Working Diagnosis:
Vertebral artery dissection

Treatment:
Patient was sent to the ER based on the imaging finding and was evaluated by neurology. As MRI brain showed no infarct at that time and her National Institutes of Health Stroke Scale score was 0 without exam deficits, they recommended daily aspirin 81 mg until outpatient follow up. She was restricted from activities that would significantly increase blood pressure, such as weightlifting and underwater diving.

Outcome:
CTA head/neck ~2 months post-injury showed resolution of previous vertebral artery filling defect. At a 3 month follow up with neurology, she had returned to her neurologic baseline and was cleared for all normal work duties, including her previous role as a lifeguard. Neurology recommended lifelong antiplatelet use and advised avoiding high-risk contact sports and chiropractic manipulation.

Author's Comments:
Vertebral artery dissections (VAD) most commonly occur in the setting of trauma, often mild in nature. Even seemingly benign activities such as amusement park rides, swimming, or high-ropes courses hold potential for arterial dissection. Initial symptoms can include ipsilateral head/neck pain (60-90% of cases), pulsatile tinnitus, Horner syndrome, cranial neuropathies (most commonly CN XII and IX), and dizziness/vertigo. Clinicians should have a high degree of suspicion for arterial dissection in patients with acute head or neck pain and/or other neurologic symptoms in the setting of trauma or sporting activity. Diagnosis is confirmed with MRI brain and neck and MRA head/neck. Patients with VAD will want to avoid significant blood pressure elevating activities, neck manipulation, or any activities that predispose to sudden head motions (roller coasters) for at least 3 months, and are typically on anticoagulation/antiplatelet medication for at least 3 months. Case Photo #5

Editor's Comments:
The incidence of Vertebral artery dissections (VAD) in the general population is 1.3-1.5 per 1000,000 with only a small portion occurring during sports participation. However, given the potential catastrophic consequences, risk reduction in sports is necessary through sports specific rules, personal protective equipment, and education to reduce trauma to the head and neck. The mechanism of injury is not clear but is likely a combination of factors. A small trauma may cause large injury in a predisposed individual whereas another may require extreme force. In particular, impact to the area behind and below the ear as well as extreme neck movement are most associated with fatalities. Early recognition of symptoms and imaging are important factors in successful treatment.

References:
Engelter ST, et al. Cervical Artery Dissection: Trauma and Other Potential Mechanical Trigger Events. Neurology. 2013;80(21):1950-57.

Lee VH, et al. Incidence and Outcome of Cervical Artery Dissection: A Population-Based Study. Neurology. 2006;67(10):1809-12.

Cadena R. Cervical Artery Dissection: Early Recognition and Stroke Prevention. Emerg Med Pract. 2016;18(7):1-24.

Saw, A.E., McIntosh, A.S., Kountouris, A. et al. Vertebral Artery Dissection in Sport: A Systematic Review. Sports Med 49, 553-564 (2019). https://doi-org.proxy.lib.uiowa.edu/10.1007/s40279-019-01066-0

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