Vertebral Artery Dissection: A Pain in the Neck

Vertebral artery dissection (VAD) is increasingly identified as a cause of ischemic stroke in young adults. Patients most commonly present with neck pain, headache, visual disturbance, or focal extremity weakness. We present a case of spontaneous VAD in a patient whose only symptoms at presentation were neck pain and headache. A 42-year-old male presented to the emergency department with one week of left neck pain and headache. Computed tomography (CT) neck with contrast was initially ordered for neck pain. CT neck revealed an incidental anterior communicating artery (ACOM) aneurysm. Digital subtraction angiography (DSA) performed for ACOM aneurysm coiling demonstrated a left VAD, which was the attributable etiology to the patient's presentation. Subsequent magnetic resonance angiogram (MRA) neck confirmed this finding. Follow-up brain MRI revealed a small acute left occipital lobe infarct secondary to thromboembolism from the VAD. The patient underwent endovascular coiling of the ACOM aneurysm and received aspirin for the VAD, obtaining resolution of his symptoms. VAD involves an intimal tear of the vasa vasorum leading to narrowing of the vessel lumen that can result in thromboembolic complications. Risk factors for development of VAD include neck manipulations, trauma, or abnormal posturing. DSA remains the gold standard imaging exam for diagnosis of VAD. However, recognition of VAD on more common non-invasive modalities, such as computed tomography angiogram or MRA, remains critical for establishing the correct diagnosis. Although the clinical presentation of VAD is highly variable, dissection should be considered in a young patient with craniocervical pain, even in the absence of neurological symptoms. Early diagnosis and treatment of VAD can lower the risk of long-term neurologic sequelae.