Artery Dissection: Warning Symptoms, Clinical Features and Prognosis
in 26 Patients
Bin Saeed, Ashfaq Shuaib, Ghanem Al-Sulaiti and Derek Emery
Background and objectives: Internal carotid artery
dissection has been extensively studied and well-described.
Although there has been a recent increase in the number of reported
cases of vertebral artery (VA) dissection, the clinical variety
of presentation and the early warning symptoms have not been
well-described before. Our objectives in this study include:
(1) To determine the early symptoms and warning signs which
may help the clinician in the early identification and treatment
of patients with VA dissection. (2) To explore the variety of
clinical presentation of VA dissection and its relation to prognosis.
Design and setting: Retrospective analysis of
hospital records in a tertiary academic centre for the period
1989-1999. Results: Twenty-six patients were identified
(13 men and 13 women). The mean age was 48. Possible precipitating
factors were identified in 14 patients (53%). Sporting activity
and chiropractic manipulations were the most common (15% and
11% respectively). Headache and/or neck pain was the prominent
feature in 88% of patients and was a warning sign in 53%, preceding
onset of stroke by up to 14 days. The most common clinical features
included vertigo (57%), unilateral facial paresthesia (46%),
cerebellar signs (33%), lateral medullary signs (26%) and visual
field defects (15%). Bilateral VA dissection presented in six
patients (24%). The most common region of dissection was the
C1-C2 level (16 arteries, 51%). Intracranial VA dissection was
found in eight arteries (25%). The majority of patients (83%)
had favorable outcome. Poor prognosis was associated with (1)
bilateral dissection; (2) intracranial VA dissection accompanied
by subarachnoid hemorrhage. Only two patients reported stroke
recurrence. Conclusions: Our findings show that
VA dissection affects mainly middle age persons and involves
both sexes equally. Headache and/or neck pain followed by vertigo
or unilateral facial paresthesia is an important warning sign
that may precede onset of stroke by several days. Although the
majority of patients will have excellent prognosis, this was
less likely in patients presenting with subarachnoid hemorrhage
or bilateral VA dissection. Recurrence rate was low.
Dissection de l'artère vertébrale: symptômes
d'alerte, caractéristiques cliniques et pronostic chez
26 patients. Introduction et objectifs: La
dissection de la carotide interne a fait l'objet de nombreuses
études et a été bien décrite. Bien
qu'il y ait une augmentation récente du nombre de cas
de dissection de l'artère vertébrale (AV) rapportés,
le spectre de la présentation clinique et les symptômes
d'alerte précoces n'ont pas encore été
bien décrits. Les objectifs de cette étude sont
les suivants: (1) déterminer les symptômes précoces
et les signes d'alerte qui peuvent aider le clinicien à
identifier et traiter précocement les patients porteurs
d'une dissection de l'AV; (2) explorer le spectre de la présentation
clinique de la dissection de l'AV et sa relation au pronostic.
Plan et contexte: Il s'agit d'une analyse rétrospective
de dossiers hospitaliers dans un centre académique tertiaire
de 1989 à 1999. Résultats: Vingt-six
patients ont été identifiés (13 hommes
et 13 femmes). L'âge moyen était de 48 ans. Des
facteurs précipitants possibles ont été
identifiés chez 14 patients (53%). Les activités
sportives et les manipulations de chiropractie étaient
les facteurs les plus fréquents (15% et 11% respectivement).
