Vertebral Artery Dissection

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Vertebral Artery Disease(VAD) is the more common cause of strokes in patients under the age of 45. It is closely related to Coronary Artery disease, with the exception of the unique signs and symptoms. VAD is caused by an expanding hematoma in the vertebral artery vessel wall. It can arise spontaneously or as a secondary result of trauma.

In the United States, 20% of ischemic strokes in patients between 30-45 age years old are caused of VAD, and 10% of all VAD resulting in death. The common ratio of female to male is 3:1 with the presentation of VAD.

A typical presentation of a patient with VAD will present with:

Severe occipital heachache

Posterior nuchal pain

CNS dysfunction

Ipsilateral facial dysesthesia (pain and numbness) - Most common symptom
Dysarthria or hoarseness (cranial nerves [CN] IX and X)
Contralateral loss of pain and temperature sensation in the trunk and limbs
Ipsilateral loss of taste (nucleus and tractus solitarius)
Hiccups
Vertigo
Nausea and vomiting
Diplopia or oscillopsia (image movement experienced with head motion)
Dysphagia (CN IX and X)
Disequilibrium
Unilateral hearing loss

Contralateral weakness or paralysis (pyramidal tract)
Contralateral numbness (medial lemniscus)

Causes of VAD include either spontaneous or traumatic VAD. Causes of traumatic VAD include MVA, fall, or penetrating trauma. Several risk factors of Spontaneous VAD include:

Spinal manipulation
Yoga
Ceiling painting
Nose blowing
Minor neck trauma
Judo
Medical risk factors
Hypertension (48% in one series)
Oral contraceptive use
Chronic headache syndromes/migraines
Intrinsic vascular pathology
Fibromuscular dysplasia
Cystic medial necrosis
Female sex
Recent infection

Diagnosing VAD involves all of the following workup:

Lab work is done in anticipation of the need for anticoagulants. A PT, PTT, INR, and ESR are all blood levels that will need to be evaluated in order to safely administer any anticoagulants.

CT Scan, CTA, MRI, MRA, Ultrasound Vascular Duplex Scanning, Transcranial Dopler's, and LP's are all diagnostic imaging studies that vastly aid in the diagnosing and evaluation of possible VAD and the patients additional symptoms.

Once it is ruled that anticoagulants are safe to administer, it is the preferred method of treating VAD in the emergency room.. The anticoagulants are intended to prevent thrombogenic or embolic occlusion of the vertebrobasilar network and subsequent infarction of posterior CNS structures, brain stem, and cerebellum. All patient's first under go a CT scan of the head to rule out any subarachnoid hemorrhage. Additionally, once a VAD patient is deemed stable, a neurosurgery consult should be ordered.

http://emedicine.medscape.com/