preventative approaches.

OBJECTIVE

This review aimed to understand the extent of VAD in sport and characterise trends suggestive of mechanisms of injury.

METHODS

Electronic databases were searched using terms related to VAD and sport. Records were included if they described one or more cases of VAD attributed to sport.

RESULTS

A total of 79 records described 128 individual cases of VAD in sport, of which 118 were confirmed by imaging or autopsy and included in analyses. Cases were attributed to 43 contact and non-contact sports. The median age of cases was 33 years (IQR 22-44), and 75% were male. There were 22 cases of fatal injury, of which ten involved an impact to the mastoid region and seven involved an impact to the head or neck. Non-fatal cases of VAD were attributed to impact to the head or neck (not mastoid region), movement or held position without impact, and in some cases no reported incident.

CONCLUSIONS

VAD attributed to sports participation is uncommonly reported and the mechanisms are varied. Impact to the mastoid region is consistently implicated in fatal cases and should be the focus of injury prevention strategies in sport. Efforts may also be directed at improving the prognosis of cases with delayed presentation through clinical recognition and imaging. The review was registered on the international prospective register for systematic reviews ( http://www.crd.york.ac.uk/PROSPERO ) (CRD42018090543).

Sumo-Associated Traumatic Vertebral Artery Dissection Precipitating Subarachnoid Hemorrhage in Association with Bifid Origins of the Posterior Inferior Cerebellar Artery

BACKGROUND

Traumatic vertebral artery dissection (tVAD) is frequently accompanied by cerebellar infarction, but subarachnoid hemorrhage (SAH) is rare.

CASE DESCRIPTION

We report a unique case of tVAD precipitating SAH, from which the patient fully recovered, most likely because of the protective effects of an anomalously duplicated posterior inferior cerebellar artery (PICA) origin. A 17-year-old Sumo wrestler experienced a brief loss of consciousness after an attack by an opponent to his neck. Head computed tomography imaging demonstrated diffuse posterior fossa SAH; cerebral angiography demonstrated left vertebral artery (VA) occlusion, which was thought to be most likely attributable to tVAD. Angiography revealed distal PICA reconstitution, supplied by collateral arterial flow from the meningeal branch of the proximal ipsilateral VA. An external ventricular drain was placed acutely for treatment of SAH-induced hydrocephalus; however, the patient had an otherwise uneventful course, and remained without clinical evidence of ischemic infarct. A repeat imaging confirming a probable duplicated PICA origin from the VA, distal to the tVAD-associated thrombosis.

CONCLUSIONS

Of particular interest, the patient's abnormal anatomy may have been a mixed blessing, with a more fragile bifid PICA potentially underlying the unexpected development of SAH, whereas the sister branch simultaneously spared him a potentially catastrophic infarction via arterial collateralization.

Cervical artery dissection after sports - An analytical evaluation of 190 published cases

Introduction

Cervical artery dissections may be preceded by mechanical trigger events, often related to sports.

Methods

Using the MEDLINE database, we identified case reports and case series of sports-related cervical artery dissections. Information of the type of sport, age and gender of the patient, affected vessels, associated infarction, time delay, and neurological sequelae were extracted. Demographic and clinical characteristics were compared between sport groups using analysis of variance and Chi square tests. Differences were further assessed with adjusted post hoc tests and homogenous subsets.

Results

A total of 115 reports describing 190 patients with cervical artery dissections related to 45 different sports were identified. The mean age of all patients was 35 years; 26% of all patients were women. Anterior and posterior circulation, as well as left and right side were affected with similar frequency. Patients belonging to different sport categories differed significantly with regard to age (p < 0.001), gender (p < 0.001), and affected circulation (anterior vs. posterior, p = 0.02). The posterior circulation was most often affected in golf players (88%) and least often in individuals engaging in exercise (23%) and scuba divers (29%). Laterality (left vs. right) and mortality were similar between sport groups.

Discussion

We performed a comprehensive review and analytical evaluation of case reports describing patients with cervical artery dissections after sport. Confirmation of our findings in prospective studies is needed.

Conclusion

Cervical artery dissection has been described in relation to a wide variety of sports. The risk of injury to particular neurovascular structures may depend on the type sport involved. Discipline-specific incidence rates are not known.

