A 39-year-old, right-handed male amateur golfer swung a driver with nearly maximum force while playing golf. Suddenly, he felt intense pain in his right neck that spread to the right occipital area. The patient also felt dizziness and vomited twice. These symptoms disappeared in 15 minutes, and he went home to rest. The next morning, he visited our clinic complaining of stiffness in his right neck. No neurological deficits were identified; however, magnetic resonance (MR) imaging demonstrated acute small infarction in the right cerebellar hemisphere (Figure 1A, white arrowheads), and MR angiography showed complete occlusion in the VA union (Figure 1A, white arrow). Although no blood flow was supplied from the bilateral VAs, the basilar artery was not occluded because of sufficient blood supply from the bilateral fetal-type posterior communicating arteries (P-com arteries) (red arrows). Three-dimensional computed tomographic angiography (3D-CTA) revealed complete occlusion of the right VA from the extradural portion (Figure 1B, white arrowheads) to the VA union (Figure 1B, white arrow). The bilateral VAs from C3 level to the intradural segments are shown in Figure 1C. The left VA was hypoplastic in the intradural segment but definitely enhanced from the C3 to C1 level (Figure 1C, black arrows). On the other hand, the right VA enhancement was not clearly identified from C2 level to the intradural portion, although definite enhancement of the right VA was recognized at the C3 level (Figure 1C, red arrowheads). The patient was admitted to our hospital for 1 week to prevent stroke progression. Oral aspirin (100 mg/d) and intravenous low–molecular weight dextran (500 mL/d) were administered during admission. Oral aspirin was continued after he was discharged from our hospital. One month after the onset of stroke, follow-up 3D-CTA showed complete recanalization of the right VA (Figure 1D), and the aspirin was discontinued.
Magnetic resonance imaging (MRI), MR angiography (MRA), and 3D-CTA. A, MRI demonstrates a small high-signal area in the right cerebellar hemisphere (white arrowheads) on both T2-weighted (left) and diffusion (center) images, suggesting fresh ischemic changes. The bilateral VAs are not identified on MRA (right) with complete occlusion at the VA union (white arrow). The bilateral P-com arteries are of the fetal type supplying blood flow to the posterior circulation (red arrows). B, The right VA is completely occluded from the cervical portion (white arrowheads) to the VA union (white arrow) in 3D-CTA. The left VA is hypoplastic showing the VA–posterior inferior cerebellar artery ending. C, Enhancement of the VA in the transverse foramens is identified from C3 to C1 on the left side (black arrowheads), although the enhancement is not detected in the distal segment of the right VA from the C2 transverse foramen (red arrowheads). D, 3D-CTA, performed 1 month after stroke onset, showed complete recanalization of the right VA (yellow arrowheads and arrow). The left VA is still absent, suggesting aplasia.
Clin J Sport Med. 2014;24(2):155-157. © 2014 Lippincott Williams & Wilkins