BrazJOtorhinolaryngol.2017;83(3):367---369
www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
CASE
REPORT
Vertebral
artery
dissection:
an
important
differential
diagnosis
of
vertigo
夽
Dissecc
¸ão
da
artéria
vertebral:
um
importante
diagnóstico
diferencial
de
vertigem
Maíra
da
Rocha
∗,
Bruno
Higa
Nakao,
Evandro
Maccarini
Manoel,
Guilherme
Figner
Moussalem,
Fernando
Freitas
Gananc
¸a
UniversidadeFederaldeSãoPaulo(UNIFESP),DepartamentodeOtorrinolaringologiaeCirurgiadeCabec¸aePescoc¸o,SãoPaulo, SP,Brazil
Received10March2015;accepted18August2015 Availableonline27November2015
Introduction
Vertebralarterydissection(VAD)isanimportantdifferential
diagnosisinpatientswithvertigo,andcanbeconfusedwith
vestibularmigraine.VADcancausestrokeinyoungpatients,
anditsestimatedincidenceis1---1.5/100,000/year.1
Case
report
SV,female,34,reportedhigh-intensity,stabbingleft
tem-poral headache with continuous occipital and posterior
cervical radiation, which had started two daysbefore. In
the preceding day, the patientexperienced disabling
ver-tigoandvomitingthatworsenedwithheadmovement.The
patientwenttothe hospitalwhere herconditionpartially improvedwiththeuseofanti-vertigoandpainkiller
medi-cations.Acomputedtomographyofherheadwasobtained
夽 Please cite this article as: Rocha M, Nakao BH, Manoel EM,
MoussalemGF,Gananc¸aFF.Vertebralarterydissection:an impor-tant differential diagnosis of vertigo. Braz J Otorhinolaryngol. 2017;83:367---9.
∗Correspondingauthor.
E-mail:[email protected](M.Rocha).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileirade OtorrinolaringologiaeCirurgiaCérvico-Facial.
andwasinterpretedasnormalandthepatientwasreleased withapresumptivediagnosisofvestibularmigraine.Hours
later,her problem evolved withdiplopia, dysphagia,
dys-phonia, difficulty coughing, and oscillopsia; the patient
returnedandwasadmittedtothehospital.Shehada
his-tory of hypothyroidism and migraine (eight years before,
thepatientsufferedapulsatile-typefrontalheadacheinher
premenstrualperiod,whichstoppedwiththeuseofcommon
painkillerdrugs), andwas takingoral contraceptives.She hadnohistoryofcervicaltrauma.Atadmission,herphysical examinationrevealedabroad-basedslowgaitandleft-side
ptosis,enophthalmos,andmiosis,withan arrhythmic
pat-tern, and horizontal spontaneousnystagmus to the right.
Cerebellar tests indicated severe dysmetriaand
eudiado-cokynesis.Tactilehypoesthesiaintheleftfacialhemisphere
andrighthemibodywereobserved;thislatter findingwas
associatedwith thermal hypoesthesia.No change in
mus-cle strength was noted. Magnetic resonance angiography
ofthe carotidandvertebralarteries wasobtained,
show-ing left vertebral artery dissection (VAD) with posterior
inferiorbulbinfarction(Figs.1---3).Thesearchfor autoim-munediseasethroughautoantibodysurveyandforinfectious diseases(humanimmunodeficiencyvirus,syphilis,and cul-tures)wasnegative.Thevideoheadimpulsetestsuggested hypofunctionwithlesserlateral-andleftanterior-channel gain(Fig.4).Anticoagulationwithfull-doseenoxaparinwas initiatedduringhospitalization,laterreplacedbywarfarin,
http://dx.doi.org/10.1016/j.bjorl.2015.08.020
368 RochaMetal.
Figure1 Angioresonanceshowingafillingdefectofleft
ver-tebralartery,suggestiveofvertebralarterydissection.
andresulted in a slowand gradual clinical improvement.
The patient was discharged after 18 days of
hospitaliza-tion.Threemonthsafterherhospitaldischarge,thepatient was receiving vestibular rehabilitation and daily physical
Figure2 Angioresonancedemonstratingafillingdefectofleft
vertebralartery(posteriorview).
Figure3 Axial T2-weightedmagneticresonanceimagingof
thebrainwithhyperintensesignalintheposteriorinferiorbulb region.
therapy,withprogressiveimprovementinmotorskills.She iscurrentlywalkingunassisted,butwithslightimbalance.