Cervicogenic dizziness as a cause of vertigo while swimming: an unusual case report

We present the unusual case of a competitive swimmer with cervicogenic dizziness manifesting as vertigo while she was surface swimming. This patient complained of brief and episodic room-spinning vertigo consistently associated with swimming the freestyle stroke and was referred to an otolaryngology clinic for evaluation. She did not have significant complaints of neck pain while swimming. Her history, examination findings, laboratory study results, differential diagnoses, and treatment are discussed in detail. A succinct overview of cervicogenic dizziness--a controversial diagnosis often overlooked by otolaryngologists-is also provided.

Rotational vertebrobasilar ischemia: hemodynamic assessment and surgical treatment

OBJECTIVE

Rotational vertebrobasilar insufficiency is a severe and incapacitating condition. Proper investigation and management are essential to reestablish normal posterior circulation hemodynamics, improve symptoms, and prevent stroke. We present a series of 10 patients with rotational vertebrobasilar ischemia who were treated surgically and emphasize the importance of transcranial Doppler in the diagnosis and management of this condition.

METHODS

All patients presented with symptoms of vertebrobasilar insufficiency induced by head turning. Transcranial Doppler documented a significant decrease in the posterior cerebral artery velocities during head turning that correlated with the symptoms in all patients. A dynamic cerebral angiogram was performed to demonstrate the site and extent of vertebral artery compression.

RESULTS

The surgical technique performed was tailored to each individual patient on the basis of the anatomic location, pathogenesis, and mechanism of the vertebral artery compression. Five patients underwent removal of osteophytes at the level of the subaxial cervical spine, one patient had a discectomy, two patients had a decompression only at the level of C1-C2, and two patients had a decompression and fusion at the C1-C2 level.

CONCLUSION

The transcranial Doppler is extremely useful to document the altered hemodynamics preoperatively and verify the return of normal posterior circulation velocities after the surgical decompression in patients with rotational vertebrobasilar ischemia. Surgical treatment is very effective, and excellent long-term results can be expected in the vast majority of patients after decompression of the vertebral artery.

Imaging of Traumatic Neurovascular Injury

Traumatic injury to the major vessels of the head and neck can result in potentially devastating neurologic sequelae. Until recently, conventional angiography was the primary imaging modality used to evaluate these often challenging patients. Advances in cross-sectional imaging have improved the ability to screen for these lesions, which have been found to be more common than previously thought; however, accepted protocols of imaging evaluation have not yet been fully established. This article presents a general approach to the patient with suspected neurovascular injury. This includes a discussion of the histopathologic spectrum, clinical presentation, mechanisms, radiologic work-up, pertinent issues of the most common lesions, and some of the endovascular techniques used in their management.

Cervicocranial Arterial Dissections

Cervicocranial dissections are an increasingly recognized cause of stroke in the young. When the dissections narrow the vascular lumen, they often alter blood flow enough to cause transient ischemic attacks in the brain. Alterations in the endothelium activate the coagulation cascade, leading to the formation of intramural clot that may embolize distally to cause brain infarction. Pain and neuro-ophthalmic symptoms and signs are common manifestations.

Rotational vertebral artery occlusion from occipital bone anomaly: a rare cause of embolic stroke. Case report

Vertebral artery (VA) occlusion by rotation of the head is uncommon, but can result from mechanical compression of the artery, trauma, or atlantoaxial instability. Occipital bone anomalies rarely cause rotational VA occlusion, and patients with nontraumatic intermittent occlusion of the VA usually present with compromised vertebrobasilar flow. A 34-year-old man suffered three embolic strokes in the vertebrobasilar system within 2 months. Magnetic resonance imaging demonstrated multiple infarcts in the vertebrobasilar territory. Angiography performed immediately after the third attack displayed an embolus in the right posterior cerebral artery. Radiographic and three-dimensional computerized tomography bone images exhibited an anomalous osseous process of the occipital bone projecting to the posterior arch of the atlas. Dynamic angiography indicated complete occlusion of the left VA between the osseous process and the posterior arch while the patient's head was turned to the right. Surgical decompression of the VA resulted in complete resolution of rotational occlusion of the artery. An occipital bone anomaly can cause rotational VA occlusion at the craniovertebral junction in patients who present with repeated embolic strokes resulting from injury to the arterial wall.