Une céphalée et/ou une douleur cervicale étaient
les symptômes dominants chez 88% des patients et étaient
un signe d'alerte chez 53%, précédant le début
de l'accident vasculaire cérébral (AVC) d'un laps
de temps pouvant aller jusqu'à 14 jours. Les caractéristiques
cliniques les plus fréquentes étaient le vertige
(57%), la paresthésie faciale unilatérale (46%),
des signes cérébelleux (33%), des signes médullaires
latéraux (26%) et des déficits du champs visuel
(15%). Six patients (24%) présentaient une dissection
bilatérale de l'AV. La région la plus fréquemment
touchée était le niveau C1-C2 (16 artères,
51%). Une dissection intracrânienne de l'AV a été
mise en évidence dans huit artères (25%). La majorité
des patients (83%) ont eu une évolution favorable. Un
pronostic défavorable était associé à
(1) une dissection bilatérale; (2) une dissection intracrânienne
de l'AV accompagnée d'une hémorragie sous-arachnoïdienne
(HSA). Seulement deux patients ont eu une récidive de
l'AVC. Conclusions: Nos observations démontrent
que la dissection de l'AV affecte surtout des personnes d'âge
moyen et atteint les deux sexes également. La céphalée
et/ou la cervicalgie suivie de vertiges ou de paresthésie
faciale unilatérale est un signe d'alerte important qui
peut précéder le début de l'AVC de plusieurs
jours. Bien que la majorité des patients ont un excellent
pronostic, pour ceux qui présentent une HSA ou une dissection
bilatérale de l'AV le pronostic est plus sombre. Le taux
de récidive était faible chez les patients étudiés.
J. Neurol. Sci. 2000; 27: 292-296
incidence of cervical artery dissection is unknown. In some
series of young patients with stroke, dissection accounts for
one fifth to one tenth of cases.  Internal carotid
artery dissections are widely-known and as a diagnosis are more
often sought. [2,3] Although there has been a recent
increase in the number of reported cases of vertebral artery
(VA) dissection, a study of the patients presented in this report
show that VA dissection diagnosis is frequently not considered
in the younger patient with typical symptoms. In many instances,
the diagnosis in patients with multiple suggestive symptoms
is missed until after stroke develops. Our objectives of presenting
this series include identifying the early symptoms that should
raise suspicion of VA dissection, explore the variety of clinical
presentation of VA dissection, and to evaluate the prognosis
and frequency of recurrence.
reviewed and studied medical records of all patients less than
age 60 with stroke and all patients who underwent cerebral angiography
between 1989-1999 at the University of Alberta Hospital, Edmonton.
We excluded patients with traumatic arterial dissection and
patients with only occlusion of a VA on angiograms without angiographic
evidence of dissection in the other VA. Twenty-six consecutive
patients with VA dissection were identified. We studied their
demographic features; presence or absence of warning symptoms;
cumulative symptoms and signs; the presence of predisposing
factors; the prevalence of diabetes mellitus, hypertension or
migraine; neuroimaging and angiographic findings and type of
treatment received. All patients, except one, had standard four
vessel cerebral angiography within five days of stroke onset.
One patient was diagnosed with magnetic resonance angiography.
Follow-up was possible in twenty patients. The duration of follow-up
ranged from four weeks to five years. For the purpose of classification
we used a simple four category outcome scale:
without neurological deficit;
with mild deficits, which did not prevent the patient from
performing work and/or major daily activities; for example,
with significant neurological deficit preventing from the
performance of work and/or other major activities;
the 26 patients identified, there were 13 men and 13 women.
Age ranged between 29 and 76 (mean age 48).
were categorized into warning symptoms and cumulative symptoms,
Fourteen patients reported having symptoms before onset of stroke.
The delay between onset of warning symptoms and stroke onset
ranged between 1 to 14 days. The most common warning symptom
was headache and neck pain. This was usually of sudden onset,
severe and, though not accompanied by other symptoms or signs,
persistent until the onset of stroke. With respect to cumulative
symptoms assessed in each patient, pain was again the most frequent
symptom (22 patients, 84%). Thirteen patients presented with
headache only, four patients with neck pain only and five patients
presented with both symptoms. Table
1 summarizes the location of headaches in those patients.
history revealed a possible link between the onset of dissection
and specific predisposing factor in 14 of the patients in this
series. This was related to sports activities (four patients),
chiropractic maneuvers (three patients) and possible neck injuries
in seven patients. The details of the precipitating factors
are summarized in Table
signs on presentation
signs were the most common objective finding on neurological
examination (nine patients). This was unilateral in five patients.
