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

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 54 2 54

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

4. ED Evaluation
ASA po
MRI/MRA from the ED

5. MRI/MRA Results
Left vertebral artery dissection
No thrombus

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

7. REFERENCES
Silbert et al: “Headache and Neck Pain in Spontaneous Carotid and Vertebral Artery Dissections,” Neurology 45: , 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: , 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): , 2001
Case presentation of spontaneous carotid dissection with a literature review.

8. 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

9. Summary
Etiology
History
Physical exam
Diagnostic workup
Treatment

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

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

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

13. Stroke Mechanism
Occlusion of lumen
Thrombosis/embolus

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

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

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

17. DIAGNOSTIC WORKUP
Ultrasound
MRA
Angiography

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

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

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

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

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

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