Neurologic complications of sit-ups associated with the Valsalva maneuver: 2 case reports

We present 2 cases of potentially catastrophic neurologic consequences occurring in healthy individuals engaged in sit-up exercises. Two young healthy men were engaged in sit-ups when one developed a stroke and the other developed a spinal epidural hematoma. The Valsalva maneuver involved in the sit-up exercise can produce supraphysiologic increases in blood pressure, which can lead to vascular injury and serious neurologic consequences. Proper breathing should be encouraged and patients with known predisposing factors should avoid such exercises. Prompt recognition of neurologic signs and symptoms during exercise can be life saving. This is the first report of the neurologic complications of sit-ups.

Vascular injury in neurotrauma

Traumatic vascular lesions can occur after severe or even the most mild of head and cervical trauma. The initial evaluation of the injured patient must be thorough and the clinical suspicion of vascular injury must be highly suspected based on the mechanism of injury. Traumatic vascular injuries can be broadly classified into traumatic aneurysms, dissections and occlusions and fistulae of the carotid or vertebral arteries. The current management and treatment options of each condition are discussed.

Vertebral artery dissection causing stroke in sport

Five cases of vertebral arterial dissection occurring in sport are presented. These cases emphasise the diagnostic and management difficulties in this setting. Stroke in sport, although uncommon, is predominantly due to arterial dissection in either the vertebral or carotid arteries. Physicians involved in athlete care need to be aware of this diagnosis.

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.

Spontaneous vertebral artery dissection mimicking acute vertigo. Case report

A patient with acute vertigo, and normal findings on neurologic examination, was found to have vertebral artery dissection (VAD). This case shows that the clinical picture of VAD can mimic vertigo of labyrinthine (i.e, peripheral) origin.

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.

Bilateral cortical blindness after lumbar spine surgery. A case report

STUDY DESIGN

A report of the unusual perioperative complication of bilateral cortical blindness after lumbar spine surgery. The hypothetical causes that can lead to this syndrome in spine surgery and the precautions are discussed.

OBJECTIVES

The circumstances surrounding the occurrence of perioperative cortical blindness, the explanation of possible mechanisms, and the patients at risk are evaluated.

SUMMARY OF BACKGROUND DATA

There have been no similar reports.

METHODS

Case report with description of the syndrome of cortical blindness, the diagnostic tools, and the different pathophysiologic causes.

RESULTS

The severe impairment of visual capacities remained unchanged; some color discrimination and the differentiation between dark and daylight were possible.

CONCLUSIONS

In obese patients (body mass index > 30) puncture of the subclavian vein and rotating and positioning of the patient in one step should be performed carefully.

Vertebral artery dissection

Vertebral artery dissections (VADs) following a variety of minor traumatic mechanisms have been previously reported. This article reports 2 cases of VAD with delayed recognition following motor vehicle collisions (MVCs). The first VAD patient developed major neurologic abnormalities 28 hours after an MVC. The second VAD patient presented with 3 weeks of neck and head pain beginning 8 weeks after an MVC and subsequent chiropractic manipulation. The anatomy and pathophysiology of VAD are reviewed. Early ED recognition prior to the onset of major neurologic deficits (e.g., paresis, dysarthria, ataxia, or altered mental status) is emphasized. An algorithm for the ED management of the entity is suggested.

Carotid and vertebral artery dissections

Dissections of the carotid and vertebral arteries are a common cause of stroke in young adults. The diagnosis may be missed because the typical signs and symptoms are often delayed in onset, or easily confused with other more commonly encountered entities. Dissections of the carotid and vertebral arteries may occur spontaneously or may accompany mild to severe trauma. They present with a variety of findings including headache, neck and face pain, Horner's syndrome, or stroke.

Quadriplegia after lumbar disc surgery. A case report

STUDY DESIGN

Case report.

OBJECTIVE

To report a case of quadriplegia after surgery in the prone position for a herniated lumbar disc.

