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Vertebral Artery Dissection

Summary

  • Vertebral artery dissection (VAD) is a tear in the inner lining of the vertebral artery, leading to intramural haematoma formation
  • Presents with neck pain, headache, and posterior circulation ischaemic symptoms
  • Diagnosis relies on clinical presentation and neuroimaging findings1

Pathophysiology

  • Intimal tear allows blood to enter the arterial wall, creating a false lumen
  • Mechanisms:
    • Spontaneous: often associated with connective tissue disorders
    • Traumatic: minor trauma or sudden neck movements
  • Consequences:
    • Luminal stenosis or occlusion
    • Thrombus formation and distal embolisation
    • Subarachnoid haemorrhage (rare)

Demographics

  • Incidence: 1-1.5 per 100,000 per year
  • Age: typically affects young to middle-aged adults (mean age 40-45 years)
  • Gender: slight female predominance
  • Risk factors:
    • Hypertension
    • Smoking
    • Migraine
    • Oral contraceptive use
    • Connective tissue disorders (e.g., Ehlers-Danlos syndrome, Marfan syndrome)

Diagnosis

  • Clinical presentation:
    • Neck pain or occipital headache (often unilateral)
    • Posterior circulation ischaemic symptoms:
    • Vertigo
    • Diplopia
    • Ataxia
    • Lateral medullary syndrome (Wallenberg syndrome)
  • Physical examination:
    • Horner's syndrome (ipsilateral miosis, ptosis, and anhidrosis)
    • Nystagmus
    • Cerebellar signs
  • Laboratory tests:
    • No specific blood markers for VAD
    • Consider testing for connective tissue disorders if suspected

Imaging

  • CT angiography (CTA):
    • First-line imaging modality
    • Findings:
    • Eccentric luminal narrowing
    • Intramural haematoma (crescent sign)
    • Vessel irregularity or pseudoaneurysm formation
  • MRI and MR angiography (MRA):
    • Superior soft tissue contrast
    • Findings:
    • Intramural haematoma: hyperintense on T1-weighted fat-suppressed images
    • Luminal narrowing or occlusion on MRA
  • Digital subtraction angiography (DSA):
    • Gold standard for diagnosis
    • Reserved for cases with equivocal non-invasive imaging or when endovascular treatment is planned
    • Findings:
    • String sign (long, irregular narrowing)
    • Pearl-and-string sign (alternating dilatations and stenoses)
    • Pseudoaneurysm formation

panels-1

  • A 30-year-old patient presented with dizziness, nystagmus, dysphagia and ataxia.
  • CT showed a subtly hyperdense rim around the left V3 vertebral artery (red arrow).
  • The corresponding thrombus caused DWI hyperintensity (red arrow) and T1-shortening on the ToF angiogram (red arrow) next to flow-related signal from the narrowed lumen (blue arrow).
  • The Wallenberg syndrome was caused by a lateral medullary infarct.

Treatment

  • Antiplatelet or anticoagulation to prevent thromboembolic (posterior circulation) stroke; endovascular treatment for refractory cases
  • The crescentic T1-hyperintense intramural haematoma on fat-saturated imaging is the most specific sign

  1. Clark et al. A review of carotid and vertebral artery dissection. 2022. British journal of hospital medicine (London, England : 2005) - Open in new tab. ↩