Delayed Presentation of Vertebral Artery Dissection

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. 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.

A female patient sustained neck trauma. An uneven C5–6 disc space and a small avulsed bony fragment were demonstrated on a CT C-Spine. The GCS dropped to 12 (E3 V4 M5). MRI 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.

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 33–39% of cases. That of CTA has a pick-up of 30%. Angiography is the gold standard, but it is invasive. It is prone to complications in critically ill patients. MRI angiography is noninvasive requiring no contrast is best suited for critically ill patients. CTA is more optimal and noninvasive and produces images having three-dimensional manipulations.

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