Gait ataxia was evident in the remaining four patients. Lateral
medullary syndrome signs were present in seven patients, these
were partial in five of them. Four patients had visual field
abnormalities (two had homonymous hemianopia and two had homonymous
quadranopia). Three patients presented with basilar artery syndromes,
all had decreased level of consciousness, one of them had Parinaud
syndrome and one presented with quadriparesis. There were no
clinical findings in three patients &endash; all of them came
to medical attention because of vertigo or headache.
nine patients neuroimaging was normal. Infarction was noted
in 17 patients. The most common radiological finding in these
patients was cerebellar infarction which was evident in ten
patients. The second most common site of involvement was the
occipital lobe, which was involved in four patients. Subarachnoid
hemorrhage (SAH) was noted in three patients. The dissection
was found to be intracranial in all three patients with SAH.
Cerebral angiography findings are summarized in Table
3. Two representative images are shown in Figure
1 and 2.
treatment modalities were used in our patients according to
clinical situation and physician judgment. All three patients
who presented with intracranial VA dissection associated with
SAH were treated with endovascular occlusion. This was followed
by surgical clipping of the pseudo-aneurysm in one patient.
Two patients (7%) were treated with intra-arterial thrombolysis.
One of these patients presented with signs of basilar artery
thrombosis. Cerebral angiography revealed extracranial VA dissection
with thrombosis extending to basilar artery. She was treated
with intra-arterial t-PA and made an excellent recovery. The
other patient had dissection with occlusion of one extracranial
VA and hypoplasia of the other artery and developed subacute
progressive brain stem signs. She was unsuccessfully treated
with intra-arterial Urokinase. Eight patients (30%) received
antiplatelet agents as the only treatment and 13 patients (50%)
received anticoagulation treatment. The duration of anticoagulation
was very variable. This was for less than a week in four patients,
for two months in two patients and for six months in another
three patients. The duration of anticoagulation could not be
identified in four patients.
the 20 patients who were available for follow-up, eight (40%)
had no residual neurological deficit. Eight patients (40%) had
mild residual symptoms. These consisted of mild imbalance and
dizziness in six patients, partial visual field defects in two
and difficulty with fine motor movements in one patient. Two
patients (10%) were left with disabling deficits. Two other
patients in our series died in the acute stage. Only two patients
(10%) have had recurrent neurological symptoms that were transient
in both cases.
dissection is an important cause of stroke in young patients.
The incidence of VA dissection is not known precisely.
Once thought to be relatively uncommon, it is now being recognized
more frequently. In our series, more than 60% of the cases studied
were diagnosed in the last two years compared to only one patient
diagnosed before 1995. During 1998, ten patients with VA dissection
were identified in our institute. Although some earlier reports
suggested a predominance of VA dissection in females,[5,6]
our data did not show any significant difference in incidence
between women and men. With a mean age of 48, the present study
also confirmed that VA dissection mainly affects middle-aged
found a precipitant factor in 53% of our patients. Sports activity
and chiropractic manipulation were again prominent precipitating
factors. After reviewing 90 reported cases of VA dissections
in the literature, we found that a similar percentage (49%)
was associated with minor trauma or neck manipulation.[2,5,7,8-12]
It is important to inquire in detail about recent physical activities
if arterial dissection is suspected as the etiology of a stroke.
role of trivial, unnoticed trauma producing dissection is not
clear. It has been suggested that patients with "spontaneous"
VA dissection may have had unrecognized trauma or sudden neck
motion that was forgotten or considered insignificant by the
patient and thus not reported to the physician.
in our series was a crucial symptom seen in the majority of
patients (88%). This was mainly headache with or without neck
pain. Typically, the headache was occipital and severe in nature.
