Background
Vertebral artery pseudoaneurysm dissection is a rare vascular pathology affecting 1–5 per 100,000 individuals yearly. Over 80% of vertebral dPSAs are extracranial and can present with a wide variety of symptoms from headache, neck pain, arm pain due to mass effect, to TIA or stroke due to embolic phenomena or mass effect. While blunt trauma often precipitates vertebral dPSAs, the pathology can occur unprovoked. Risk factors for the condition include migraine with aura, smoking, female sex, and hyperlipidemia in addition to trauma. Coiling, flow diversion, and stenting can be used in treatment, however, current literature suggests medical management with anticoagulation is sufficient to achieve good outcomes in most cases.
Case Presentation
We present the case of a 33-year-old woman with pain and decreased strength and sensation in the right face, neck, and upper extremity who was found to have a dPSA of the right extracranial vertebral artery. The patient had a history of migraine with aura, nephrolithiasis, and cholecystitis status post cholecystectomy. She presented with 2 hours of unprovoked pain and weakness with a NIH stroke scale of 6. A brain attack was called on presentation. On exam, she was writhing in bed and would not move her right arm or move her head due to pain. Morphine was given and a CTA head and neck was obtained that showed a 3x6x3mm dPSA of her right V2 at the level of C6. The patient was initiated on DAPT with ASA and plavix. She was admitted to inpatient neurology where she was found to be pregnant in her first trimester. Her symptoms of pain and weakness resolved and she was discharged the following day with presumed MCA TIA as the ultimate cause of her symptomatology.
Conclusion
This case highlights the commonly unprovoked nature of dPSAs and the importance of considering extracranial as well as intracranial vascular pathology for a patient presenting with headache and neurological symptoms.
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Acute Presentation of Dissecting Pseudoaneurysm of the Extracranial Vertebral Artery by Alayna Arnholt & Stephanie Crapo, MD