Chronicles of an Inner City Hospital Resident Doctor #8

Hi everyone! I'm a 2nd year resident doctor in an inner city hospital. This is a blog to document some of the experiences I encounter as a training doctor, and some of the things that I learn in the process. After all, being a physician means that I'll be learning some fascinating topics for the rest of my career, and seeing how I can use those to help patients.

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Let's get started with today's topic, inspired by some reading I did today:

Vertebral Artery Dissection

What is the vertebral artery? It’s an artery that’s located on both sides of the neck, leading towards smaller arteries that go into the brain. It stems from a branch coming from the aorta. here’s is a great diagram that I found showing the location of these important arteries. Source

Fun (I hope!) fact: the larger arteries that you see off to the sides of the vertebral arteries are the carotid arteries. They tend to carry greater amounts of blood to the brain than the vertebral arteries, and are common sources of imaging when evaluating for the source of strokes.

Back on topic: what is vertebral artery dissection? This is a condition that occurs when 1 or more layers of the artery is/are torn apart, typically due to some force or positioning causing stress on the artery. This can include weightlifting, contact sports, overextending the neck, mechanical injuries (such as motor vehicle accidents), sudden sharp neck movements, and chiropractic manipulation of the neck.

It’s more commonly seen among the younger population <45 years of age), and risk factors for dissection to occur include, but are not limited to: smoking, hypertension (particularly arterial hypertension), various types of vasculitis, fibromuscular dysplasia, Ehlers-Danlos Syndrome, Marfan Syndrome, osteogenesis imperfecta, and polycystic kidney disease. A common thread among these risk factors is either a weakness of the layers of the artery and/or increased pressure upon the walls of artery, which cause it to be more fragile.

How is a vertebral artery dissection dangerous?

The most dangerous aspect of such a dissection comes from an increased risk of strokes. These can include both ischemic strokes (due to a traveling blood clot), or hemorrhagic strokes (bleeding). Ischemic strokes can cause a lack of blood flow to portions of the brain, leading to death of that part of the brain, and impaired function of anything that is controlled by that region of the brain; these are the most common types of strokes caused by vertebral artery dissections. Hemorrhagic strokes can put pressure on multiple areas of the brain and also compromise blood flow to all areas, thus leading to impaired function of anything that is controlled by those regions of the brain; these are less commonly caused by vertebral artery dissections, except if all 3 layers of the artery are torn.

What steps should be taken in a vertebral artery dissection?

It’s important to first establish a diagnosis, which will be based on the history of presentation (refer to the section above listing what can cause stress on the vertebral artery), how the patient appears clinically (sudden headache, vision changes, changes in ability to speak, vision changes, ability to move various parts of the body, etc.), and imaging.

In regards to imaging, the standard procedure is to start with a CT scan of the Head, without contrast. The reason contrast isn’t used is because of the possibility of a hemorrhagic stroke – you don’t want contrast leaking into the brain and causing further damage. Once a CT scan detects a bleed, and the history appears to resemble that of a vertebral artery dissection, you’d continue with a CT Angiogram of the Head and Neck. This is a test that uses a special dye that to highlight the blood vessels; thus the CT Angiogram would help visualize the vertebral artery and any abnormalities it contains, including a dissection.

If the initial CT scan of the Head is normal (which is common in early ischemic strokes), and there is still a suspicion of vertebral artery dissection, then a CT Angiogram of the Head and Neck is still something that can be done to confirm its presence.

For those who have experienced strokes, you might ask why an MRI or Ultrasound is not done after the CT Head (and I asked the same question when learning this topic as well), because this is standard procedure in strokes. In this case, the MRI is a great test of choice, but takes too long. The Ultrasound might not catch the vertebral artery dissection as well as the CT Angiogram.

How are vertebral artery dissections treated?

Usually the dissections themselves are not treated, as the risks of invasive treatments usually outweigh the benefits, and the dissections tend to heal on their own. There may be exceptions, such as a complete tear of all layers of the artery which continues hemorrhagic bleeding, or if the dissection extends into the arteries that in the brain. In such cases, it would be best to consult a neurosurgeon and vascular surgeon to determine whether intraoperative or endovascular (inside the vessels) repair may be required.

Otherwise, for most cases, the treatment is preventive: the goal is to prevent ischemic strokes, which is the most dangerous complication of vertebral artery dissections. This is done with anticoagulation (blood thinners), typically with a prophylactic dose of heparin. Monitoring on the general medical floors is continued for a few days, followed by repeat imaging on an outpatient basis a few months later.

I personally have not yet seen a vertebral artery dissection, but the knowledge of what to do in case I suspect one is available to me… and, should I suspect one, I pray that the resources at my hospital will be available to get everything done on a timely basis!


I hope you've enjoyed this little snippet of a topic I learned as a resident in an inner city hospital. I'll have many more stories and learning experiences coming in the future, so stay tuned.

Sources:

  1. https://lakesidemedicalcare.com/history-osteopathic-medicine/
  2. https://123sonography.com/vertebral-artery-pathologies
  3. https://my.clevelandclinic.org/health/diseases/23961-vertebral-artery-dissection
  4. https://www.ncbi.nlm.nih.gov/books/NBK441827/
  5. Me 😊

Disclaimer: this blog is for entertainment (and possibly educational) purposes only. This is not medical advice. If you have any questions or concerns about your own health, please contact a healthcare provider.


Here are the previous editions of this blog:
Chronicles of an Inner City Hospital Resident Doctor #7
Chronicles of an Inner City Hospital Resident Doctor #6
Chronicles of an Inner City Hospital Resident Doctor #5
Chronicles of an Inner City Hospital Resident Doctor #4
Chronicles of an Inner City Hospital Resident Doctor #3
Chronicles of an Inner City Hospital Resident Doctor #2
Chronicles of an Inner City Hospital Resident Doctor #1



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