Spontaneous Vertebral Artery Dissection Is an Under-Recognized Cause of Stroke in Young Patients: Two Case Reports and Review

Abstract

Cervicocerebral artery dissection (CAD) is an important and under-recognized cause of strokes in young and middle-aged patients. Spontaneous vertebral artery dissection (VAD) is a rare condition that can potentially cause a stroke without any preceding trauma or other causes of dissection. VAD rarely simulates classical headache syndromes. In this report, we discuss two young patients who were initially misdiagnosed as cases of headache until they presented with ischemic events, and were eventually diagnosed with spontaneous VAD. Case 1 involves a 41year-old male patient who presented with severe headache radiating to left posterior neck pain and dizziness. He was initially misdiagnosed as a case of cervicogenic headache. He was subsequently diagnosed with extracranial VAD complicated by a delayed embolic ischemic stroke. However, he made full recovery within the next few days. Case 2 pertains to a 33-yearold female patient who presented with right-sided headache mimicking migraine; later on, new neurological signs prompted a diagnosis of acute ischemic infarction as a complication of intracranial VAD. In conclusion, VAD should be seriously considered when dealing with patients complaining of the first attack of headache that mimics migraine or those with cervicogenic headaches, which fail to respond to the usual treatment. Moreover, posterior circulation stroke among young patients or stroke with pain in the head and neck should be investigated carefully with extensive neuroimaging. Finally, prompt and accurate diagnosis of VAD followed by proper treatment is crucial for good outcomes and will prevent disability or even fatal complications in patients.

Atraumatic Vertebral Dissection in a Patient With Altered Mental Status

“…Pain is often a frequent preceding symptom, especially in traumatic dissections, and in spontaneous dissections, it can be delayed for hours to days [ 7 ]. It is usually characterized as severe, dull, and non-throbbing and generally localized in the upper portion of the neck and occiput, ipsilateral to the side of the dissection [ 8 ]. In our case, the patient presented with generalized neck pain, which many physicians misinterpret as musculoskeletal in nature.…”

Basilar Artery Occlusion Caused by Extracranial Vertebral Artery Dissection on Its Entry into the Transverse Foramen of the C6 Vertebra: Case Report

“…Although spontaneous VAD could be considered, it is also possible that connective tissue diseases, such as Ehlers−Danlos syndrome, which can lead to vascular fragility, may be the cause of this VAD and should be investigated genetically. 13 , 16) In approximately 90% of cases, 17 , 18) the VA runs steeply into the transverse foramen at the level of the C6 vertebra and is prone to be injured by external forces such as flexion or rotation. 12) Even in cases where it is presumed to be spontaneous VAD, there is a certain number of cases that have been preceded by minor trauma such as various sports-related injuries, stretching, or severe coughing.…”

“…12) Even in cases where it is presumed to be spontaneous VAD, there is a certain number of cases that have been preceded by minor trauma such as various sports-related injuries, stretching, or severe coughing. 16) Additionally, the connection point between the longitudinal dorsal artery and the seventh cervical segmental artery during the embryonic development process [17][18][19] could lead to dissection due to its potentially histological fragility. 20) Furthermore, in this case, convulsion and apnea required intratracheal intubation, which delayed the diagnosis.…”

Exploring the Nexus: A Systematic Review on the Interplay of the Methylenetetrahydrofolate Reductase (MTHFR) Gene C677T Genotype, Hyperhomocysteinemia, and Spontaneous Cervical/Vertebral Artery Dissection in Young Adults

“…We reviewed 11 research papers comprising a total of 4,840 patients. From these finalised studies, we identified two case-control studies [ 2 , 5 ], three case reports [ 6 , 13 , 14 ], three narrative reviews [ 3 , 4 , 9 ], one retrospective observational study [ 1 ], one cohort study [ 12 ], and one experimental study [ 15 ]. All the studies include young patients presenting to the hospital with either TIA or stroke, evaluated to identify HHCY and further MTHFR gene C677T polymorphism, or patients with cervical/vertebral artery dissections, presenting with cervicogenic headache, which were often initially misdiagnosed as migraine with aura, until later returning with more serious outcomes.…”

“…Additionally, HCY may contribute to the onset of migraines by generating superoxide anions, leading to oxidative damage to the vascular endothelium and hence this forms the primary presenting complaint of most individuals [ 4 , 21 ]. Elkady et al, in their case studies, concluded that presentations of CAD and VAD are frequently subject to misdiagnosis, and diagnosis is often delayed until ischemic events occur [ 13 ]. They observed that genetic connective tissue conditions, migraine with aura, hypertension, HHCY, and a recent history of infections were reported more frequently in patients with VAD compared to healthy controls.…”