SUMMARY OF BACKGROUND DATA

Ischemia in the vascular territories of the vertebral arteries after back surgery in the prone position is rare. Degenerative changes of the cervical spine or decreased blood flow to the head with mechanical vessel obstruction during extreme neck movements, systemic hypotension, and thromboembolism have mostly been implicated in the pathogenesis.

METHODS

The case of a 33-year-old man undergoing surgery for an unilateral single level disc herniation at L4-L5 is presented. Within a few hours after surgery he developed quadriplegia and signs of occipital lobe dysfunction. He underwent magnetic resonance imaging investigation. Therapy included arterial blood pressure control, low molecular dextran, dexamethasone, bladder catheterization, and physiotherapy.

RESULTS

Magnetic resonance imaging demonstrated intramedullary ischemic changes in the cervical spinal cord and at the borderline between anterior and posterior circulation. Outcome after 2 years is fair regarding the severe initial deficit-the patient walks alone with a cane and bladder function is under control. He is employed in a sedentary job.

CONCLUSIONS

The authors believe that a temporary mechanical occlusion of a vertebral artery led to stasis, formation of thrombi, and subsequent embolism in the vertebrobasilar vascular territory. Extreme head rotation and neck extension is to be avoided in the prone position.

Spontaneous vertebral dissection: clinical, conventional angiographic, CT, and MR findings

OBJECTIVE

The purpose of this study was to determine if typical clinical and neuroradiologic patterns exist in patients with spontaneous vertebral artery (VA) dissection.

MATERIALS AND METHODS

The medical records and neuroradiologic examinations of 14 patients with spontaneous VA dissection were reviewed. The medical records were examined to exclude patients with a history of trauma and to record evidence of a nontraumatic precipitating event ("trivial trauma") and presence of possible risk factors such as hypertension. All patients underwent conventional angiography, 13 either CT or MRI (11 both CT and MRI), and 3 MRA. Conventional arteriograms were evaluated for dissection site, evidence of fibromuscular dysplasia, luminal stenosis or occlusion, and pseudoaneurysm formation. CT examinations for the presence of infarction or subarachnoid hemorrhage. MR examinations for the presence of infarction or arterial signal abnormality, and MR angiograms for abnormality of the arterial signal column.

RESULTS

Seven patients had precipitating events within 24 h of onset of symptoms that may have been causative of dissection and five had hypertension. At catheter angiography, two patients had dissections in two arteries (both VAs in one patient, VA and internal carotid artery in one patient), giving a total of 15 VAs with dissection. Dissection sites included V1 in four patients, V2 in one patient, V3 in three patients, V4 in six patients, and both V3 and V4 in one patient. Luminal stenosis was present in 13 VAs, occlusion in 2, pseudoaneurysm in 1, and evidence of fibromuscular dysplasia in 1. Posterior circulation infarcts were found on CT or MR in five patients. Subarachnoid hemorrhage was found on CT in two patients and by lumbar puncture alone in two patients. Abnormal periarterial signal on MRI was seen in three patients. MRA demonstrated absent VA signal in one patient, pseudoaneurysm in one, and a false-negative examination in one. Repeat catheter angiography of nine VAs at an interval ranging from 2 weeks to 1 year showed progression to occlusion in two arteries, unchanged appearance in 4, and angiographic resolution in three, which did not closely correlate with clinical outcome.

CONCLUSION

No preferred site of dissection along the course of the VA was found in this study. CT and MR examinations of the head are frequently normal in patients with VA dissections. No correlation between clinical outcome and findings at repeat angiography was demonstrated.

Critical neck position as an independent risk factor for posterior circulation stroke. A magnetic resonance angiographic analysis

