Presentation
Sudden onset vertigo with emesis since about 5 hours.
Patient Data
CT performed some 5 hours after symptom onset shows reduced contrast in the left vertebral artery compared to the right side, suspicious for at least partial thrombotic occlusion, starting in the V2 segment and almost up to the basilar artery, with frank arterial wall dissection at the level of C2-C4. The non-contrast CCT performed just before the CTA does not show obvious infarction or intracranial hemorrhage.
MRI performed some 9 hours after symptom onset shows multiple, embolic, partially hemorrhagic cerebellar and brainstem infarctions bilaterally in the vascular territories of the superior cerebellar artery, the posterior inferior cerebellar artery and basilar artery.
Digital subtraction angiography (DSA) performed some 10 hours after symptom onset shows proximal occlusion of the left vertebral artery with minimal collateralisation. Subsequently a stent was placed at V1-V2 level (not shown).
Case Discussion
Vertebral artery dissection is a rare cause of stroke in the general population. It represents one of the more common causes of stroke in younger patients. Often neck distortion such as blunt trauma, bending of the neck, or chiropractic manipulation causes the dissection; however, spontaneous dissections have also been reported. Signs and symptoms of the dissection itself can be vague (neck pain, headaches).
Dissection of the vertebral artery may ultimately lead to a posterior circulation stroke, often several days following the acute dissection, patients usually presenting with sudden onset vertigo, emesis, ataxia, dysarthria and/or other motor deficit symptoms.
In the case of this 60 year old patient, the ultimate cause for the dissection could not be established. First-line CT demonstrated the left side vertebral artery dissection, while MRI done a few hours later showed bilateral infarctions of the posterior circulation. At the time angiography was performed, the left vertebral artery showed almost complete occlusion starting at the V1 segment. The patient was treated with a stent at this site and went one to receive ergotherapy and logopedic therapy.