A 27 yo F presents to the ED for a burn to her R forearm and during her visit mentions she has been having R sided neck pain x 1 week. She notes acute onset of the neck pain 1 week ago with valsalva having a bowel movement. Her neck pain is described as a "tearing" sensation that radiates upward to her head. Pain is intermittent, wose with defecation or movement of neck into certain positions. Her physical exam including a full neurologic exam is normal, other than a small blister to R forearm. A CTA is done. What's the diagnosis? (scroll down for answer)

Answer: Vertebral Artery Dissection

• Background
• Common cause of stroke in younger patients
• Risk factors: trauma, smoking, infection/inflammation, connective tissue disorders
• Mechanism: rupture of the arterial intima resulting in creation of a false lumen (blood may enter false lumen resulting in stenosis/occlusion 
• Complications: ischemic stroke, SAH
• Presentation
• Often presents with dizziness/vertigo, headache, and/or neck pain
• Also may see hearing loss, dysarthria, unilateral facial paralysis, visual disturbance, ataxia, n/v, extremity weakness or numbness
• Keep in mind presentation varies based on location of dissection, degree of obstruction, and collateral circulation
• Diagnosis
• CT/CTA
• MRI/MRA
• Treatment
• Medical management: thrombolytics vs. anticoagulation vs. antiplatelet therapy
• Endovascular/surgical treatment
• ED Management
• Recognize signs/symptoms 
• Early specialist consultation
• Initiate anticoagulation or antiplatelet therapy (**goal is for secondary prevention of stroke) 

References:

Arnold M, Bousser MG, Fahrni G, et al. Vertebral artery dissection: presenting findings and predictors of outcome [published correction appears in Stroke. 2007 Jan;38(1):208].Stroke.2006;37(10):2499-250