Spontaneous bilateral vertebral artery dissections: case report and literature review

Ominous Causes of Headache

PURPOSE OF REVIEW

While primary headaches like migraines or cluster headaches are prevalent and often debilitating, it's the secondary headaches-those resulting from underlying pathologies-that can be particularly ominous. This article delves into the sinister causes of headaches, underscoring the importance of a meticulous clinical approach, especially when presented with red flags.

RECENT FINDINGS

Headaches, one of the most common complaints in clinical practice, span a spectrum from benign tension-type episodes to harbingers of life-threatening conditions. For the seasoned physician, differentiating between these extremes is paramount. Headache etiologies covered in this article will include subarachnoid hemorrhage (SAH), cervical artery dissection, cerebral venous thrombosis, meningitis, obstructive hydrocephalus, and brain tumor.

Postpartum Acute Basilar Artery Occlusion Secondary to Vertebral Artery Dissection. Case Report and Literature Review

Female patients in the peripartum and postpartum periods have an increased risk of stroke than nonpregnant women. Cerebrovascular complications of pregnancy represent a significant cause of maternal mortality and morbidity and are potentially disabling. Acute basilar artery occlusion secondary to spontaneous vertebral artery dissection in the postpartum period is an infrequent entity and a major diagnostic and treatment challenge. In the present case, a 37-year-old female patient, eight weeks after caesarean delivery, presented with a history of sudden cervical pain, followed by headache and dizziness. Some hours later, she was found unconscious by her family and was transferred to the emergency department, where a neurological status assessment suggested vertebrobasilar stroke. The imagistic workup revealed right vertebral artery dissection and basilar artery occlusion without constituted ischemic lesions. The patient underwent endovascular intervention with dilation of the narrowed vertebral artery and stent retriever basilar artery thrombectomy, with a favourable clinical outcome. This report first presents the details of this case and the relevant literature data on postpartum arterial dissections and the subsequent ischemic complications and available treatment options.

Bilateral Vertebral Artery Dissection: A Case Report with Literature Review

Vertebral artery dissection (VAD) is a rare cause of ischemic stroke in young patients. The largely nonspecific symptoms and delayed presentation pose a serious diagnostic challenge. Medical management with either anticoagulation or antiplatelet therapy is recommended, but there are no reports of successful dual therapy. We report a case of spontaneous bilateral vertebral artery dissections (VADs) treated with both anticoagulation and antiplatelet therapy and a literature review on clinical presentation and the current medical and surgical management options. A 37-year-old healthy female presented to the emergency department with worsening neck pain and headache for two weeks despite over-the-counter medication, block therapy, yoga, and deep tissue neck massage. She denied any trauma but admitted to multiple roller coaster rides over the past few months. CT angiography was concerning for VADs, and MRI brain revealed multiple strokes in the left posterior inferior cerebellar artery (PICA) territory. Cerebral arteriography confirmed the diagnosis of VADs. The patient was initiated on warfarin, along with atorvastatin and aspirin. She was discharged home with no complications and followed up with neurology as an outpatient. MR angiography after three months revealed complete resolution of the dissection. The patient did not report any bleeding complications from dual therapy.

Postpartum vertebral artery dissection

We report a case of a right vertebral artery dissection in a 35-year-old woman, 3 weeks post partum, with manifestations of vertebrobasilar disease. She was 3 weeks out from the uneventful delivery of her fourth child, with presentation of acute neurological symptoms, predominantly intractable vertigo. Vertigo can have many non-specific generalised symptoms and clinical findings. Postpartum women have a lengthy list of possible aetiologies of vertigo not limited to our initially suspected preeclampsia, dural venous thrombosis and vertebral dissection.

Subarachnoid haemorrhage with bilateral intracranial vertebral artery dissecting aneurysms treated by staged endovascular stenting

Bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid haemorrhage (SAH) are an exceedingly rare and deadly clinical dilemma. Prompt intervention in the case of unilateral VADAs is advocated to prevent rebleed; however, in the case of bilateral VADAs, the optimal therapeutic intervention is unclear. We describe the case of a patient presenting with SAH with bilateral VADAs treated by staged endovascular stenting. This led to resolution of the aneurysms with patency of both vertebral arteries. Stent-based therapy of the symptomatic aneurysm followed by staged stenting of the asymptomatic, contralateral aneurysm appears to be a viable treatment option. This method allows the ability to preserve flow in both vertebral arteries with minimal changes in flow characteristics that may threaten the contralateral, asymptomatic VADA, and appears to be the ideal treatment in these rare cases.

Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

BACKGROUND:

Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.

OBJECTIVE:

To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.

METHODS:

We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.

RESULTS:

For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).

CONCLUSION:

Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

Diagnosis of ischemic stroke

Early stroke management, and early initiation of secondary stroke prevention, may improve outcomes in patients with acute ischemic stroke. However, <10% of patients with acute ischemic stroke arrive at the receiving hospital within 3 hours of symptom onset. Factors such as poor public awareness of symptoms, lack of rapid detection by emergency medical services (EMS), poor coordination between EMS and the hospital emergency department, or delay of diagnosis on arrival at the emergency department are all contributing factors in the failure to provide prompt diagnosis and treatment of acute ischemic stroke. This article focuses on the critical steps in diagnosing ischemic stroke, starting at the initial patient evaluation by emergency personnel. Stroke mimics and different imaging techniques that may be used in the differential diagnosis and evaluation of acute ischemic stroke are also discussed.

