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Vertebral Artery Dissection Evaluation and Management William Barsan, M.D. University of Michigan

Vertebral Artery Dissection Evaluation and Management William Barsan, M.D. University of Michigan. History.

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Vertebral Artery Dissection Evaluation and Management William Barsan, M.D. University of Michigan

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  1. Vertebral Artery Dissection Evaluation and Management William Barsan, M.D. University of Michigan

  2. History • 29 y.o. female with hx of migraine. Had sudden onset of falling and vertigo for 1 minute in the morning - resolved. Felt light headed and noticed left neck pain radiating to left temporal area (dull ache - not migrainous). • Past History: migraine • Meds: BCP, Imitrex prn

  3. Evaluation • BP: 137/88 P: 80 Afebrile • Eyes: normal w/o nystagmus • Neuro: no focal deficits • MRI/MRA: left vertebral artery dissection

  4. Management • Admission to Neurology service • IV Heparin, d/c on Warfarin • Evaluation for Ehler-Danlos IV

  5. References Silbert et al: “Headache and Neck Pain in Spontaneous Carotid and Vertebral Artery Dissections,” Neurology 45:1517-1522, 1995. Documents signs and symptoms in 161 patients with dissection. Biousse et al: “Head Pain in Non-Traumatic Carotid Artery Dissection,” Cephalgia 14:33-36, 1994. Discusses presenting signs and symptoms of carotid artery dissection. Schierink et al: “Heritable Connective Tissue Disorders in Cervical Artery Dissections,” Neurology 50:1166-1169, 1998. Documents that connective tissue disorders are common in dissection patients although they don’t meet the classic criteria for diagnosis. Wityk: “Stroke in a Healthy 46 year old man,” JAMA 285(21):2757-2762, 2001 Case presentation of spontaneous carotid dissection with a literature review.

  6. Outcome • MRI/MRA 6 months later • Normalization of vertebral artery appearance • Workup for connective tissue disorder negative • Coumadin d/c • Remains well one year later

  7. Summary • Etiology • History • Physical exam • Diagnostic workup • Treatment

  8. Etiology • Peak incidence 40’s • 2.5% of first strokes • Carotid - males = females • Vertebral - females > males • Association with arteriopathy/trauma

  9. Arteriopathies • Fibromuscular dysplasia • Ehlers-Danlos type IV • Marfan’s

  10. Etiology • Trauma - may be mild • Spontaneous • Cervical manipulation • Association with migraine • Respiratory infections (?)

  11. Stroke Mechanism • Occlusion of lumen • Thrombosis/embolus

  12. History • Precedent trauma • Associated neurological symptoms • Migraine (25-50%) • Headache, neck pain • Amaurosis fugax • Pulsatile tinnitus • Cranial nerve paresis

  13. Carotid vs. Vertebral • Neck pain - 26% vs. 46% • Headache - 68% vs. 69% • Symptom development - 4 days vs. 14 hours • Carotid - eye, facial, ear pain

  14. Physical Exam • Horner’s syndrome (carotid) • Cranial nerve palsies • II, IV, V, VI, VII, IX, X, XII • Stroke syndrome

  15. Diagnostic Workup • Ultrasound • MRA • Angiography

  16. Location of Dissection • Carotid - C1 - C2 level • Vertebral - C1 - C2 level

  17. Treatment • Acute stroke - thrombolysis • IV heparin • Admission • Warfarin for 3-6 months • Re-imaging

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