Vertebral artery dissection causing stroke in sport

doi:10.1054/jocn.1999.0189

Journal of Clinical Neuroscience

Volume 7, Issue 4, July 2000, Pages 298-300

https://doi.org/10.1054/jocn.1999.0189 Get rights and content

Abstract

Five cases of vertebral arterial dissection occurring in sport are presented. These cases emphasise the diagnostic and management difficulties in this setting. Stroke in sport, although uncommon, is predominantly due to arterial dissection in either the vertebral or carotid arteries. Physicians involved in athlete care need to be aware of this diagnosis.

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Cited by (25)

Sumo-Associated Traumatic Vertebral Artery Dissection Precipitating Subarachnoid Hemorrhage in Association with Bifid Origins of the Posterior Inferior Cerebellar Artery
2020, World Neurosurgery
Traumatic vertebral artery dissection (tVAD) is frequently accompanied by cerebellar infarction, but subarachnoid hemorrhage (SAH) is rare.
We report a unique case of tVAD precipitating SAH, from which the patient fully recovered, most likely because of the protective effects of an anomalously duplicated posterior inferior cerebellar artery (PICA) origin. A 17-year-old Sumo wrestler experienced a brief loss of consciousness after an attack by an opponent to his neck. Head computed tomography imaging demonstrated diffuse posterior fossa SAH; cerebral angiography demonstrated left vertebral artery (VA) occlusion, which was thought to be most likely attributable to tVAD. Angiography revealed distal PICA reconstitution, supplied by collateral arterial flow from the meningeal branch of the proximal ipsilateral VA. An external ventricular drain was placed acutely for treatment of SAH-induced hydrocephalus; however, the patient had an otherwise uneventful course, and remained without clinical evidence of ischemic infarct. A repeat imaging confirming a probable duplicated PICA origin from the VA, distal to the tVAD-associated thrombosis.
Of particular interest, the patient's abnormal anatomy may have been a mixed blessing, with a more fragile bifid PICA potentially underlying the unexpected development of SAH, whereas the sister branch simultaneously spared him a potentially catastrophic infarction via arterial collateralization.
Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain
2019, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
Cassidy et al31 concluded that the association between chiropractic care and vertebral basilar artery–related stroke found in previous studies was likely explained by presenting symptoms attributable to evolving VAD and found similar risks between primary care physicians and chiropractors, which might be explained by the fact that patients with evolving VAD typically have headaches and neck pain. Several recent papers have associated VAD with a variety of common activities,32-36 and others failed to find any high-quality evidence to support a causal link between chiropractic manipulation and cervical artery dissection.35 Doctors of chiropractic need to be aware of possible signs and symptoms of potential VAD and stroke, and there are simple, clinically relevant questions and examination findings DCs should be looking for.36
The purpose of this study was to develop best-practice recommendations for chiropractic management of adults with neck pain.
A steering committee of experts in chiropractic practice, education, and research drafted a set of recommendations based on the most current relevant clinical practice guidelines. Additional supportive literature was identified through targeted searches conducted by a health sciences librarian. A national panel of chiropractors representing expertise in practice, research, and teaching rated the recommendations using a modified Delphi process. The consensus process was conducted from August to November 2018. Fifty-six panelists rated the 50 statements and concepts and reached consensus on all statements within 3 rounds.
The statements and concepts covered aspects of the clinical encounter, ranging from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral for patients presenting with neck pain.
These best-practice recommendations for chiropractic management of adults with neck pain are based on the best available scientific evidence. For uncomplicated neck pain, including neck pain with headache or radicular symptoms, chiropractic manipulation and multimodal care are recommended.
Vertebral artery dissection in sport: Expert opinion of mechanisms and risk-reduction strategies
2019, Journal of Clinical Neuroscience
Citation Excerpt :
Trauma to this region of the vessel (V3) may cause a dissection which extends intracranially, or a concomitant intracranial lesion, which may rupture the thinner vessel wall and cause subarachnoid haemorrhage which may be immediately fatal. This mechanism, presentation, and outcome is consistent with sports cases reported in the literature, including ice hockey [3], karate [16], and Australian Rules Football [1]. Impact to the head, neck, or body which causes cervical spine trauma or rapid extreme movement of the neck is also concerning.