Spontaneous bilateral carotid and vertebral artery dissections associated with multiple disparate intracranial aneurysms, subarachnoid hemorrhage and spontaneous resolution. Case report and literature review

Spontaneous bilateral carotid and vertebral artery dissections (CADs and VADs) are rare. A 29-year-old female presented with a collapse, 4 weeks after a sudden onset of severe neck and shoulder pain. CT scan revealed diffuse subarachnoid hemorrhage (SAH) and early hydrocephalus. Angiography revealed bilateral CADs and VADs, along with multiple fusiform and saccular aneurysms. Systemic vessels - including the renal arteries - were normal, and no risk factors or underlying vasculopathy were apparent. The presumed source of SAH (a posterior cerebral artery aneurysm) was successfully clipped. Each dissection, by contrast, was managed conservatively with heparin prophylaxis; and spontaneous CAD and VAD resolution occurred within 6 months. We present a unique case of four-vessel dissection associated with multiple disparate saccular and fusiform aneurysms. We suspect that underlying vasculopathy - perhaps novel - may become apparent with time.

Spontaneous Dissection of the Extracranial Vertebral Artery: Indications and Long-Term Outcome of Surgical Treatment

Spontaneous dissection of the vertebral artery (VA) is usually managed medically. The objective of this report was to describe 10 patients treated surgically for spontaneous dissection of the VA. Seven men and three women with a mean age of 52.5 +/- 11.3 years were treated between December 1978 and January 2001. In eight cases the presenting symptom was neck pain. Transient ischemic attack or completed stroke in the vertebrobasilar distribution followed in nine cases. In the remaining case, symptoms resulted from irritation of the superior roots of the brachial plexus. Dissection was located in one segment of the VA in seven cases and two contiguous segments in three cases. Lesions involved aneurysm in seven cases, tight stenosis in two, and occlusion in one. The decision to perform surgery was made because of either continued symptoms despite maximal anticoagulation therapy or the presence of an aneurysm causing recurrent thromboembolism or threatening rupture. In eight cases the revascularization procedure consisted of bypass from the carotid artery to the distal VA. In the remaining two cases revascularization was achieved by transposition of the VA directly onto the common or internal carotid artery. Postoperative recovery was uneventful in all cases. No further neurological events were observed in any patient at a mean follow-up of 96.9 +/- 66 months (range, 12-216 months). Long-term resolution of vertebrobasilar symptoms was achieved in all cases, including one patient whose bypass occluded at 6 months. From these results we conclude that surgical treatment is the method of choice for spontaneous dissection of the extracranial VA associated with continued vertebrobasilar symptoms despite maximal medical therapy or with an expanding aneurysm. The most useful technique is bypass to the distal VA. Morbidity is low and long-term outcome is excellent.

Spontaneous resolution of nontraumatic bilateral intracranial vertebral artery dissections

A 49-year-old man presented with nontraumatic bilateral intracranial vertebral artery dissections without subarachnoid hemorrhage manifesting as Wallenberg's syndrome on the right. Magnetic resonance imaging revealed an infarct in the right dorsolateral aspect of the medulla oblongata. Antiplatelet therapy was administered. Vertebral angiography performed on the 9th hospital day (Day 9) revealed pearl and string sign in the right vertebral artery and narrowing of the left vertebral artery. Second angiography performed on Day 25 showed no change, but third angiography performed on Day 74 revealed spontaneous resolution of the bilateral vertebral artery dissections. Magnetic resonance angiography performed on Day 250 showed no evidence of dissection. However, magnetic resonance imaging revealed a small infarct in the splenium of the corpus callosum. Spontaneous resolution of stenotic dissections of the bilateral vertebral arteries is extremely unusual. Serial cerebral angiography and magnetic resonance angiography are very important for monitoring the time course of changes in patients with vertebral artery dissections.

Trampolines, children, and strokes

Strokes in children related to sports injuries are rare, but pediatric trampoline injuries are dramatically increasing. Minor trauma to the vulnerable extracranial vertebral arteries as they travel superficially through the dorsum of the neck can begin a cascade of events that results in arterial dissection, thrombus formation, and embolization with cerebral infarction. We present the case of an 11-yr-old boy who developed left vertebral artery dissection subsequent to a trampoline injury.

Stroke in young adults and children

Data from studies of 337 children and 1606 young adults are summarized to identify the major causes of stroke in these age groups. In children under 15 years of age, stroke occurs in patients with congenital heart disease, nonatherosclerotic vasculopathies, infection, and hematologic defects like sickle cell disease. In patients 15 to 35 years of age, dissection, cardioembolism, nonatheroslerotic vasculopathies, and prothrombotic states cause a significant percentage of strokes. In adults over 35 years of age, traditional atherosclerotic risk factors predominate. Lifestyle choices (e.g., cigarette smoking, alcohol consumption, and illicit drug use) can significantly increase the rate of stroke among young adults in a community. Limited access to healthcare may increase the role of infectious disease and peripartum complications.