A preschool-age child with first-time seizure and ataxia

We present a case of a 4-year-old previously healthy child who had a possible first-time seizure at home, and upon a second Emergency Department evaluation was found to have gross cerebellar ataxia suggestive of acute stroke. Initial computed tomography scan and metabolic work-up were unrevealing. Subsequent neuroimaging demonstrated stroke in the left medulla and cerebellum secondary to left vertebral artery dissection. Cervical artery dissection may cause up to 20% of strokes in childhood and adolescence. Unlike typical adult presentations, antecedent or concurrent head and neck pain occurs less often in pediatric dissections. Symptoms of posterior circulation ischemia resulting from vertebral artery dissection may include vertigo, vomiting, ataxia, dysarthria, and seizure. Willingness to utilize newer, non-invasive imaging modalities may lead to earlier recognition of cervical artery dissection when patients have prodromal symptoms or episodes of transient ischemia. Vertebral artery dissection should be included in the differential diagnosis when evaluating children with first time seizure, headache, or neck pain.     

Imaging in the diagnosis and follow-up evaluation of vertebral artery dissection.

The purpose of this report is to discuss the value of ultrasonographic examination in the diagnosis and follow-up evaluation of vertebral artery dissection. We collected data on 8 patients with 11 pathologic vessels: 9 were affected intracranially and 6 were affected extracranially. Four vessels were affected in both intracranial and extracranial segments. Extracranial color-flow duplex sonography could detect abnormalities in every extracranial vertebral artery dissection. Most abnormal findings were non-specific, including severely reduced flow, absence of flow, and absence of diastolic flow. A specific finding (intramural hematoma) was noted in one artery. Abnormal transcranial color-coded sonographic findings included absence of flow, reduced velocity and reversed flow direction. Three intracranial dissecting arteries showed normal findings on transcranial color-coded sonography. Ultrasonographic follow-up study revealed evidence of improvement; this was noted almost exclusively in the extracranial segments of the vertebral artery but infrequently in the intracranial segment. Extracranial color-flow duplex sonography is sensitive in the detection of extracranial vertebral artery dissection, both in initial diagnosis and in follow-up evaluation.     

Lesson of the month (1). Homonymous left hemianopia secondary to traumatic extracranial vertebral artery dissection

This lesson reports the case of a 32-year-old female presenting with left-sided homonymous hemianopia after a road traffic accident. A diagnosis of vertebral artery dissection (VAD) was missed at presentation after an initial computed tomography head scan was normal. Later, VAD was confirmed on neck magnetic resonance imaging. VAD is an uncommon cause of stroke in the young and, to date, there are no current emergency guidelines available for the management of patients with the condition.     

Is it time to stop functional pre-manipulation testing of the cervical spine?

The combined extended and rotated cervical spine position has been postulated to affect vertebral artery blood flow by primarily causing a narrowing of the vessel lumen, usually within the artery contralateral to the side of head rotation. The production of brainstem symptoms during the manoeuvre has generally been considered to be a positive test result. As a consequence, functional pre-manipulation testing of the cervical spine has been part of clinical screening undertaken by chiropractors and other manual practitioners to rule out the risk of possible injury to the vertebral artery. To date, these testing procedures are taught to students and carried out in daily clinical practice, despite the considerable controversy that exists about their validity. This paper considers and discusses the usefulness of functional pre-manipulation testing for clinical scenarios, involving dissection, spasm or stenosis of the vertebral artery, and makes the following recommendations: (1) Practitioners must assess the patient thoroughly, through careful history taking and physical examination, for the possibility of vertebral artery dissection. It is important to note that vertebral artery dissection (VAD) may present as pain only, and may not be associated with symptoms and signs of brainstem ischaemia. (2) If there is a strong likelihood of VAD, provocative pre-manipulation tests should not be performed, and the patient must be referred appropriately. (3) In the patient presenting with symptoms of brainstem ischaemia due to non-dissection stenotic vertebral artery pathologies, provocative testing is very unlikely to provide any useful additional diagnostic information. (4) In the patient with unapparent vertebral artery pathology, where spinal manipulative therapy (SMT) is considered as the treatment of choice, provocative testing is very unlikely to provide any useful information in assessing the probability of manipulation induced vertebral artery injury.     

