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

2. William Barsan, M.D. 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. William Barsan, M.D. Evaluation BP: 137/88 P: 80 Afebrile Eyes: normal w/o nystagmus Neuro: no focal deficits MRI/MRA: left vertebral artery dissection

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

5. William Barsan, M.D. 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. William Barsan, M.D. 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. William Barsan, M.D. Summary Etiology History Physical exam Diagnostic workup Treatment

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

9. William Barsan, M.D. Arteriopathies Fibromuscular dysplasia Ehlers-Danlos type IV Marfan’s

10. William Barsan, M.D. Etiology Trauma - may be mild Spontaneous Cervical manipulation Association with migraine Respiratory infections (?)

11. William Barsan, M.D. Stroke Mechanism Occlusion of lumen Thrombosis/embolus

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

13. William Barsan, M.D. 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. William Barsan, M.D. Physical Exam Horner’s syndrome (carotid) Cranial nerve palsies –II, IV, V, VI, VII, IX, X, XII Stroke syndrome

15. William Barsan, M.D. Diagnostic Workup Ultrasound MRA Angiography

16. William Barsan, M.D. Location of Dissection Carotid - C 1 - C 2 level Vertebral - C 1 - C 2 level

17. William Barsan, M.D. Treatment Acute stroke - thrombolysis IV heparin Admission Warfarin for 3-6 months Re-imaging