Clinical Characteristics of Symptomatic Vertebral Artery Dissection

A Systematic Review

Rebecca F. Gottesman, MD, PhD; Priti Sharma, MBBS; Karen A. Robinson, PhD; Martinson Arnan, MD; Megan Tsui, BA; Karim Ladha, BA; David E. Newman-Toker, MD, PhD

Disclosures

Neurologist. 2012;18(5):245-254. 

In This Article

Abstract and Introduction

Abstract

Background: Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed with adverse consequences. We assessed the frequency of head/neck pain, other neurological symptoms, and cerebrovascular events in symptomatic VAD.
Methods: We conducted a systematic review of observational studies, searching electronic databases (MEDLINE, EMBASE) for English-language manuscripts with >5 subjects with clinical or radiologic features of VAD. Two independent reviewers selected studies for inclusion; a third adjudicated differences. Studies were assessed for methodological quality, and clinical data were abstracted. Pooled proportions were calculated.
Results: Of 3996 citations, we screened 511 manuscripts and selected 75 studies describing 1972 VAD patients. The most common symptoms were dizziness/vertigo (58%), headache (51%), and neck pain (46%). Stroke was common (63%), especially with extracranial dissections (66% vs. 32%, P<0.0001), whereas transient ischemic attack (14%) and subarachnoid hemorrhage (10%) were uncommon. Subarachnoid hemorrhage was seen only with intracranial dissections (57% vs. 0%, P=0.003). Fewer than half of the patients had obvious trauma, and only 7.9% had a known connective tissue disease. Outcome was good (modified Rankin scale 0 to 1) in 67% and poor (modified Rankin scale 5 to 6) in 10% of patients.
Conclusions: VAD is associated with nonspecific symptoms such as dizziness, vertigo, headache, or neck pain. Ischemic stroke is the most common reported cerebrovascular complication. VAD should be considered in the diagnostic assessment of patients presenting with dizziness or craniocervical pain, even in the absence of other risk factors. Future studies should compare clinical findings as predictors in well-defined, undifferentiated populations of clinical VAD suspects.

Introduction

Vertebral artery dissection (VAD) is one of the most common identifiable causes of stroke in those aged 18 to 45,[1] with an estimated annual incidence between 1 and 1.5 per 100,000.[2] As VAD is a potentially treatable cause of transient ischemic attack (TIA) and stroke,[3] and the greatest risk of stroke in craniocervical dissections seems to occur in the first few weeks after dissection,[4] prompt diagnosis is essential. Unfortunately, VAD is not always easily recognized, and young patients with missed VAD may suffer potentially disastrous neurological complications or death.[5]

Frank presentations of stroke, TIA, or subarachnoid hemorrhage (SAH) are likely to initiate an inpatient hospitalization and complete diagnostic workup, including vascular imaging, but patients with VAD may present with nonspecific complaints such as dizziness with neck pain or headache with nausea and vomiting. Although VAD is more likely to be considered in patients with a clear history of trauma or with known underlying connective tissue disease, in some cases neither of these known risk factors is present.

The literature describing VAD is varied in quality and content, and many studies report on only a few patients. The purpose of this study was to conduct a systematic review of studies reporting clinical and radiographic data on individuals with VAD, to determine both the level of evidence available on this topic, and to identify core clinical features of the syndrome. We sought to characterize the frequency of various symptoms, ischemic complications, and spectrum of outcomes in individuals with VAD.

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