Hospital: HOSPITAL UNIVERSITARIO DE ALAVA.
Aut@r o Autores: N. Serrano Usaola, A. Sanchez Garcia, E. Diez Lasheras, A. Valero Macias, D. Quintana Blanco, G. Finol Vaccariello.
A 59 year-old man who came to the emergency room of our hospital, for a 48-hour history of cervical pain with episodes of dizziness lasting seconds, turning objects sensation and vomiting, associating slight occipital headache. He related these symptoms to vertigo, that he had had years ago. Neurological examination was normal, with no other focality except for instability. Initial diagnosis was peripheral vertigo, starting treatment for it. Since there was noimprovement, cranial CT without intravenous contrast was performed, which showed no findings of acute significance. The patient was admitted for symptomatic control and study. In reexamination, he reported that the symptoms started suddenly after a cervical flexion to pick up an object from the ground. It was like a nonspecific dizziness, which subsided, to reappear hours later in the way referred, being the most pronounced complaint the intense cervical pain with progressive improvement of the rest of the symptoms. Taking into account all the information, an angioCT of cervical and intracranial vessels was done for vertebral dissection screening, revealing an absence of contrast in the extracranial foraminal segment of the right vertebral artery, with posterior filiform flow in distal segments, compatible with the suspected dissection. Treatment was initiated with antiaggregation. Currently the patient is pending evolution and subsequent controls.
Extracranial cervical arteries dissection, carotid and vertebral, is a common cause of focal neurological deficit in young people under 50 years-old. The etiology can be traumatic or non-traumatic, in which case it is called spontaneous dissection. The second one is more frequent and may be related to minor and low energy traumas like sudden cervical movements of flexo-extension, lateral rotation of the head, or Valsalva maneuvers. The extracranial segments of the cervical carotid and vertebral arteries are the most frequently affected, due to their greater length and mobility, in the case of the vertebral artery the extracranial foraminal segment, as in our case. Although most are asymptomatic, the most common symptom is headache and /or intense cervical pain. The headache can be gradual, in occipital location in case of vertebral arteries dissection, and more frontotemporal in case of the anterior circulation. Neurological deficits may appear secondary to the reduction of cerebral flow. Both angioCT and angioMRI are valid imaging studies for the diagnosis, continuing conventional angiography as the gold standard technique. The radiological findings will be identification of the flap and the double vascular lumen, intramural hematoma,thrombus formation and/or dissecting aneurysms. Therapeutic management, usuallly, is conservative, reserving more invasive procedures for selected cases.
For the early diagnosis of this entity, in order to perform the most adequate management, is necessary a great clinical suspicion, knowing the risk factors, possible triggers and specific symptoms.
- Maruyama H, Nagoya H, Kato Y, Deguchi I, Fukuoka T, Ohe Y et al. Spontaneous cervicocephalic arterial dissection with headache and neck pain as the only sympton. J.Headache Pain 2012,13:247-253 - Caicedo J, Ortiz Lopez A, Cardozo A, Cohe Cajiao JI. Spo