Abstract W P35: Is it Safe for Patients with Acute Cervical Vertebral Artery Dissection to Rotate Their Head During the Early Period of Dissection?

Abstract

Introduction: The authors present a prospective series of 4 consecutive patients with symptomatic acute spontaneous cervical vertebral artery dissection (VAD) in which a dynamic catheter cerebral angiogram conclusively demonstrated adverse near complete or complete occlusion of the dissected VA associated with rotation of the head. We present clinical and angiographic data and management of these patients not previously reported in the literature. Methods: From 2012 to 2014, we performed a prospective study of 4 consecutive patients with spontaneous acute cervical VAD. We reviewed initial and follow up clinical data and diagnostic imaging including magnetic resonance angiogram (MRA) or computed tomographic angiogram (CTA) of head and neck and dynamic catheter cerebral angiogram. Results: A total of 4 patients (Age 36 +/- 5.4; M=3, F=1) presented with acute cerebellar or brain stem stroke due to a total of 6 cervical VAD at the level of V3 (N=4) and V2 (N=2) segments diagnosed by CTA or MRA. Initial mRS and NIHSS scores on admission were 3 +/- 0.8 and 1.5 +/-1, respectively. Dynamic cerebral angiogram performed with patient’s head in neutral position showed VAD with average stenosis of 74.16 % +/- 20.59. Near complete or complete occlusion of the dissected VA was observed and associated with worsening neurological symptoms when the head was rotated beyond 45 degrees to the right side (N=3) and left side (N=3). All patients were treated with daily Aspirin and Plavix for at least 3 months and placed on cervical collar for one month to prevent rotational occlusion of VA. Repeat dynamic cerebral angiogram at 2.5 months +/- 1.91 showed resolution of the VAD. Clinical follow up evaluation at 11.5 months +/- 8.5 showed mRS score of 1.5 +/- 1.0 and NIHSS score of 0.75 +/- 0.96 with no recurrence of stroke. Conclusion: Patients with cervical VAD may be at risk of developing ischemic or embolic stroke associated with rotation of the head. Current diagnostic imaging studies are performed with the patient’s head in neutral position and fail to show dynamic changes of VAD. The authors emphasize the importance of performing dynamic cerebral angiogram during the evaluation of patient with VAD and consider changes in the Guidelines on the Diagnosis and Management of Cervical VAD.