University of Michigan A Case of Dizziness William Barsan, M.D. University of Michigan 54 1 54

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 54 2 54

Physical Examination BP: 137/88 P: 80 Afebrile Eyes: normal w/o nystagmus Neuro: no focal deficits 54 3 54

ED Evaluation ASA po MRI/MRA from the ED

MRI/MRA Results Left vertebral artery dissection No thrombus

Management Admission to Neurology service IV Heparin, d/c on Warfarin Evaluation for Ehler-Danlos IV 54 4 54

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.

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 5 17

Summary Etiology History Physical exam Diagnostic workup Treatment

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

Arteriopathies Fibromuscular dysplasia Ehlers-Danlos type IV Marfan’s

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

Stroke Mechanism Occlusion of lumen Thrombosis/embolus

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

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

PHYSICAL EXAM Horner’s syndrome (carotid) Cranial nerve palsies II, IV, V, Vi, VII, IX, X, XII Stroke syndrome

DIAGNOSTIC WORKUP Ultrasound MRA Angiography

Location of Dissection Carotid - C1 - C2 level Vertebral - C1 - C2 level

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

The most appropriate acute treatment for extracranial artery dissection is: Angioplasty and stenting Endarterectomy IV Heparin Arterial ligation Beta blockers and antihypertensives

Which of the following in most often associated with arterial dissections? Atherosclerosis History of MI Prior intracranial hemorrhage Migraine Aortic dissection

Which of the following is NOT a common presenting complaint with dissection? Neck pain Facial pain Headache Nuchal rigidity Neurological deficit

The diagnostic test of choice for diagnosis of arterial dissection is: Contrast angiography Magnetic resonance angiography Duplex ultrasound CT PET imaging