Dissection of the vertebral arteries: Case report and discussion

Vertebral artery dissection is an unusual condition with potentially protean neurologic presentations. It may occur spontaneously or follow apparently minor neck trauma. Ischemic symptoms related to the posterior circulation ensue and may be due to obstruction or embolization. The ensuing stroke is ischemic, although subarachnoid hemorrhage may be a complication as well. A case of vertebral artery dissection in a young woman who developed symptoms approximately one week after mild neck injury is reported, and the topic is reviewed.     

Carotid and Vertebral Dissection Imaging

Carotid or vertebral artery dissection is the result of a tear in the vessel lining wherein the intima separates the media. This creates a false or pseudo lumen, often accompanied by hemorrhage into the arterial wall. Dissection of these craniocervical vessels often manifests with pain alone but, if untreated, may result in severe neurologic compromise. The causes of dissection are multifactorial, including spontaneous, iatrogenic, and traumatic insults. Regardless of etiology, treatment consists primarily of anticoagulation, whereas endovascular therapy is reserved for cases with persistent thrombus or flow limitation. Given the high risk of neurological compromise or death and the propensity of these injuries to occur in younger individuals, early diagnosis of carotid and vertebral artery dissections is critical. Although angiography remains the criterion standard for diagnosis, advances in noninvasive imaging have placed magnetic resonance and computed tomography at the forefront of diagnosis. This article examines the current imaging modalities used to diagnose this under-recognized entity.     

Emergency Bedside Ultrasound Diagnosis of Superior Mesenteric Artery Dissection Complicating Acute Aortic Dissection

Background

A timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection.

Objective

Our aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies.

Case Report

We report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia.

Conclusion

Superior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.     

Review article: Non-penetrating neck artery dissection in young adults: Not to be missed!

Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front-line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi-disciplinary team management of this condition. In general, guideline-based recommendation for the management of neck artery dissection involving an intimal flap is by anti-platelet therapy while treatment of neck artery dissection that results in a pseudo-aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.     

Headache and Neck Pain: The Warning Symptoms of Vertebral Artery Dissection

SYNOPSIS
The clinical features of headache and neck pain in 14 patients with extracranial vertebral artery dissection proven by angiography or magnetic resonance imaging are reported. Pain was always located on the side of the dissected vertebral artery. Whereas eleven patients had head and posterior neck pain, the others had either only posterior neck pain, no change of a chronic pre-existing headache or no pain at all. Pain started suddenly, was of sharp quality and severe intensity, different from any previously experienced headache. Following acute onset, the time course of pain was monophasic with gradual remission of a persistent headache lasting one to three weeks. A delay between onset of head or posterior neck pain and onset of neurologic dysfunction was noted in 12 patients and was less than one day and between one day and three weeks in six each. Report of this distinct type of pain, although non-specific as an isolated symptom, should raise suspicion of an underlying vertebral artery dissection. Early confirmation of this diagnosis and subsequent anticoagulation if dissection does not extend intracranially may help prevent vertebro-basilar ischemic deficits.     

Uncommon ultrasound findings in traumatic extracranial vertebral artery dissection.

We report a case of internal carotid artery dissection (ICAD) associated with contralateral vertebral artery dissection (VAD). The interest of this case is to discuss an unusual Doppler pattern manifesting by a spectrum of an alternating vertebral artery flow suggesting a hemodynamic contribution from the contralateral vertebral artery (VA) and a clear depiction of both antegrade (red) and retrograde (blue) flow within the false and true lumen of the VAD by color Duplex flow imaging.     

