(P17) Head Whip

Chief Complaint : A 33-year-old female with no past medical problems presents with headache and neck pain for 2 days.

History of Present Illness : She states she had a right sided headache that started 2 nights ago. The headache is worsening and is now predominantly on the left sided neck. She reports associated numbness to the face and lips as well feeling off balance. Denies fever, neck stiffness, visual changes, recent tick bites.

Pertinent Physical Exam: Vitals: BP 128/87 HR 76 RR 16 SpO2 100%
Head: normocephalic, atraumatic. No hematoma. No tenderness to palpation.
Eyes: pupils equal, round, and reactive to light.
Neck: full range of motion, no bruit, no swelling, no tenderness to palpation.
Cardiac: regular rate and rhythm, radial and dorsalis pedis pulses 2+.
Lungs: clear to auscultation bilaterally.
Neuro: right sided facial droop with forehead sparing. Decreased sensation to the left upper extremity as compared to right upper extremity. Strength 5/5 to bilateral upper and lower extremities. Unsteady gait.

Pertinent Laboratory Data:

Case Discussion: Initially this patient received Reglan and normal saline, which helped resolve the headache. Due to severe neck pain with neurologic deficits, the patient received a CT head as well as a CTA and MRA of the head and neck. Imaging showed a left vertebral artery intramural hematoma and dissection. The patient was treated with aspirin. It was found during the hospital course that the patient started zumba classes recently and this was likely the cause of the dissection.

A vertebral artery dissection occurs due to compromise of the structural integrity of the arterial wall. Causes generally include minor trauma such as coughing, vomiting, or exercise. Damage to the arterial wall results in hematoma and clot formation, leading to stenosis and possibly stroke.

Symptoms of a vertebral artery dissection include acute and severe unilateral neck pain and/or headache. Neurologic deficits are present in about 70% of patients. Extracranial dissections will usually have bruits and intracranial dissections may more often show subarachnoid hemorrhage.

Imaging modality of choice is CTA or MRA of the head and neck to fully assess vasculature.
Treatment is heparin or TPA if found within 4.5 hours of symptom onset and subsequently 6 months of anticoagulation. About 80% of patients have a full recovery.

References and Acknowledgements (Optional): Britt TB, Agarwal S. Vertebral Artery Dissection. [Updated 2022 Mar 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441827/