A 49-year-old Man With Neck Pain, Vertigo, Headache, and Ataxia

Andrew N. Wilner, MD

Disclosures

March 10, 2010

Case History

One week before admission, a 49-year-old man awoke with neck and shoulder pain and felt that he had "slept wrong." He tried to alleviate the pain using an "inversion table," without success. The next day, while sitting at his desk, he suddenly felt dizzy and sweaty and then vomited. He went to the emergency department, was treated with fluids and antiemetics, and was sent home. That night, he developed severe pain from the back of his neck to the top of his head, which increased when he blew his nose or defecated. The following day, his family noted that he was listing to the left when he walked, as if he were drunk. He saw his family doctor, who ordered a computed tomography (CT) scan of his brain and subsequently sent him to the emergency department.

The patient reported no head or neck trauma. He had no double vision, numbness, tingling, weakness, or fever.

He has no history of diabetes, hypertension, heart disease, or any other major illness. He takes no medicines, has no allergies, and doesn't smoke or drink. He is an office worker, is married, and has 3 children. Family history is negative for stroke, aneurysms, and connective tissue disease.

On examination, he is anxious, alert, and cooperative. Blood pressure is 130/90 mm Hg, heart rate is 70 beats/min, respiratory rate is 20 breaths/min, and temperature is 36.7 degrees F. Medical examination findings are normal. Neurologic examination reveals normal cranial nerves without nystagmus, normal motor reflexes, and normal results on sensory examination. Finger-to-nose, heel-to-shin, rapid alternating movements, and foot tapping findings are normal. However, he is unsteady on his feet and cannot tandem walk.

CT of the brain reveals a left medial cerebellar infarct. This is better visualized on subsequent magnetic resonance imaging (Figure 1).

Figure 1.

Increased T2-weighted magnetic resonance imaging signal of medial aspect of lower left cerebellar hemisphere and left side of lower vermis.

Magnetic resonance angiography of the neck reveals a dissection in the extracranial portion of the left vertebral artery (Figure 2). The other blood vessels are normal.

Figure 2.

Focal narrowing of the lower cervical segment of the left vertebral artery.

CT angiography of the neck confirms the filling defect in the left vertebral artery at the C5 level, consistent with a vertebral dissection, intraluminal thrombus, or embolus.

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