Experiential knowledge was collated to improve understanding of the mechanism of vertebral artery dissection (VAD) and inform recommendations for risk-reduction strategies in sport. Fourteen experts from fields of neurology, forensic pathology, biomedical engineering, radiology, physiotherapy, and sport and exercise medicine participated in semi-structured interviews. Experts were asked to provide their hypothesised mechanism of VAD, and suggest strategies to reduce the risk of VAD in non-motorised sports. Experts agreed that there is no single mechanism of VAD. Factors relating to predisposition, susceptibility, and an inciting event exist on a spectrum, as does the severity of the resulting VAD. Particularly concerning inciting events which may occur during sports participation include blunt force impact to the specific area behind and below the ear; and extreme movement of the neck, which may be facilitated by impact to the head or neck. Risk reduction strategies must be feasible within the particular sporting context. Strategies include rules, personal protective equipment, and education to reduce the risk of impact to the head or neck. Education may also serve to improve early recognition of VAD. VAD is a risk (low frequency, severe consequence) in sports in which athletes are exposed to head or neck impact from an object or opponent. Best practice risk management suggests that sports governing bodies should assess VAD risk and consider risk controls.
Traumatic Intracranial and Extracranial Vascular Injuries in Children
2010, Neurosurgery Clinics of North America
Citation Excerpt :
The presence of retinal hemorrhage in these cases should be interpreted with caution as it can be simply the consequence of SAH (Terson syndrome). Patients with vertebral artery dissections usually have a lucid interval after trauma until they present with symptoms.45,46 Ipsilateral headache, neck pain, dizziness, and neurologic deficits are the most common symptoms of vertebral artery dissections.47
Vertebral artery injury after blunt cervical trauma: An update
2006, Surgical Neurology
Vertebral artery injury (VAI) after blunt cervical trauma has been considered to be rare. The incidence of VAI has increased dramatically within the last decade after a heightened awareness of this entity on the part of spine surgeons. Diagnostic or therapeutic guidelines for VAI have not been established fully, however.
A review of the literature published between 1990 and 2004 was conducted.
The incidence of VAI among total blunt trauma admissions ranged from 0.20% to 0.77%. Most VAI patients remained asymptomatic, but sudden unexpected deterioration was often reported. Distraction/extension, distraction/flexion, and lateral flexion injuries were the major mechanisms of injury. Dissection and occlusion were the frequent vascular injury patterns. Facet joint dislocations and the fractures extending into the transverse foramen were the spine injury patterns closely associated with VAI. Digital subtraction angiography was the most sensitive imaging study, but because of invasiveness, its role as a screening study remained questionable. Neuroradiological intervention was used successfully to treat hemorrhagic VAI and progressing vertebrobasilar stroke. Systemic anticoagulation with heparin was the preferred treatment for mild ischemia. Treatment of asymptomatic patients has been controversial because the natural history of VAI has not been elucidated. Prophylactic anticoagulation with heparin or the use of antiplatelet agents was advocated in recent studies.
Preemptive treatment may be reasonable in selected patients considering the devastating potentials of VAI. The potential risks of heparin or antiplatelet agents in relation to early cervical spine surgery have not been addressed fully, however, and spine surgeons have to weigh the risk and benefit of such treatment cautiously.
Imaging of traumatic neurovascular injury
2006, Radiologic Clinics of North America

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Clinical studyVertebral artery dissection causing stroke in sport

Abstract

Paediatr Neurol

J Emerg Med

Lancet

Lancet

Revue de Medicine Interne

Lancet

Stroke in athletes

Vertebral arterial dissection

Neurology

Vertebral artery dissection during paroxysmal coughing: a case report

Ann Emerg Med

Infarction of the medulla and cervical cord following fitness exercises

Stroke

Headache and neck pain: the warning symptoms of vertebral artery dissection

Headache

Dissecting aneurysm of the vertebral artery and cervical manipulation

Neurology

Spontaneous dissection associated with proximal vertebral artery anomaly

Int Med

Vertebral artery dissection

Acad Emerg Med

The incidence of vertebral artery injury after mid-cervical fracture or subluxation

Neurosurgery

Delayed sequelae of vertebral artery dissection and occult cervical fractures

Neurology

Panic with a twist: an unusual presentation of combined psychiatric and neurological symptoms in a tactical jet aviator

Aviat Space Envir Med

Traumatic carotid and vertebral artery dissection in a professional jockey

Br J Sports Med

Extra-cranial vertebral artery dissections: a review of 13 cases

Stroke

Clinical study
Vertebral artery dissection causing stroke in sport