Prolonged interval between vertebral artery dissection and ischemic stroke

The quality of reports on cervical arterial dissection following cervical spinal manipulation

BACKGROUND

Cervical artery dissection (CAD) and stroke are serious harms that are sometimes associated with cervical spinal manipulation therapy (cSMT). Because of the relative rarity of these adverse events, studying them prospectively is challenging. As a result, systematic review of reports describing these events offers an important opportunity to better understand the relation between adverse events and cSMT. Of note, the quality of the case report literature in this area has not yet been assessed.

PURPOSE

1) To systematically collect and synthesize available reports of CAD that have been associated with cSMT in the literature and 2) assess the quality of these reports.

METHODS

A systematic review of the literature was conducted using several databases. All clinical study designs involving CADs associated with cSMT were eligible for inclusion. Included studies were screened by two independent reviewers for the presence/absence of 11 factors considered to be important in understanding the relation between CAD and cSMT.

RESULTS

Overall, 43 articles reported 901 cases of CAD and 707 incidents of stroke reported to be associated with cSMT. The most common type of stroke reported was ischemic stroke (92%). Time-to-onset of symptoms was reported most frequently (95%). No single case included all 11 factors.

CONCLUSIONS

This study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke. Improving the quality, completeness, and consistency of reporting adverse events may improve our understanding of this important relation.

Vertebral artery dissection associated with viral meningitis

Background

Vertebral artery dissection (VAD) is often associated with trauma or occurs spontaneously, inevitably causing some neurological deficits. Even though acute infection can be related to the development of spontaneous VAD (sVAD), VAD associated with viral meningitis has never been reported in the literature.

Case presentation

A 42-year-old man with fever, sore throat, and runny nose developed sudden onset of occipital headache, vertigo, transient confusion, diplopia, and ataxia. Brain stem encephalitis was diagnosed initially because the cerebrospinal fluid (CSF) study showed inflammatory changes. However, subsequent diffusion-weighted (DWI) magnetic resonance imaging of his brain demonstrated left lateral medullary infarction, and the digital subtraction angiography (DSA) confirmed VAD involving left V4 segment of the artery. Consequently, the patient was diagnosed as VAD accompanied by viral meningitis.

Conclusion

This case suggests that viral meningitis might lead to inflammatory injury of the vertebral arterial wall, even sVAD with multiple neurological symptoms.

Multidetector computed tomography angiography: Application in vertebral artery dissection

BACKGROUND AND PURPOSE

Multidetector computed tomography angiography (MDCTA) is a minimally invasive radiological technique providing high-resolution images of the arterial wall and angiographic images of the lumen. We studied the radiological features of vertebral artery dissection (VAD) in a consecutive series of patients investigated for acute stroke and subarachnoid hemorrhage (SAH) in order to confirm and define the diagnostic features of VAD on MDCTA.

PATIENTS AND METHODS

Review of patients identified prospectively over a 4-year period with VAD assessed by MDCTA was conducted. Radiological features of VAD on MDCTA were reanalyzed utilising previously reported criteria for VAD.

RESULTS

Thirty-five patients (25 males, mean age 49.6 years) with a total of 45 dissected vertebral arteries were reviewed. MDCTA features of VAD included increased wall thickness in 44/45 (97.7%) arteries and increased total vessel diameter in 42/45 arteries (93.3%). All dissected arteries had either lumen stenosis (21/45) or associated segmental occlusion (24/45). An intimal flap was detected in 6/45 (13.3 %) vessels. Twenty-five patients had follow-up imaging, 14/32 vessels returned to normal, 4 showed improvement in stenosis but did not return to normal and 14 demonstrated no change. The majority of non-occluded vessels became normal or displayed improved patency. Only 4/17 occluded arteries demonstrated re-establishment of flow. No adverse effects were recorded.

CONCLUSIONS

MDCTA is a safe and reliable technique for the diagnosis of VAD. Increased wall thickness (97.7%) and increased vessel wall diameter (93.3%) were the most frequently observed features.

Vertebral artery dissection after direct laryngoscopy: case report and literature review

OBJECTIVE

We report a case of vertebral artery dissection following direct laryngoscopy, and we provide an update on current knowledge regarding this condition and its relationship to movements of the neck.

METHOD

A case report and review of the world literature are presented.

RESULTS

Vertebral artery dissection is an uncommon event leading to stroke. It has been associated with many risk factors, particularly extreme movement of the cervical spine. The pathogenesis of the condition and the true aetiological significance of neck movement are not known.

CONCLUSION

To our knowledge, we present the first case of vertebral artery dissection following direct laryngoscopy. We highlight the need for caution when considering neck pain in patients after direct laryngoscopy.

Vertebral artery dissection presenting as acute cerebrovascular accident

Vertebral artery dissection is a lesser known but significant cause of stroke in young, healthy people. Given its infrequency of presentation, emergency physicians may not always recognize its common symptoms--vertigo, diplopia, ataxia, and dysarthria--as a stroke. In this case report, we describe a patient with vertebral artery dissection presenting with atypical symptoms and discuss the epidemiology, risk factors, presentation, clinical examination findings, imaging modalities, and treatment of this disease.

Blunt cervical spine trauma as a cause of spinal cord injury and delayed cortical blindness

STUDY DESIGN

Case report.

OBJECTIVE

To present and discuss the case of a patient who sustained a significant flexion compression injury of the cervical spine with resulting tetraplegia and development of cortical blindness.

SETTING

National Spinal Injuries Unit and Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland, UK.

METHODS

Clinical and radiological follow-up of the patient.

RESULTS

Cortical blindness resulted from vertebral artery dissection associated with blunt cervical spine trauma. The patient is registered blind and is ventilator dependent.

CONCLUSION

The potential complications of blunt vertebral artery injury remain poorly recognised. Screening is routinely not performed. Advances in noninvasive radiological techniques may result in recognition of asymptomatic disease and the potential for therapeutic intervention.

Endovascular management of intracranial vertebral artery dissecting aneurysms

Object

Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and dramatic neurological injury. The authors reviewed the management of 23 cases in an effort to evaluate treatment efficacy and outcomes.

Methods

The records of 23 patients who underwent endovascular treatment were reviewed to determine symptoms, type of therapy, complications, and clinical outcomes. All patients were evaluated using records kept in a prospectively maintained database.

Ten men and 13 women (age range 35–72 years; mean age 49 years) were treated over an 8-year period. Twelve patients presented with poor-grade SAH, five with good-grade SAH, three with headache, and two with stroke. The other patient's aneurysm was discovered incidentally. Treatment included coil occlusion of the artery at the aneurysm in 21 patients and stent-assisted coil placement in two. Parent artery sacrifice was successful in all cases, whereas both patients treated with stent-assisted coil insertion suffered recurrences. No patient sustained permanent complications as a result of treatment. Two patients died due to the severity of their original SAH. Findings were normal in 14 patients on follow-up review (including five of the 12 presenting with poor-grade SAH), five had fixed neurological deficits but were able to care for themselves, and one was permanently disabled.

Conclusions

Despite their often aggressive neurological presentation, intracranial VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery. Even patients presenting in poor neurological condition may improve dramatically.