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 41-year-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-year-old 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.
Highlights
The incidence of stroke among patients aged >65 years has decreased over the past couple of decades; population-based studies have shown a growing incidence of ischemic strokes in young adults [1]
While both internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD) are associated with headache and neck pain and delayed ischemic events, ICAD could be recognized earlier due to its presentation with focal neurological signs as Horner syndrome [5]
Spontaneous VAD typically begins with ipsilateral neck pain or headache, while ischemic events with focal neurological signs could be delayed for days or even weeks
Summary
The incidence of stroke among patients aged >65 years has decreased over the past couple of decades; population-based studies have shown a growing incidence of ischemic strokes in young adults [1]. CAD is usually associated with trauma, spontaneous dissection is being increasingly reported with the advent of advanced neurovascular imaging [4] While both ICAD and VAD are associated with headache and neck pain and delayed ischemic events, ICAD could be recognized earlier due to its presentation with focal neurological signs as Horner syndrome [5]. Conventional cerebral angiography was performed, which revealed bead-like stenosis of the V1 segment of the right vertebral artery with distal dilatation and heterogeneous irregularities of the lumen (Figure 6A), which was evaluated as a pearl and string sign. Cerebral conventional angiography of right vertebral artery; cervical part (A) showing bead-like stenosis of V1 segment (arrows) followed by heterogeneous irregularities of the lumen (head arrows) (pearl and string sign); intracranial part (B) revealed another tapered stenosis after the branching of the posterior inferior cerebellar artery (arrows), with distal dilatation and intimal flap rising (head arrow). Because of her good recovery from all symptoms, she refused to undergo a follow-up CTA three months later
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