The Use of Tissue Plasminogen Activator in the Treatment of Wallenberg Syndrome Caused by Vertebral Artery Dissection

Background

Acute cerebrovascular accident (CVA) is a devastating cause of patient morbidity and mortality. Up to 10% of acute CVAs in young patients are caused by dissection of the vertebral or carotid artery. Wallenberg syndrome results from a CVA in the vertebral or posterior inferior artery of the cerebellum and manifests as various degrees of cerebellar dysfunction. The administration of a thrombolytic medication has been recommended in the treatment of patients with stroke caused by cervical artery dissection. Surprisingly, there is scant literature on the use of this medication in the treatment of this condition.

Isolated unilateral hypoglossal nerve palsy due to vertebral artery dissection

We report the case of a patient with unilateral tongue weakness secondary to an isolated lower motor neuron hypoglossal nerve palsy that was caused by a right vertebral artery dissection in the lower neck. The patient had a boggy tongue with a deviation to the right side but an otherwise normal neurological examination. Magnetic resonance angiography showed a narrow lumen of the right vertebral artery in the neck. After initially treating the patient with aspirin in the emergency room and later with warfarin for three months, there was complete recanalization of the right vertebral artery. Only one other case of vertebral artery dissection and twelfth nerve palsy has been reported before.     

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.     

Acute Demyelination Mimicking Vascular Hemicrania

A 29-year-old woman presented with acute hemicrania, trigeminal neuropathy and posterior fossa dysfunction. The admission differential diagnosis included vertebral artery dissection, posterior circulation aneurysm, vascular malformation and brainstem infarction. However, radiographic and CSF studies indicated demyelination. Acute demyelination should be in the differential diagnosis of vascular hemicrania with signs of posterior fossa dysfunction.     

彩色多普勒超声与三维增强磁共振血管成像在糖尿病患者椎动脉供血不足病因诊断中的应用

目的探讨彩色多普勒超声(CDFI)与三维增强磁共振血管成像(3D CE MRA)在糖尿病患者椎基底动脉供血不足(VBI)病因诊断中的价值。方法对92例糖尿病并椎动脉供血不足患者行3D CE MRA及CDFI检查,观察椎动脉供血不足的椎动脉病因基础。结果 CDFI检查阳性76例,其中单侧椎动脉受累64例,双侧受累12例,3D CE MRA检查阳性80例,其中单侧椎动脉受累66例,双侧受累14例。两者总的阳性率比较,差异无统计学意义(χ2=0.67,P0.05)。CDFI与3D CE MRA对于椎动脉病变造成的供血不足诊断符合率较高,为95%(76例,80例),在椎动脉狭窄造成椎动脉供血不足诊断中符合率为97%(66例,64例),对椎动脉闭塞造成的供血不足的诊断符合率为100%(4例,4例),对椎动脉发育异常造成供血不足的诊断符合率较低为50%(6例,12例)。结论 3D CE MRA除对局部狭窄所致椎动脉供血不足具有较高准确率外还容易诊断弥漫性长节段狭窄、闭塞及走形异常所致VBI,不足之处费用较高。CDFI和3D CE MRA联合应用能更全面地反映病情,提高VBI诊断阳性率。     

Headache as a manifestation of a life-threatening vascular disorder

Headache is a common complaint among patients seeking medical assistance. The differentiation between a primary headache disorder versus headache as a symptom of a serious underlying disease is of crucial importance. Dissections of the carotid or vertebral arteries frequently present with headache and can result in ischemic stroke. Rarely, headache or neck pain is a presenting symptom in patients with spontaneous proximal aortic dissection. We report on a 53-year-old man with a history of migraine with aura, who was admitted to the hospital because of severe frontal headache and neck pain. An anterior chest pain lasting for 10 minutes the day before and a diastolic heart murmur suggested a proximal aortic dissection, which was confirmed by transesophageal echocardiography. Patients with proximal aortic dissection rarely have headache or neck pain, reflecting the low incidence of carotid artery involvement in this disease. However, differentiation between an isolated cervical artery dissection and a proximal aortic dissection extending to the carotid arteries is pivotal, since treatment options are vastly different.     

