eMedicine Specialties > Emergency Medicine > Cardiovascular

Dissection, Vertebral Artery: Differential Diagnoses & Workup

Author: Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Coauthor(s): Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ, Director, Emergency Department, Associate Professor, Faculty of Medicine, Section of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Contributor Information and Disclosures

Updated: Aug 5, 2009

Differential Diagnoses

Cervical Strain
Stroke, Hemorrhagic
Fractures, Cervical Spine
Stroke, Ischemic
Headache, Migraine
Subarachnoid Hemorrhage
Headache, Tension
Vertebrobasilar Atherothrombotic Disease

Other Problems to Be Considered

Vasculitis affecting the vertebrobasilar circulation

Workup

Laboratory Studies

  • VAD is a disease of young, generally healthy individuals. Laboratory evaluation is directed toward establishing baseline parameters in anticipation of anticoagulant therapy.
  • Prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) are the usual monitoring parameters for patients on anticoagulant medication.
  • Erythrocyte sedimentation rate (ESR), if elevated, may suggest vasculitis involving the cerebrovascular circulation.

Imaging Studies

  • CT scanning
    • CT scan is useful in identifying patients with the complication of subarachnoid hemorrhage.7
    • Absence of hemorrhage, as demonstrated by CT scan, is a prerequisite for instituting anticoagulant therapy.
  • Four-vessel cerebral angiography15
    • Prior to development of noninvasive techniques such as MRI and Doppler ultrasound, cerebral angiography was the criterion standard in diagnosing VAD. These noninvasive techniques are supplanting angiography as the imaging techniques of choice for patients in whom VAD is suspected.
    • The characteristic angiographic finding in a dissected vertebral artery is the string or "string and pearl" appearance of the stenotic vessel lumen.16
    • Because of the high incidence (up to 40% in some series) of multiple extracranial cervical artery dissections occurring simultaneously in the same patient, 4-vessel angiography is the angiographic technique of choice in all patients with potential CAD or VAD.17
  • Magnetic resonance imaging7,15
    • MRI detects both the intramural thrombus and intimal flap that are characteristic of VAD.16
    • Hyperintensity of the vessel wall seen on T1-weighted axial images is considered by some to be pathognomonic of VAD.
  • Magnetic resonance angiography7,15
    • Magnetic resonance angiography (MRA) can identify abnormalities that are characteristic of the disturbed arterial flow seen in VAD. These include the presence of a pseudolumen and aneurysmal dilation of the artery.16
    • MRI and MRA are less sensitive than cerebral angiography for the detection of VAD, although they probably have equivalent specificity.
    • Cerebral angiography is indicated when clinical suspicion is high but MRI/MRA has failed to isolate the lesion.
  • Vascular duplex scanning
    • Duplex sonography of the vertebral arteries demonstrates abnormal flow in 95% of patients with VAD.
    • Ultrasonographic signs specific to VAD (eg, segmental dilation of the vessel, eccentric channel) are detectable in only 20% of patients.
  • Transcranial Doppler
    • Transcranial Doppler is approximately 75% sensitive to the flow abnormalities seen in VAD.
    • It is useful also in detecting high-intensity signals (HITS), which are characteristic of microemboli propagating distally as a result of the dissection.
    • HITS are associated with symptomatic ischemic symptoms both in VAD and in other types of cerebrovascular disease.

Procedures

  • Patients with suspected subarachnoid hemorrhage and a normal CT scan may undergo lumbar puncture (LP) if VAD is not pursued by other imaging modalities.

More on Dissection, Vertebral Artery

Overview: Dissection, Vertebral Artery
Differential Diagnoses & Workup: Dissection, Vertebral Artery
Treatment & Medication: Dissection, Vertebral Artery
Follow-up: Dissection, Vertebral Artery
References
Further Reading
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References

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  2. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ. Jul 11 2000;163(1):38-40. [Medline].

  3. Rubinstein SM, Peerdeman SM, van Tulder MW. A systematic review of the risk factors for cervical artery dissection. Stroke. Jul 2005;36(7):1575-80. [Medline].

  4. Stahmer SA, Raps EC, Mines DI. Carotid and vertebral artery dissections. Emerg Med Clin North Am. Aug 1997;15(3):677-98. [Medline].

  5. Saeed AB, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Can J Neurol Sci. Nov 2000;27(4):292-6. [Medline].

  6. Silbert PL, Mokri B, Schievink WI. Headache and neck pain in spontaneous internal carotid and vertebral artery dissections. Neurology. Aug 1995;45(8):1517-22. [Medline].

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  8. Raupp SF, Jellema K, Sluzewski M. Sudden unilateral deafness due to a right vertebral artery dissection. Neurology. Apr 27 2004;62(8):1442. [Medline].

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  15. Levy C, Laissy JP, Raveau V, et al. Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography. Radiology. Jan 1994;190(1):97-103. [Medline].

  16. Yoshimoto Y, Wakai S. Unruptured intracranial vertebral artery dissection. Clinical course and serial radiographic imagings. Stroke. Feb 1997;28(2):370-4. [Medline]. [Full Text].

  17. Prabhu V, Kizer J, Patil A, et al. Vertebrobasilar thrombosis associated with nonpenetrating cervical spine trauma. J Trauma. Jan 1996;40(1):130-7. [Medline].

  18. Ramphul N, Geary U. Caveats in the management and diagnosis of cerebellar infarct and vertebral artery dissection. Emerg Med J. Apr 2009;26(4):303-4. [Medline].

  19. de Bray JM, Penisson-Besnier I, Dubas F, Emile J. Extracranial and intracranial vertebrobasilar dissections: diagnosis and prognosis. J Neurol Neurosurg Psychiatry. Jul 1997;63(1):46-51. [Medline].

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Keywords

VAD, vertebral artery dissection, stroke, aneurysm, arteria vertebralis, hematoma, carotid artery dissection, CAD, stroke rehabilitation

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Contributor Information and Disclosures

Author

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ, Director, Emergency Department, Associate Professor, Faculty of Medicine, Section of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Marc Afilalo, MD, FACEP, FRCPC, MCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Royal College of Physicians and Surgeons of Canada, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph J Sachter, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center
Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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