A Case of Dizziness

1
A Case of Dizziness

• William Barsan, M.D.
• University of Michigan

2
History

• 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

3
Physical Examination

• BP 137/88 P 80 Afebrile
• Eyes normal w/o nystagmus
• Neuro no focal deficits

4
ED Evaluation

• ASA po
• MRI/MRA from the ED

5
MRI/MRA Results

• Left vertebral artery dissection
• No thrombus

6
Management

• Admission to Neurology service
• IV Heparin, d/c on Warfarin
• Evaluation for Ehler-Danlos IV

7
REFERENCES

• Silbert et al Headache and Neck Pain in
  Spontaneous Carotid and Vertebral Artery
  Dissections, Neurology 451517-1522, 1995.
• Documents signs and symptoms in 161 patients with
  dissection.
• Biousse et al Head Pain in Non-Traumatic
  Carotid Artery Dissection, Cephalgia 1433-36,
  1994.
• Discusses presenting signs and symptoms of
  carotid artery dissection.
• Schierink et al Heritable Connective Tissue
  Disorders in Cervical Artery Dissections,
  Neurology 501166-1169, 1998.
• Documents that connective tissue disorders are
  common in dissection patients although they dont
  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.

8
OUTCOME

• MRI/MRA 6 months later
• Normalization of vertebral artery appearance
• Workup for connective tissue disorder negative
• Coumadin d/c
• Remains well one year later

9
Summary

• Etiology
• History
• Physical exam
• Diagnostic workup
• Treatment

10
Etiology

• Peak incidence 40s
• 2.5 of first strokes
• Carotid - males females
• Vertebral - females gt males
• Association with arteriopathy/trauma

11
Arteriopathies

• Fibromuscular dysplasia
• Ehlers-Danlos type IV
• Marfans

12
Etiology

• Trauma - may be mild
• Spontaneous
• Cervical manipulation
• Association with migraine
• Respiratory infections (?)

13
Stroke Mechanism

• Occlusion of lumen
• Thrombosis/embolus

14
History

• Precedent trauma
• Associated neurological symptoms
• Migraine (25-50)
• Headache, neck pain
• Amaurosis fugax
• Pulsatile tinnitus
• Cranial nerve paresis

15
Carotid vs. Vertebral

• Neck pain - 26 vs. 46
• Headache - 68 vs. 69
• Symptom development - 4 days vs. 14 hours
• Carotid - eye, facial, ear pain

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PHYSICAL EXAM

• Horners syndrome (carotid)
• Cranial nerve palsies
• II, IV, V, Vi, VII, IX, X, XII
• Stroke syndrome

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DIAGNOSTIC WORKUP

• Ultrasound
• MRA
• Angiography

18
Location of Dissection

• Carotid - C1 - C2 level
• Vertebral - C1 - C2 level

19
Treatment

• Acute stroke - thrombolysis
• IV heparin
• Admission
• Warfarin for 3-6 months
• Re-imaging

20
The most appropriate acute treatment for
extracranial artery dissection is

• Angioplasty and stenting
• Endarterectomy
• IV Heparin
• Arterial ligation
• Beta blockers and antihypertensives

21
Which of the following in most often associated
with arterial dissections?

• Atherosclerosis
• History of MI
• Prior intracranial hemorrhage
• Migraine
• Aortic dissection

22
Which of the following is NOT a common presenting
complaint with dissection?

• Neck pain
• Facial pain
• Headache
• Nuchal rigidity
• Neurological deficit

23
The diagnostic test of choice for diagnosis of
arterial dissection is

• Contrast angiography
• Magnetic resonance angiography
• Duplex ultrasound
• CT
• PET imaging