A Case of Dizziness

William Barsan, M.D.

University of Michigan

William Barsan, MD

HistoryHistory• 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

William Barsan, MD

Physical ExaminationPhysical Examination

• BP: 137/88 P: 80 Afebrile

• Eyes: normal w/o nystagmus

• Neuro: no focal deficits

William Barsan, MD

ED EvaluationED Evaluation

• ASA po

• MRI/MRA from the ED

William Barsan, MD

MRI/MRA ResultsMRI/MRA Results

• Left vertebral artery dissection

• No thrombus

William Barsan, MD

ManagementManagement

• Admission to Neurology service

• IV Heparin, d/c on Warfarin

• Evaluation for Ehler-Danlos IV

William Barsan, MD

REFERENCESREFERENCESSilbert 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.

William Barsan, MD

OUTCOMEOUTCOME

• MRI/MRA 6 months later– Normalization of vertebral artery appearance

• Workup for connective tissue disorder negative

• Coumadin d/c

• Remains well one year later

William Barsan, MD

SummarySummary

• Etiology

• History

• Physical exam

• Diagnostic workup

• Treatment

William Barsan, MD

EtiologyEtiology

• Peak incidence 40’s

• 2.5% of first strokes

• Carotid - males = females

• Vertebral - females > males

• Association with arteriopathy/trauma

William Barsan, MD

ArteriopathiesArteriopathies

• Fibromuscular dysplasia

• Ehlers-Danlos type IV

• Marfan’s

William Barsan, MD

EtiologyEtiology

• Trauma - may be mild

• Spontaneous

• Cervical manipulation

• Association with migraine

• Respiratory infections (?)

William Barsan, MD

Stroke MechanismStroke Mechanism

• Occlusion of lumen

• Thrombosis/embolus

William Barsan, MD

HistoryHistory• Precedent trauma

• Associated neurological symptoms

• Migraine (25-50%)

• Headache, neck pain

• Amaurosis fugax

• Pulsatile tinnitus

• Cranial nerve paresis

William Barsan, MD

Carotid vs. VertebralCarotid vs. Vertebral• Neck pain - 26% vs. 46%

• Headache - 68% vs. 69%

• Symptom development - 4 days vs. 14 hours

• Carotid - eye, facial, ear pain

William Barsan, MD

PHYSICAL EXAMPHYSICAL EXAM

• Horner’s syndrome (carotid)

• Cranial nerve palsies– II, IV, V, Vi, VII, IX, X, XII

• Stroke syndrome

William Barsan, MD

DIAGNOSTIC WORKUPDIAGNOSTIC WORKUP

• Ultrasound

• MRA

• Angiography

William Barsan, MD

Location of DissectionLocation of Dissection

• Carotid - C1 - C2 level

• Vertebral - C1 - C2 level

William Barsan, MD

TreatmentTreatment

• Acute stroke - thrombolysis

• IV heparin

• Admission

• Warfarin for 3-6 months

• Re-imaging

William Barsan, MD

The most appropriate acute treatment The most appropriate acute treatment for extracranial artery dissection is:for extracranial artery dissection is:

• Angioplasty and stenting

• Endarterectomy

• IV Heparin

• Arterial ligation

• Beta blockers and antihypertensives

William Barsan, MD

Which of the following in most often Which of the following in most often associated with arterial dissections?associated with arterial dissections?

• Atherosclerosis

• History of MI

• Prior intracranial hemorrhage

• Migraine

• Aortic dissection

William Barsan, MD

Which of the following is NOT a common Which of the following is NOT a common presenting complaint with dissection?presenting complaint with dissection?

• Neck pain

• Facial pain

• Headache

• Nuchal rigidity

• Neurological deficit

William Barsan, MD

The diagnostic test of choice for The diagnostic test of choice for diagnosis of arterial dissection is:diagnosis of arterial dissection is:

• Contrast angiography

• Magnetic resonance angiography

• Duplex ultrasound

• CT

• PET imaging