The purpose of this study was to compare the effects of critical neck angulation (rotation and hyperextension) on vertebral artery perfusion in symptomatic and control populations and to determine whether this represents a risk factor for ischemic stroke. In a cross-sectional study, 64 symptomatic individuals with well-documented brainstem ischemic events (average age, 70.9 yr) and 37 control subjects (average age, 66.3 yr) were evaluated using a dynamic magnetic resonance angiography technique designed to mimic activities of daily living. Abnormalities of perfusion at the atlantoaxial and atlantooccipital junction and distal vertebral artery were recorded and scored independently by two neuroradiologists. Volume flow analysis was also recorded at the basilar artery, and distal and proximal vertebral arteries. Symptomatic subjects displayed a consistent pattern (56.4%) of contralateral hypoperfusion at the atlantoaxial and atlantooccipital junction and distal segments (grades 3 and 4) (p < 0.001). Unsuspected hypoplasia was noted in 13% of the symptomatic subjects with a right-sided preponderance (88%), suggesting developmental susceptibility. Occlusion was noted in all subjects with contralateral neck rotation. Postpositional ischemia was present (68%) and correlated with female gender (p < 0.001), severity of stenosis (p < 0.001), vascular risk factors (p < 0.001), and microinfarction on magnetic resonance images (p < 0.05). Flow analysis showed low basilar artery perfusion (< 25 ml/min) in 63.6%, and unsuspected steal with neck motion in 4 subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Rotational occlusion of the vertebral artery at the atlantoaxial joint: is it truly physiological?

We present a patient with vertebrobasilar insufficiency, with vertigo and horizontal nystagmus, induced by turning the head to the right. Angiography demonstrated transient occlusion of the left vertebral artery at the atlantoaxial joint during rotation of the head. The pathogenesis and angiographic findings are discussed.

Traumatic lesion of the extracranial vertebral artery--a note-worthy potentially lethal injury

The autopsy findings from routine neuropathological investigations of the cervical spine after any history of trauma emphasized the vulnerability of the extracranial vertebral arteries. In 21 cases with trauma to the head and neck, normal autopsy procedures did not succeed in revealing an obvious cause of death. Traumatic lesions of the spinal cord such as contusion or neurorrhexis were seen in 10 cases. In 15 cases we observed different degrees and stages of traumatic lesions of the extracranial vertebral arteries. Sudden death due to acute brain stem ischemia might be considered as an explanation in some of these cases. Six case reports with traumatic vertebral artery (VA) lesions after severe or minor extracranial trauma are presented. A review of the literature revealed that this vascular injury has only rarely been directly established by gross pathological examination. Possible consequences of blunt trauma to the head and neck include angiorrhexis, subintimal, intramural and perivascular hemorrhage leading to a partial narrowing of the injured vessel. These processes can be complicated by thrombosis. Unilateral VA obliteration may be an occult risk of acute brain stem ischemia when associated with contralateral reduction of the posterior circulation.

Medical problems in a sports medicine setting

Becoming reliant on a diagnostic repertoire limited to common sports-related problems can result in delayed diagnoses and potential disservice to the athlete. Remaining aware of other conditions that can mimic the common disorders and maintaining an index of suspicion for their occurrence can aid both the primary care physician and the specialist when challenged with a refractory or atypical presentation in an athlete. Reliance on a thorough history and physical examination, with judicious use of ancillary testing, is the cornerstone for any medical evaluation and no less important in this scenario. When equipped with such knowledge and skills, the physician caring for athletes can provide the best possible service, insuring not only the individuals' overall health, but also their safe and complete return to their chosen sport.

Vertebral artery dissection due to minor neck trauma

Vertebral artery dissection has been previously reported following minor head and neck trauma. Such activities as rapid head turning, tennis, yoga, and vigorous exercise have been implicated. We report a case of vertebral artery dissection following minor neck trauma suffered in a volleyball game. The anatomy of the vertebral artery, pathophysiology of dissection, and emergency department recognition and treatment of this disorder are discussed.

