who had it!
Vertebrobasilar artery thrombosis or dissection affecting the posterior circulation can be extraordinarily difficult to diagnose. In the failure to diagnose specialties such as
primary care, internal medicine, family practice, emergency medicine and urgent care where the door is open to all, risk and safety education and evaluation focused around this deadly high-risk clinical entity is critical.
The TSG Mission is to reduce the failure to diagnose medical errors and improve patient safety. This seems like a tall order, but it is absolutely manageable as we have demonstrated with several large organizations in the United States over the last 20 years. The key is to understand cause and effect at the most granular level and then build education and other cognitive tools to avoid
the failure to diagnose.
That said, I gave a presentation on vertebrobasilar artery disease and posterior circulation deficits at a recent American College of Emergency Physicians Scientific Assembly. During that meeting, an emergency physician approached me after the presentation and mentioned that he actually had a vertebral artery dissection. It is one thing to look at litigation in retrospect; it is quite another to get a first-hand account of the day-to-day symptom progression of a disorder from a practicing emergency physician! Here is that physician’s story.
To start – I have no known medical issues and don’t take any daily prescribed medications. No significant family history.
At some point during the day, noticed a posterior neck pain, but mostly point tenderness at the base of the skull right along the lymph nodes. Pushing on that spot would cause a parietal headache, which would improve when I stopped pushing. I also noted some pretty significant hyperesthesia of the scalp (like a sunburn) that started on the forehead just below hairline to the parietal region. I never get headaches and did comment on the fact that this was a weird one to a coworker that day. I took Tylenol, Motrin and then later Robaxin, which did not provide any relief. However, lying on my side (either right or left), the pain would resolve. Both heat and ice also helped. I did notice during dinner that day that the sniffing position was very uncomfortable for me. No neuro symptoms. No dizziness.
That night, still tossing and turning due to pain but still felt OK when on my side. However, standing would now lead to a more mild but persistent parietal (pre-orbital) headache. We were supposed to be on a plane that AM to Hawaii for the wedding, but since the little one was up all night with her itching, we decided to postpone for a day. During the day, the headache became more persistent, but still no neuro symptoms. No relief with OTC meds. Ice was helping a bit less. Almost went to the ED, but since it still seemed pretty clearly muscular (or maybe neuralgia-y), figured that CT wouldn’t be indicated. However, with no rash yet, dissection was now at least being considered.
Get to the ED and was examined. Everyone felt that this was muscular. Even had a nice tender point right on the back of my neck. So decided to try a trigger point injection, figuring if that helped, end of story. Unfortunately, it didn’t help, so we got a CT/CTA, mostly to make me and my wife feel ok about flying later that day. CTA showed a long segment left VAD without intracranial extension and no thrombosis. So since I was still coughing and now NPO for possible angiogram, I got 2mg of MS for the cough (which helped) and I was admitted to the Neuro ICU.
Got a transcranial Doppler, which showed no emboli, and an MRI/A head, which showed no CVA (and surprisingly little white matter disease). Noted my BP was 160s/110s, which was left alone. IM/NS/Neuro decided to skip the angio and start me on ASA/Plavix for 6 weeks. Also Lisinopril if my BP didn’t get more reasonable, and Lipitor. Coumadin considered but not favored by this group. Mentioned that they don’t use the novel anticoagulants. They also mentioned “sacrificing” the artery could be an option … which I’d rather not do since there may come a day that I need that one … like when I cough my right one into dissecting.
Did well that day, but then made the mistake of accepting Norco, which I promptly vomited (along with some soup) … apparently vomiting is frowned upon with VADs. Slept very poorly that night.
Plan is to lay low for 6 weeks and get a repeat CTA. If things are better, back to normal.
So yes, very odd. I still don’t think that the original CTA was indicated and there really wasn’t a good reason for the dissection in the first place. I’m curious to hear any thoughts about this. I know that I for one will unfortunately probably order more of these tests for weird symptoms without a definite clear cause.
Well that’s scary! This individual had no apparent risk factor or predisposition, and the dissection apparently started with a cough. Medicine will never be an “exact” science, and sometimes there is simply not a good explanation for a clinical presentation; but it is fascinating to hear this practitioner’s day-by-day explanation of the evolution of his dissection.
Was there an indication for a CT? Even in his own case, this doc felt that the day the scan was done, it was only for reassurance and without a clinical indication. All involved felt this was musculoskeletal. But was there enough to raise the red flag for further diagnostics?
He never had headaches before. His symptoms were: posterior neck pain, parietal headache, scalp hyperesthesia (forehead to parietal), sniffing position uncomfortable, scalp pain, and later persistent parietal and pre-orbital headache. Headaches were never described as severe or thunderclap, and there were no neurologic deficits.
There is no vertebral artery dissection rule. No thrombosis guideline. Perhaps we should consider the neck pain and headache. Let’s run his symptoms against the Ottawa Subarachnoid Hemorrhage Rule for Headache Evaluation. He would score a 1 for “Neck Pain or Stiffness.” The Rule tells us: “This patient cannot be ruled out for subarachnoid hemorrhage by the Ottawa SAH Rule.”
Let’s run the presentation by the MIPS/MACRA measure #419, Overuse of Neuroimaging for Patients with Primary Headache. The measure suggests that CT not be performed unless:
“Very young” is not defined, but this practitioner was relatively young with unexplained headache symptoms. Interestingly, this case would probably fail the MACRA or PQRS quality measure for CT utilization in primary headache.
So what’s the answer? Does the evidence point us in a particular direction? There is certainly nothing definitive. The answer is that these guidelines and rules are just that - guideposts. They often don’t fit a particular clinical encounter, and ultimately we rely on clinical judgment. In this case, the symptom constellation was very unusual in an otherwise very healthy young man. It absolutely pointed to the central neurologic system, and CT/CTA seems completely reasonable and perhaps life-saving in this case.
The bottom line - good outcome, health emergency physician, and an incredibly interesting recount of the onset and progression of a vertebral artery dissection. I hope there is a pearl in this story that positively impacts your clinical practice.
As always, we are interested in your thoughts and comments.
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