Right vertebral artery dissection with subtotal occlusion secondary to trauma
The patient was started on anticoagulation with heparin drip followed by Lovenox. He was then bridged to Coumadin. Activity was limited to walking. Plan was made for repeat imaging at 3 months.
Repeat imaging at 3 months showed resolution of his vertebral defect. At that time, Coumadin was discontinued. His activity restriction was lifted, however, the patient was discouraged from returning to contact sports.
Currently, there are no evidenced based trials regarding anticoagulation vs antiplatelet therapy, length of therapy or recommendations on return to play.
Vertebral and carotid artery dissections are a rare cause of neck pain, with an incidence of 2.6 per 100,000 per year. It is often misdiagnosed as a neck strain, which can lead to further complications due to a delay in treatment. Vertebral dissections should be considered if an athlete presents with traumatic neck pain, especially if he has such associated symptoms as headache, visual changes, or dizziness. Physical exam may be largely unremarkable, however patients can present with focal neurologic deficits, such as cranial nerve palsies, Horner’s syndrome, and ataxic gait. Diagnosis can be made with MRI or MRA, CT angiography, or conventional angiography. Once the diagnosis is made, anticoagulation or antiplatelet therapy should be initiated to prevent further thrombotic or embolic complications. Unfortunately, there is not much data available with regards to the duration of therapy or indications for return to play.
Goyal. The diagnosis and management of supraaortic arterial dissections. Current Opinion in Neurology. 2009.
Norris. Management of cervical arterial dissection. International Journal of Stroke. May 2006.
Schievink. Spontaneous dissection of the carotid and vertebral arteries. New Eng J Med. 2001.
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