Delayed Presentation of Vertebral Artery Dissection

Background The vertebral artery is prone to injury from cervical spine trauma. This is due to the anatomical relationship of its second segment to bony structures.¹ Symptoms include neck pain and cerebellar signs. The interval between injury and neurological symptoms may be delayed by 3 months. Subsequent stroke increases if injury from blunt cervical spine trauma cannot be diagnosed. Diagnosis is based on a clinical pattern and supporting radiological evidence.

Method: A 39-year-old woman presented due to nausea and drowsiness (Glasgow Coma Scale [GCS] 15). The patient sustained neck trauma 2 months ago. Computed tomography (CT) of cervical spine demonstrated an uneven C5-6 disc space and a small avulsed bony fragment. The GCS dropped to 12 (E3 V4 M5). Magnetic resonance (MR) imaging established acute infarction of the cerebellar vermis and lateral ventricular dilatation. The impression was a stroke due to a gradual dissection from the original injury. Management included an external ventricular drain and subsequently a ventriculoperitoneal shunt.

Results: Risk factors for injury include factures of the transverse foramen, subluxation, and those involving the upper cervical spine. Use of four vessel angiography in cervical spine fracture reports injury in 33 to 39% cases. That of CT angiogram has a pickup of 30%.¹ Angiography is the gold standard but invasive. It is prone to complications in critically ill patients. MR angiography is noninvasive requiring no contrast being more suited in critically ill patients. CTA is more optimal and noninvasive and produces images having three-dimensional manipulations.

Conclusion: Dissection is a diagnostic dilemma carrying increased morbidity and mortality if clinical presentation is delayed.