Cardiovascular Injury-Marathon Running

Abstract

HISTORY: A 48-year-old female competitive marathon runner with no significant past medical history developed right sided neck pain while running a race. The patient completed the race at her typical pace, finishing top five in her age group. After the race, her right sided neck pain persisted. Around thirty minutes post-race she began to have sudden onset dizziness, causing her to fall to the ground. While on the ground, she soon developed severe vertigo, nausea, and emesis. EMS was immediately called and she was transported to the hospital. During transport the patient had loss of consciousness. PHYSICAL EXAMINATION: Examination in the emergency room found the patient to be hemodynamically stable. She was noted to be lethargic but arousable, unable to stand due to vertigo, and had continued nausea and emesis. The rest of her physical exam was benign. DIFFERENTIAL DIAGNOSIS: Cardiac arrest Carotid artery dissection Exercise associated hyponatremia Exercise associated hypotension Hemorrhagic stroke Hypoglycemia Ischemic stroke Vertebral artery dissection TEST AND RESULTS: BMP, CBC, Troponin, UDS, EKG, and CT Head without contrast were all normal. CT angiography of the neck: Acute focal right vertebral artery dissection at C2-C3. MRI of the brain and MR angiography of the neck: Right cerebellar vermis infarct and confirmed right vertebral artery dissection at C2-C3 with associated thrombus. Cerebral angiography: Dissection of the right vertebral artery with associated non-occlusive thrombus and distal occlusion of the right PICA. FINAL WORKING DIAGNOSIS: Right vertebral artery dissection and right cerebellar vermis infarct TREATMENT AND OUTCOMES: The patient was started on a heparin drip with transition to warfarin for anticoagulation and secondary stroke prevention. The patient will continue on warfarin for at least 3 months. The patient was admitted to inpatient stroke rehabilitation and discharged to home after 5 days at an independent level. The patient continued to suffer from vertigo for which she was started on Clonazepam 0.5mg three times daily as needed which controlled her symptoms. She is enrolled in vestibular outpatient physical therapy. The patient is determined and plans to run the 2017 Boston marathon which she has already qualified for.