Endovascular treatment of vertebral artery dissections and pseudoaneurysms

Sixteen patients with dissecting aneurysms or pseudoaneurysms of the vertebral artery, 12 involving the intradural vertebral artery and four occurring in the extradural segment, were treated by endovascular occlusion of the dissection site. Patients with vertebral fistulas were excluded from this study. The dissection was caused by trauma in three patients (two iatrogenic) and in the remaining 13 no obvious etiology was disclosed. Nine patients presented with subarachnoid hemorrhage (SAH), two of whom had severe cardiac disturbances secondary to the bleed. The nontraumatic dissections occurred in seven women and six men, with a mean age on discovery of 48 years. Fifteen patients were treated with endovascular occlusion of the parent artery at or just proximal to the dissection site. One patient had occlusion of a traumatic pseudoaneurysm with preservation of the parent artery. Four patients required transluminal angioplasty because of severe vasospasm produced by the presenting hemorrhage, and all benefited from this procedure with improved arterial flow documented by transcranial Doppler ultrasonography and arteriography. In 15 patients angiography disclosed complete cure of the dissection. One patient with a long dissection of extracranial origin extending intracranially had proximal occlusion of the dissection site. Follow-up angiography demonstrated healing of the vertebral artery dissection but persistent filling of the artery above the balloons, which underscores the need for embolic occlusion near the dissection site. No hemorrhages recurred. One patient had a second SAH at the time of therapy which was immediately controlled with balloons and coils. This patient and one other had minor neurological worsening resulting from the procedure (mild Wallenberg syndrome in one and minor ataxia in the second). Symptomatic vertebral artery dissections involving the intradural and extradural segments can be effectively managed by endovascular techniques. Balloon test occlusion and transluminal angioplasty can be useful adjuncts in the management of this disease.

Recurrent ischemic events in two patients with painless vertebral artery dissection

BACKGROUND AND PURPOSE

Vertebral artery dissection causes endothelial changes and stenosis that may lead to recurrent ischemic neurological events. The diagnosis may not be obvious because the dissection may be painless and "spontaneous" (no obvious trauma). Magnetic resonance angiography has increasingly been used to screen patients for this disorder, but its accuracy has not yet been established.

CASE DESCRIPTION

Two patients were admitted with repeated transient ischemic attacks and strokes over 11 months and 1 month, respectively. Neither had a history of trauma, cervical pain, or headache. Magnetic resonance angiography failed to visualize vertebral artery dissections that were later revealed by conventional angiography. One patient's events were stopped by balloon occlusion of the vertebral artery proximal to the posterior inferior cerebellar artery branch.

CONCLUSIONS

Magnetic resonance angiography is not yet sensitive enough to always visualize vertebral artery dissection. Vertebral artery dissection is a life-threatening condition that requires aggressive evaluation and treatment.

Perforating injury of the neck and vertebral artery trauma

A 10-year-old schoolboy presented with a penetrating wound to the neck after a children's slide accident. A CT scan and endoscopy showed a traumatic oesophageal-cutaneous fistula. Neurologically the child deteriorated over a period of 34 hours and finally succumbed to a respiratory arrest. Post-mortem findings showed a hypoplastic right vertebral artery. In the left suboccipital triangle a venous clot had blocked the dominant artery thus leading to cerebellar and brainstem infarction. This extraluminal compression leading to obstruction of an otherwise non traumatized vertebral artery is unique in the literature.

Cerebellar infarction in the young

BACKGROUND AND PURPOSE

Ischemic cerebrovascular disease in children and young adults usually affects the anterior circulation.

SUMMARY OF REPORT

We describe two cases of cerebellar infarction in the territory of vertebral artery supply, associated with physical exertion, in a young adult and in a child. Review of 31 previous cases of cerebellar infarction occurring in the first 2 decades of life demonstrated a mostly obscure causation; where a likely cause was found, trauma was most frequent. In 12 of the 31 patients, a vertebral artery (usually the left) was occluded. Patients were sometimes predisposed to such occlusions by subluxation between the first and second cervical vertebrae, allowing abnormal neck movements that can cause arterial injury and thromboembolism. Some of these cerebellar infarcts, like those of our patients, have followed physical exertion.

CONCLUSIONS

Cerebellar infarction can be life-threatening, but half of the patients, including ours, have had complete or near-complete recovery.

Increased blood-brain barrier permeability following acute short-term swimming exercise in conscious normotensive young rats

