Stroke after a visit to the hairdresser

Abstract

SIR—N Nwokolo and D E Bateman (Sept 20, p 866) describe an acute carotid dissection associated with neck hyperextension in a beauty salon. The key question is did this woman suffer from an intimal-medial defect or was this a cumulative response to trivial traumas by repeated visits to the beauty parlour? In 1992, I described the “beauty parlor stroke syndrome” in elderly women, with subsequent demonstration of vertebral artery flow reduction at the atlanto-occipital junction by hyperextension and rotational movements. The vertebral artery is especially vulnerable to mechanical compression and intimal injury. Magnetic resonance angiography and two-dimensional phase-contrast techniques, to depict in-vivo blood flow, yielded volume flow rates reflecting end-organ perfusion and flow velocity changes in both carotid and vertebral arteries in neutral, sustained hyperextension, and rotational positions. Distinct haemodynamic changes were identified only in the vertebral arteries with selective vulnerability in individuals harbouring a hypoplastic vertebral artery. Carotid flow was not greatly influenced. Recently, 160 patients were studied in this way with sustained hyperextension for 12 min, simulating tracheal intubation. No substantial haemodynamic changes were noted in the carotid circulation; nor was there evidence of dissection. Profound haemodynamic changes (slow flow, reversal of flow and occlusion) were only identified in individuals with hypoplastic vertebral arteries. There was also a higher incidence of stroke on magnetic resonance imaging, indicating that neck hyperextension may be a neglected haemodynamic factor with a pivotal role in the pathogenesis of stroke. Beauty parlour shampooing is generally safe but it may be hazardous for certain people. An individual’s threshold for ischaemic symptoms depends on several factors, including speed and duration of movements, intactness of collateral blood flow, extent of atherosclerosis, and presence of congenital hypoplasia or intimal arterial defects. Early arterial dissection should be suspected if an anterior headache develops after the shampoo, suggesting internal carotidartery dissection rather than a vertebral artery dissection (which usually produces posterior head-andyears of age without cancer and six beyond 40 years of age. Many of the people were initially managed by their local surgeons with an ileostomy, but in only two cases was it documented that this surgery was for extensive rectal disease (at 32 and 33 years). Four individuals from a family with a codon 1557 mutation have had rectums clear of polyps before any surgery at ages 33, 36, 39, and 54 years. Vasen and co-workers make no comment on whether any of their cases had mutations 3' of codon 1440. Restorative panproctocolectomy obviates the need for continued sigmoidoscopy (proctoscopy is probably still required), but is associated with increased stool frequency, incontinence, and postoperative complication rates. If individuals with 3' mutations undergo surgery in their late teens, it is probably advisable that they still have an IRA with a planned colectomy before the age of 40 years. Major improvements in polyp and cancer prevention with dietary starch, non-steroidals, and even gene-related therapy are likely in the future. Families with mutations 3' of codon 1440 should be distinguished from those with mutations between 1250 and 1440. We therefore advocate that decisions about the choice between primary surgery with IRA or restorative proctocolectomy should be based on various factors, such as age, degree of rectal disease, patient’s preference, with mutations between codons 1250–1440 offering only a further guide.