Isolated basilar artery dissection following blunt trauma challenging the Glasgow coma score: A case report

Blunt cerebrovascular injury is a very rare complication of blunt trauma and a diagnostic challenge. A 14 year old male fell 10 m sustaining multi system trauma. The atypical Glasgow Coma Score was six with a fully preserved eye component. Initial whole-body CT scanning demonstrated multiple injuries but no obvious brain injury. Trauma management involved non-operative resuscitation and was successful, however profound coma occurred and brain stem reflexes disappeared on day two. Repeat brain CT scan demonstrated multiple cerebral and cerebellar ischemic lesions and no opacification of the vertebral or basilar arteries. Secondary analysis of the first CT scan demonstrated a small focal basilar artery dissection not initially reported.Our case report highlights an unusual cause of coma after traumatic brain injury where the clinical scenario mimics locked in syndrome. In such circumstances cerebrovascular injury, and in particular traumatic basilar artery dissection, must be actively excluded.     

超声心动图诊断肺动脉夹层--附3例报告

目的初步评价超声心动图诊断肺动脉夹层的价值。方法结合文献，回顾性分析3例肺动脉夹层患者的经胸超声心动图表现。结果3例肺动脉夹层患者均为左向右分流的先天性心脏病患者，其中动脉导管未闭2例，房间隔缺损合并右肺静脉畸形引流1例，均合并重度肺动脉高压，肺动脉显著扩张。其中2例成功行肺动脉夹层缝闭术。超声心动图均能准确显示夹层发生部位、剥离的内膜及破口情况。结论肺动脉夹层是一种罕见且病程凶险的疾病，大部分患者合并原发或继发性肺动脉高压，肺动脉显著扩张。超声心动图是肺动脉夹层的首选影像学诊断方法。     

Vertebral artery flow and cervical manipulation: an experimental study.

BACKGROUND: Spinal manipulation therapy is used by millions of patients each year to relieve symptoms caused by biomechanical dysfunction of the spine. Cerebrovascular accidents in the posterior cerebral circulation are a feared complication, but little research has been done on vertebral artery hemodynamics during cervical manipulation. OBJECTIVE: The purpose of this study was to develop an experimental model for investigations of volume blood flow changes in the vertebral arteries during premanipulative testing of these vessels and during spinal manipulation therapy of the cervical spine. DESIGN AND SETTING: An experimental study in a university biomedical laboratory. MATERIAL AND METHODS: The vertebral arteries were exposed in 8 adult pigs after extensive mediastinal dissection. Volume blood flow was measured on both sides simultaneously by advanced transit-time flowmetry. RESULTS: After cervical manipulation, the vertebral artery volume blood flow increased significantly for 40 seconds before returning to baseline values in less than 3 minutes. We found no significant changes in volume flow during premanipulative testing of the vertebral arteries (DeKleyn's test). CONCLUSION: We present an experimental model for investigations of vertebral artery hemodynamics during biomechanical interventions. We found a modest and transient effect of cervical manipulation on vertebral artery volume flow. The model may have further applications in future biomechanical research, for example, to determine whether any of several spinal manipulative techniques imposes less strain on the vertebral artery, thereby reducing possible future cerebrovascular accidents after such treatment.     

Headache as only symptom in multiple cervical artery dissection

We describe a patient with atypical headache as the only presenting symptom of spontaneous triple cervical artery dissection. As the patient suffered from arterial hypertension, a causative relation between headache and arterial hypertension was initially taken into consideration. However, four-vessel arteriography disclosed a dissection of both internal carotid arteries and the right vertebral artery. This unique case highlights the value of conventional arteriography for diagnosing cervical artery dissection. Since multiple cervical artery dissections are not rare, all cervical arteries should be examined by means of conventional arteriography when a dissection is suspected.