Discussion
Connectivetissuediseases andtrauma areriskfactorsfor
VAD, but such occurrences are absent in most patients,
requiringstrongclinicalsuspicionfortheirdiagnosis.1
The association with migraine is well documented;
migrainecanactasapredisposingfactorfornontraumatic
VAD. It is postulated that repeated episodes of migraine
couldcausetheinvolved arteriestobecomevulnerableto
dissection.2
In a systematic review, vertigo was the most common
symptom, present in 58% of cases of VAD, followed by
headacheandneckpain,whichweretheinitialsymptoms
in67%ofcases.1Thevertebralarterycannourishthe cervi-calanteriorspinalartery;anassociation betweenVADand cervicalcordischemiahasbeendescribed.3
The present case is characteristic of Wallenberg
syn-drome, caused by the occlusion of the posterior inferior
cerebellarartery, usuallyasa resultofVAD,in which the patientpresentswithdysphagia,dysphoniathrough
involve-ment of the nucleus ambiguous of the vagus, vertigo,
sensory changes in the face, ipsilateral Horner and
cere-bellarsyndromes,andthermalandalgichemianesthesiaof
contralateralbody.4
Vertebralarterydissection:animportantdifferentialdiagnosisofvertigo 369
Lateral Impulse Test: 28/04/2014 15:17 Test Operator: Default Administrator
LARP Impulse Test: 28/04/2014 15:20 Test Operator: Default Administrator
Left Mean: 0.45, σ: 0.12 Right Mean: 0.94, σ: 0.39
LA Mean: 0.27, σ: 0.37 RP Mean: –0.14, σ: 0.21
Left Mean Right Mean LA Mean RP Mean LA RP Left Right Gain
Head & Ey
e v
elocity
Head & Ey
e v elocity 1.6 300 200 0 –100 300 200 0 –100 –140 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0
40 60 80 100120140160180200 300 0 560 –140 0 560
Peak velocity (deg/sec) Left lateral ms
Head & Ey
e v elocity 300 200 0 –100
–140 0 560
Left anterior ms
Right lateral ms
Head & Ey
e v elocity 300 200 0 –100
–140 0 560
Right posterior ms 220240260280 Gain 1.2 1.0 0.8 0.6 0.4 0.2 0.0
40 60 80 100120140160180200 300 Peak velocity (deg/sec)
220240260280
Figure4 Videoheadimpulsetestshowingdecreasedgaininleftlateralandanteriorchannels.Left,leftlateralchannel;Right,
rightlateralchannel;LA,leftanteriorchannel;RP,rightposteriorchannel.
improvesthe prognosis,whichemphasizestheimportance
of early diagnosis.1,2 Due to possible adverse effects of
anticoagulants,in many cases, preference is givento the
useofantiplateletagents.2 TheCADISSstudywasthefirst
randomized clinical trial to compare antiplatelet versus
anticoagulant treatment for extracranial cases of carotid
and vertebral artery dissection. After three months of
treatment, nodifferences weredetected between groups
regardingdeathorstroke.5
Stroke wasdiagnosedin63% ofcases,withthehighest
prevalence in patients with extracranial dissection;
sub-arachnoidhemorrhagewasobservedin10%ofcases,allof
themwithintracranialVAD,probablyduetothelongcourse ofthearterythroughthesubarachnoidspace.1Studying bul-barinfarction,Kim etal.statedthat VADwasresponsible
for 9.2% of the cases, and that 34.5% of these cases had
beencausedbylarge-vesselatherosclerosis,thathasbeen
blamed asthe primary etiology.6 Most cases of VAD have
a good progression, witha poor prognosis in only 10% of
patients.1
Conclusion
Asthisisapotentiallytreatablecauseofstroke,VADshould
be considered in patients with vertigo and craniocervical
pain,eveninthosewithout riskfactors.Early diagnosisis
criticalfortheearlyinstitutionofanticoagulationtoprovide thebestopportunityforanimprovedprognosis.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.GottesmanRF,SharmaP,RobinsonKA,ArnanM,TsuiM,Ladha K,etal.Clinicalcharacteristicsofsymptomaticvertebralartery dissection.Asystematicreview.Neurologist.2012;18:245---54.
2.YenJ-C,ChanL,LaiY-J.Vertebralarterydissectionpresented aslateralmedullarysyndromeinapatientwithmigraine:acase report.ActaNeurolTaiwan.2010;19:275---80.
3.TakahashiPG,CuryRG,LopesCG,SimabukuroMM,MarchioriPE. Unilateralnontraumaticvertebralarterydissectionwithcervical spinalcordinfarction.ArqNeuropsiquiatr.2012;70:162.
4.SarrazinJ-L,ToulgoatF,BenoudibaF.Thelowercranialnerves: IX,X,XI,XII.DiagnIntervImaging.2013;94:1051---62.
5.CADISStrialinvestigators,MarkusHS,HayterE,LeviC,Feldman A,VenablesG,etal.Antiplatelettreatmentcomparedwith anti-coagulationtreatmentforcervicalarterydissection(CADISS):a randomisedtrial.LancetNeurol.2015;14:361---7.
