Vertebral Artery Dissection Clinical Presentation

Updated: Feb 21, 2019
  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Presentation

History

The typical presentation of vertebral artery dissection (VAD) is a young person with severe occipital headache and posterior nuchal pain [29, 30] following a recent, relatively minor, head or neck injury. [3, 31] The trauma is generally from a trivial mechanism but is associated with some degree of cervical distortion.

Focal neurologic signs attributable to ischemia of the brainstem or cerebellum ultimately develop in 85% of patients; however, a latent period as long as 3 days between the onset of pain and the development of central nervous system (CNS) sequelae is not uncommon. Delays of weeks and years also have been reported. Many patients present only at the onset of neurologic symptoms. Thus, when VAD is suspected, clinicians should evaluate patients for the presence of a unilateral headache and/or neck pain and vertigo, with or without objective neurologic signs. [29]

When neurologic dysfunction does occur, patients most commonly report symptoms attributable to lateral medullary dysfunction (ie, Wallenberg syndrome).

Patient history may include the following:

  • Ipsilateral facial dysesthesia (pain and numbness) [6] : Most common symptom

  • Dysarthria or hoarseness (cranial nerves [CN] IX and X)

  • Contralateral loss of pain and temperature sensation in the trunk and limbs

  • Ipsilateral loss of taste (nucleus and tractus solitarius)

  • Hiccups

  • Vertigo [1]

  • Nausea and vomiting

  • Diplopia or oscillopsia (image movement experienced with head motion)

  • Dysphagia (CN IX and X)

  • Disequilibrium

  • Unilateral hearing loss [2]

Rarely, patients may manifest the following symptoms of a medial medullary syndrome:

  • Contralateral weakness or paralysis (pyramidal tract)

  • Contralateral numbness (medial lemniscus)

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Physical Examination

The physical examination of patients who have not yet manifested neurologic dysfunction may be misleading. The occipital and nuchal pain associated with vertebral artery dissection (VAD) mimics musculoskeletal pain and often is attributed to the mechanical strain that precipitated the dissection.

Depending upon which areas of the brain stem or cerebellum are experiencing ischemia, the following signs may be present:

  • Limb or truncal ataxia

  • Nystagmus [3]

  • Ipsilateral Horner syndrome in as many as one third of patients with VAD (ie, impairment of descending sympathetic tract) [4]

  • Ipsilateral hypogeusia or ageusia (ie, diminished or absent sense of taste)

  • Ipsilateral impairment of fine touch and proprioception

  • Contralateral impairment of pain and thermal sensation in the extremities (ie, spinothalamic tract)

  • Lateral medullary syndrome [6]

Cerebellar findings may include the following:

  • Nystagmus

  • Medial medullary syndrome

  • Tongue deviation to the side of the lesion (impairment of CN XII)

  • Contralateral hemiparesis

  • Ipsilateral impairment of fine touch and proprioception (nucleus gracilis)

  • Internuclear ophthalmoplegia (lesion of the medial longitudinal fasciculus)

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