Diagnostic Considerations

Important diagnostic considerations include the following:

Consider the diagnosis of verterbral artery dissection (VAD). The routine emergency department (ED) evaluation of headache (computed tomography [CT] scanning and lumbar puncture [LP]) fails to identify patients with VAD. Most patients are evaluated by one other physician before the diagnosis of VAD is established.
Differentiate between the pain associated with VAD and musculoskeletal pain in the absence of a significant mechanism of injury.
Consider occipital headache as a sign of VAD. Occipital headache lacks features that traditionally indicate a serious etiology. Headaches associated with VAD lack a thunderclap onset, are not associated with meningismus or fever, and are not associated with a history of significant head trauma.
Consider etiologies of the stroke syndrome, other than atherosclerosis, if the patient presents with brainstem or cerebellar dysfunction. This is especially true in the context of a negative CT scan and/or LP.

Differential Diagnoses

Cervical Spine Fracture Evaluation
Cervical Strain (Whiplash)
Emergent Management of Subarachnoid Hemorrhage
Migraine Headache
Stroke, Hemorrhagic
Stroke, Ischemic
Tension Headache
Vasculitis affecting the vertebrobasilar circulation
Vertebrobasilar Atherothrombotic Disease

Workup

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Media Gallery

A, Dissection of the left vertebral artery secondary to guidewire injury. B, Complete resolution occurred in 6 months with only aspirin and clopidogrel (Plavix) therapy.
Gunshot wound to the right side of the neck. A, The angiogram shows transections of the right vertebral artery (RVA) and the right internal maxillary artery (RIMAX), with partial transection and pseudoaneurysm formation of the midcervical right internal carotid artery (RICA). The transected segments of the RVA and RIMAX were embolized with coils. B and C, The RICA pseudoaneurysm was successfully treated with a 7 x 40-mm covered stent (Wallgraft).

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Author

Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Canadian Association 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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Inderjeet (Indy) S Sahota, MD, MSc, CCFP Resident Physician, CCFP-EM Emergency Medicine R3, University of British Columbia Faculty of Medicine, Canada

Inderjeet (Indy) S Sahota, MD, MSc, CCFP is a member of the following medical societies: Canadian Association of Emergency Physicians, Canadian Cardiovascular Society, Canadian Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Amin Antoine Kazzi, MD Professor of Clinical Emergency Medicine, Department of Emergency Medicine, American University of Beirut, Lebanon

Amin Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

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, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.