Our data are consistent with previously reported cases of reported
neck pain or headache in 76-100% of VA dissection patients.
and neck pain were also an important warning sign before the
onset of stroke. This was reported by 53% of the patients, one
day to two weeks before the onset of their stroke. Some of the
patients had sought medical advice for these early signs. One
patient, who presented initially with acute neck pain and vertigo,
underwent lumbar puncture to rule out SAH and then was discharged
from hospital, presented later with brain stem infarction.
extracranial cerebral arteries are known to be pain sensitive
and the pain may be a signal of mural hemorrhage. According
to Sturzenegger,3 who studied warning symptoms in 44 patients
with internal carotid artery dissection, this pain seems to
be a key symptom with regard to starting anticoagulation before
cerebral infarction has occurred. This may be of similar importance
in VA dissection, especially with the observation in our study
that 12% of patients had no abnormal signs on presentation and
many presented with minimal signs. Some patients repeatedly
presented to the emergency room before developing brainstem
or cerebellar strokes. Four other important symptoms reported
by about half of our patients were: (1) vertigo; (2) nausea
or vomiting; (3) unilateral facial numbness (this symptom was
subjective and no abnormality was found by sensory testing);
of our patients presented with SAH due to intracranial segment
VA dissection. Their age was relatively older than the other
patients (54, 55 and 76-years-old). Two were diabetic and one
was hypertensive. Two patients had a favorable outcome with
no significant deficit. However, one patient died due to hydrocephalus
and other complications. SAH as a complication of intracranial
VA dissection has been reported before in the literature.[15-18]
The proposed mechanism is a dissecting hematoma that originates
between the media and adventitia. This is more likely to happen
in intracranial arteries which lack a well-developed external
elastic membrane and have muscularis and adventitial layers
that are only about two-thirds as thick as extracranial arteries.[17-19]
VA dissection was found in six patients (23%). This was also
found in previous reports in a range between 15%-61%.[6,8,10,11]
Compared to patients with unilateral VA dissection, patients
with bilateral VA dissections tended to have a more severe presentation.
Two such patients developed bilateral pontine infarction signs,
while another two had cerebellar infarction. One had lateral
medullary syndrome and one patient had posterior cerebral artery
territory infarction. Multi-vessel involvement in the absence
of a history of trauma raises the possibility that an underlying
arteriopathy may predispose the vessels to dissection. Only
two patients had angiographic evidence of fibromuscular dysplasia.
No other vascular abnormalities could be identified. The possibility
of an as yet unknown arteriopathy in some of the cases cannot
be entirely excluded.
angiography was not used as a diagnostic modality in one of
our patients. This patient was diagnosed on the basis of his
typical clinical presentation, as well as evidence of dissection
on MR angiography (Figure
3). Some recent reports suggested that new noninvasive methods,
like vertebral Doppler, magnetic resonance imaging and angiography,
are useful in detection and monitoring of VA dissection.[9,20,21]
overall prognosis was good on clinical follow-up in the majority
of patients. Almost 80% made complete or near complete recovery.
The most important factors associated with unfavorable prognosis
(disabling outcome or death) were (1) bilateral dissection;
(2) dissection associated with subarachnoid hemorrhage.
recurrence rate of strokes or transient ischemic attacks was
very low, occurring in two patients during the available follow-up
conclusion, VA dissection is increasingly being diagnosed. It
mainly affects middle-aged persons and both sexes are equally
affected. Headache and/or neck pain are prominent features that
may precede onset of stroke by several days. Although the majority
of patients will have excellent prognosis, this was less likely
in patients presenting with SAH or bilateral VA dissection.
Recurrence rate was low.
authors thank Heather Richardson; Research Co-ordinator, Clinical
Trials, University of Alberta Hospital in data collection and
Dr. Muzaffar M Siddiqui; Research Fellow, Stroke Research Unit,
University of Alberta Hospital for editing this manuscript.
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From the Department of Medicine, Division of Neurology
(A.B.S., A.S., D.E.) and Neurosurgery (G.A.-S.), University
of Alberta, AB, Canada
Received December 7, 1999. Accepted in final form February
Reprint requests to: Ashfaq Shuaib, Professor of Medicine
and Director of Neurology, University of Alberta Hospital,
Rm 2E3.13, Edmonton, AB T6G 2B7 Canada.
J. Neurol. Sci. 2000; 27: 292-296