4: Vertigo after MVA
A woman in her 40’s is discharged from the ED with right shoulder and neck pain after she was T-boned driving her car.
She returns 17 days later with vomiting and vertigo but no headache or abdominal pain. A neurological evaluation and head CT demonstrate no abnormality. Two days later she returns yet again with persistent non-positional vertigo. She keeps her eyes closed because it is so bad. Neurologic exam is again unremarkable without nystagmus, Romberg abnormality or dysmetria. She has a screening study for further evaluation which is abnormal. This is followed by the diagnostic study below.
What is the diagnosis? Â What is the treatment?
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ANSWER:
The image is an MRA of the Carotid and Vertebral arteries. The right vertebral doesn’t fill as well as the left, does it? That is because this patient had a vertebral dissection related to the MVA, a subsequent visit to the chiropractor or both. The MRI showed multiple strokes in the posterior circulation. Better to diagnose this one and treat with blood thinners before it progresses to a basilar artery occlusion. Note how the right vertebral artery does not fill well on the MRA.
Carotid/Vertebral Dissection from “Quick Essentials“
Sx: Sudden or gradual neck/face pain p even minor trauma; Delayed TIA/CVA
Precipitants: Twist, fall, cough, sneeze, vomit, yoga, painting, archery
Risks: PCKD, Marfan, HTN, Ehler Danlos, SLE, OB
Carotid: Face/anterior neck pain. Horner’s, pulsatile tinnitus,
Signs: CN12 > MCA stroke findings
Vertebral: Neck/occipital/supraorbital pain, mimics strain, V, Vertigo
Signs: Horners, CN, brainstem, CBL
Tests: Duplex, MRA, CT-angiogram
Rx: Heparin (contraindicated if intracranial extension) > IR > (OR)
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