Vertebral Artery Dissection: A Pain in the Neck

Introduction: Vertebral artery dissection (VAD) accounts for less than 2.5% of all strokes. VAD disproportionately affects younger, healthier patients. VAD can cause vague symptoms and may be easily misdiagnosed. Patients most commonly present with neck pain, headache, visual disturbance, or focal extremity weakness. We present a case of spontaneous VAD in an otherwise healthy patient whose only symptoms were neck pain and headache. Case Presentation: A 42-year-old male presented with 8 days of left neck pain and headache. CT neck with contrast was initially ordered to rule out tonsillitis. CT revealed an incidental anterior communicating artery (ACOM) aneurysm, however a left VAD was initially missed. Digital subtraction angiography (DSA) performed for ACOM aneurysm coiling demonstrated a left VAD as the culprit for the patient’s symptoms. Brain MRI revealed a small acute left occipital lobe infarct secondary to the VAD. The patient underwent endovascular coiling of the ACOM aneurysm and received aspirin for VAD, obtaining resolution of his symptoms. Discussion: VAD is increasingly identified as a cause of ischemic stroke in young adults. VAD involves an intimal tear of the vasa vasorum leading to narrowing of the vessel lumen and thromboembolic complications. Triggers for VAD include neck manipulations, trauma, or abnormal posturing. While DSA remains the gold standard, recognition of VAD on CT or MR angiogram remains critical. Early diagnosis and treatment of VAD lowers the risk of long-term neurologic sequela. Given clinical presentation variability, the differential diagnosis of young patients with craniocervical pain, with or without neurologic deficits, should include VAD.