There are several risk factors for arterial dissection, including history of trauma to cervical spine, history of migraine-type headache, hypertension, hypercholesterolemia, cardiac diseases, vascular diseases, previous cerebrovascular ischemic attacks, diabetes mellitus, infections, blood clotting disorders, alterations in blood properties (eg, hyperhomocysteinemia), systemic connective tissue pathologies (eg, Ehlers–Danlos syndrome), anticoagulant therapy, oral contraceptives, long-term use of steroids, and current smoking.[6–8] Our case did not have any of the risk factors, and the mechanism of VA dissection caused by golf swing was deliberated.
Professional golfers look at the position of the ball on the tee or ground until they complete their follow-through (Figure 2A-a). With this type of swing, the VA is not significantly elongated or twisted (Figure 2A-b) because keeping the direction of the face same as standing direction causes little head rotation for the body trunk. In contrast, amateur golfers often look in the direction that the ball travels at the beginning of their follow-through (Figure 2B-a). In this swing, the head rotates to the left rapidly, although the body trunk remains turning to the front, causing excessive rotation of the head. The unilateral maximum range of movement between occiput and C1 is 5 degrees and that between C1 and C2 is 40 degrees. Head rotation causes little retraction or distortion of the VA segment between the C1 transverse foramen and the portion penetrating the dura, whereas the VA is elongated and twisted by the rotation between the C1 and C2 transverse foramens where the gap of the horizontal locations of the transverse foramens is greatly increased (Figure 2B-b). The right VA is predominantly distressed by the golf swing in a right-handed player (Table) as it has been reported that the reduction of blood flow during head rotation is recognized in the contralateral VA by the mechanical stress.[8,10,11]
Golf swing and VA distortion. A-a, A professional golfer looks at the position of the ball on the ground or tee until their follow-through is completed. This swing keeps the direction of the face same as standing direction and causes little head rotation for the body trunk. A-b, The VA stays straight in the transverse foramens as long as the position of the head and the body are straight. B-a, Some amateur golfers look at the direction that the ball travels at the beginning of their follow-through. In this swing, the head rotates to the left rapidly although the body trunk remains turning to the front. B-b, The rapid excessive rotation of the head to the left causes excessive elongation and distortion of the right VA.
The mortality from VA dissection caused by sudden head rotation is 18%, whereas that from VA dissection because of atherosclerosis is less than 5%. Only 3 cases of the VA dissection caused by swinging a golf club have been documented with imaging studies in the literature.[1–3] A pearl and string appearance along the VA on angiography is typical of atherosclerosis-related VA dissection, whereas severe stenosis or complete occlusion at a certain point of the VA is commonly identified in head rotation– induced VA dissection.[13,14] When the tunica media and the adventitia are split and blood flow enters in the split space, the adventitia is pushed outside creating a fusiform-type aneurysm that demonstrates a pearl and string appearance in imaging studies. When blood flows between the tunica intima and media, the tunica intima is displaced toward the lumen side causing stenosis or occlusion of the artery.[16,17] Based on this theory, the tunica intima tends to be damaged in head rotation–induced VA dissection. When the head rotation–induced VA dissection is not fatal, it substantially resolves and rarely reveals recurrence of ischemic attacks because of younger age and the lack of artherosclerotic disease in most of the patients. All previously reported cases demonstrated good prognoses (Table), and the occlusion of the VA completely resolved in 1 month in our case; however, a fatal brain stem infarction might have occurred if the bilateral P-com arteries had been the adult type. Head rotation–induced VA dissection is potentially fatal, and death from VA dissection caused by chiropractic neck manipulation or playing basketball has been reported.[5,7]
Vertebral artery dissection caused by swinging a golf club is extremely rare; however, it is crucial to use a textbook-like swing form without maximum force to avoid potentially fatal, traumatic VA dissection.
The authors report no funding or conflicts of interest.
Clin J Sport Med. 2014;24(2):155-157. © 2014 Lippincott Williams & Wilkins