The status of the blood-brain barrier (BBB) was examined following short-term forced swimming (FS) exercise in younger rats (age 8-9 wks, 80-90 g). Subjection of animals to continuous FS for 30 min duration increased the permeability of the BBB to Evans blue albumin (EBA) and 131I-sodium in 5 and 8 brain regions, respectively. Extravasation of the tracers was markedly pronounced in the cerebellum followed by the cerebral cortex. EBA staining was confined mainly to the posterior cingulate cortex, parietal and occipital cortices, whole cerebellar vermis and the mediolateral cerebellar cortices as well as the dorsal surface of the hippocampus. In addition to the above brain regions. BBB permeability to 131I-sodium extended to the caudate nucleus, thalamus and hypothalamus. At this time period, the serotonin (5-hydroxytryptamine, 5-HT) content showed a profound increase in plasma and brain of about 150% and 250% respectively from the control value. Pretreatment with p-CPA (p-chlorophenylalanine, a serotonin synthesis inhibitor) prevented both the increased permeability of the BBB and the rise in plasma and brain 5-HT level. However, prior treatment with cyproheptadine (a 5-HT2 receptor antagonist) prevented the increased permeability alone. The 5-HT level continued to remain high. These results suggest that short-term FS increases BBB permeability in specific brain regions. This increased permeability appears to be mediated through serotonin via 5-HT2 receptors.

Decompression of the vertebral artery for bow-hunter's stroke. Case report

A case of cerebellar infarction induced by repeated neck rotation ("bow-hunter's stroke") is reported. The most likely mechanism is that repeated rotational neck movement brings about thickening of the atlanto-occipital membrane, fixing the vertebral artery in the vascular groove of the atlas. The vertebral artery is thus pinched at the time of neck rotation, leading to thrombus formation. Embolization results in cerebellar infarction. Surgical decompression of the vertebral artery at the level of the atlas in this case relieved the symptoms, and postoperative angiography demonstrated good flow within the vertebral artery even when the neck was rotated. It was not necessary to restrict the patient's neck movement postoperatively.

Pseudoaneurysm of the extracranial vertebral artery. Case report

The unusual association of a giant extracranial vertebral artery pseudoaneurysm, intracranial aneurysms, and extracranial carotid occlusion in a woman with neurofibromatosis is presented. Pain as a result of expansion of the mass in the soft tissue of the neck led to her seeking evaluation. Herniation of the mass intraspinally between the occiput and C-1 resulted in myelopathy. Following balloon occlusion of the vertebral artery, the mass and associated symptoms resolved without the need for direct resection. The salient features of these unusually associated problems are discussed.

Extracranial vertebral artery dissections: a review of 13 cases

Clinical and radiologic findings in 13 patients (11 women, 2 men) with extracranial vertebral artery dissection are reported. Dissection was spontaneous in 8 patients, occurred after neck manipulation in 2 and after a potential minor injury to the neck in 3. Six had a history of common migraine, 4 were using oral contraceptives at the time of dissection, and 3 had fibromuscular dysplasia. Dissection was bilateral in 8 patients and associated with carotid dissection in 3. It usually presented with neck or occipital pain preceding basilar ischemic symptoms by a few minutes to 1 month. In 3 patients, transient ischemic attacks were the only manifestation of basilar ischemia, and in 1 patient there was no symptom of basilar ischemia despite bilateral vertebral dissection. In 19 of the 21 dissected vertebral arteries, the angiographic appearance was that of an irregular stenosis, which was associated in 6 arteries with pseudoaneurysmal formation. In 2 patients, 1 vertebral artery was occluded but the contralateral artery showed the typical irregular stenosis. The dissection involved only the third segment in 33%, only the second segment in 24%, and 2 or more segments in 38%. Eleven patients were treated with anticoagulants and 2 with aspirin; 11 recovered without sequelae and 2 had residual deficit. No recurrence was observed (mean follow-up 34 months). At control angiography (n = 12) or ultrasonic study (n = 1), 63% of dissected vertebral arteries had returned to normal, 26% showed marked improvement, and 11% were occluded. Our patient characteristics are compared with those of previously published cases. The validity of the distinction between spontaneous dissection and dissection associated with minor trauma is discussed.

Bilateral spontaneous dissection of extracranial vertebral arteries

A previously healthy 35-year-old man suddenly developed vertebrobasilar ischaemia while playing tennis. Cerebral arteriography revealed a dissecting aneurysm of the cervical portion of both vertebral arteries. The neurological deficit and the angiographic features resolved with anticoagulant treatment alone. Only 15 patients with non-traumatic extracranial vertebral artery dissection have been previously reported. It is necessary to recognize the condition very quickly, because the authors consider that anticoagulation is required as an emergency.