Verterbral artery dissection

kongen · 19-11-2010, 09:26 AM

Hi!

I am curious if anyone has actually had a patient in front of them with a suspected ongoing vertebral artery dissection, before obvious neurological signs has developed? An actual VAD that was later confirmed. If so, what was the presenting symptoms in that case?

**Bas Asselbergs** · 19-11-2010, 01:08 PM

Anders, "before" neurological signs had developed? A VAD that was discovered by chance you mean? Because how else would one know there was a VAD? After all, symptoms of VAD are part of the clinical signs we look for, aren't they?

No, never saw one. Never had any VAD case.

**Diane** · 19-11-2010, 01:12 PM

How does anyone pick up on these kinds of things before the fact? My understanding is that it's hard to tell, which is why those who feel invulnerable to the possibility continue to produce them and those who are sickened by the very thought wouldn't go anywhere near them with a ten-foot disinfected barge pole.

**John W** · 19-11-2010, 02:36 PM

Anders,

There's also the very real possibility of vertebral artery hypoplasia, which has been shown to be a risk factor for vertebrobasilar infarction, and which can only be diagnosed via arteriogram of the VB circulation (see the free access article attached).

I've got my 10-foot barge pole always at the ready.

kongen · 19-11-2010, 02:54 PM

Quote:

Originally Posted by Bas Asselbergs

Anders, "before" neurological signs had developed? A VAD that was discovered by chance you mean? Because how else would one know there was a VAD? After all, symptoms of VAD are part of the clinical signs we look for, aren't they?

No, never saw one. Never had any VAD case.

If my understanding is correct, a VAD in it's early stages can present with occipital pain, neck pain, neck stiffness. That is before any ischemia, occlusion or infarction has led to neurological symptoms. I guess my question is, without hard neurological signs, are there any other clinical signs or something about the history that could lead to a suspicion of ongoing VAD?

**John W** · 19-11-2010, 03:20 PM

I think the point is that it is extremely difficult,if not impossible, to differentiate mechanical neck pain from symptomatic VAD. Perhaps employing a careful distinction between visceral tissue damage-mediated pain and mechanical pain, which should respond significantly to movement or position, might help. But the vascular structures in question will certainly be prone to movement and positional stresses that are similar to the mechanical tissues, so I'm not sure that this distinction will be helpful here.

I suppose some VBI tests might be employed, although they haven't been shown to be very sensitive, and there may be some unnecessary risks associated with performing them.

If the patient does not respond to careful manual and movement therapies within a reasonable time frame, then, rather than proceed with more aggressive techniques (which is what some clinicians will do), then the prudent course might be to refer back for more medical work up to rule out VAD.

**Bas Asselbergs** · 19-11-2010, 05:09 PM

Sorry Anders. I considered pain a neurological sign and symptom.

I agree with John - not a heck of a lot to be sure beforehand.

**nari** · 19-11-2010, 08:58 PM

I think it would be impossible to determine the difference between a potential VAD and the more usual pain and stiffness presentation. Even if there was a subtle sign of a VAD about to occur, it is not worth the risk of doing anything which stresses the cervical spine in any way.

Which is where DNM comes in, it cannot stress or harm in any way. If there's no positive response, I'd consider a referral back for more information on the matter.
Come to think of it, we all must have done stressful things to patients whose VA was at borderline patency and got away with it. Particularly the chiros...

Nari

kongen · 19-11-2010, 09:15 PM

John,

That is my reasoning aswell, and one that I have applied to an ongoing case presentation. The signs, symptoms and lack of response to gentle treatment does not add up in my book. Getting an MD to take my concerns seriously though.. All I can do is refer. I will update this thread.

Bas,

I see your point about using the correct terminology.

kongen · 22-11-2010, 07:47 PM

The patient in question did recieve a thorough medical check up today, all clear.

**Frédéric** · 22-11-2010, 11:29 PM

I had a pt once that could have had the signs and symptoms for a VA issue after a MVA.

I even convinced the neurologist at the time to do the angio MRI and another angio test I can't recall. That was some years ago.

She had difficulty swallowing, tinnitus, hypoesthesia to the left side of the face, a change in her voice timbre. She had upper neck pain and headaches plus a focal dystonia following the accident. Dizziness was present. The VBI test was increasing some of the symptoms, mostly pain and dizziness. There where severe hypertonia in her sub-occipital muscles and sterno muscles from what I recall.

All the tests turned out negative. Her symptoms only started a few days after the accident soon after her family member had told her she could have died in such an accident. (she made a lot of tumbling at hight speed on the highway.

Now that I look back, I think she was highly sensitized and perhaps had some disseminated small neuropathies, but no VAD.

19-11-2010, 09:26 AM	#1
kongen Senior Member Join Date: Jul 2006 Location: Sweden Age: 38 Posts: 530 Thanks: 25 Thanked 15 Times in 7 Posts	Verterbral artery dissection Hi! I am curious if anyone has actually had a patient in front of them with a suspected ongoing vertebral artery dissection, before obvious neurological signs has developed? An actual VAD that was later confirmed. If so, what was the presenting symptoms in that case? __________________ Anders. "There is nothing so practical as a good theory." -Kurt Lewin

19-11-2010, 01:08 PM	#2
Bas Asselbergs Physiotherapist Join Date: Jul 2004 Location: Canada Age: 61 Posts: 3,693 Thanks: 835 Thanked 484 Times in 233 Posts	Anders, "before" neurological signs had developed? A VAD that was discovered by chance you mean? Because how else would one know there was a VAD? After all, symptoms of VAD are part of the clinical signs we look for, aren't they? No, never saw one. Never had any VAD case. __________________ We don't see things as they are, we see things as WE are - Anais Nin Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley Last edited by Bas Asselbergs; 19-11-2010 at 01:58 PM. Reason: typos

19-11-2010, 01:12 PM	#3
Diane Human Primate Social Groomer and Neuroelastician Join Date: Mar 2004 Location: Weyburn Sask. Posts: 19,667 Thanks: 1,484 Thanked 3,184 Times in 1,565 Posts	How does anyone pick up on these kinds of things before the fact? My understanding is that it's hard to tell, which is why those who feel invulnerable to the possibility continue to produce them and those who are sickened by the very thought wouldn't go anywhere near them with a ten-foot disinfected barge pole. __________________ Diane www.dermoneuromodulation.com SensibleSolutionsPhysiotherapy HumanAntiGravitySuit blog Neurotonics PT Teamblog Diane Jacobs.com (personal website) Canadian Physiotherapy Pain Science Division (Archived newsletters) Canadian Physiotherapy Association Pain Science Division Facebook page @PainPhysiosCan WCPT PhysiotherapyPainNetwork on Facebook @WCPTPTPN Neuroscience and Pain Science for Manual PTs Facebook page @dfjpt SomaSimple on Facebook @somasimple "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

19-11-2010, 03:20 PM	#6
John W Harmless creampuff Join Date: Sep 2006 Location: New Orleans, LA Age: 48 Posts: 4,643 Thanks: 614 Thanked 966 Times in 436 Posts	I think the point is that it is extremely difficult,if not impossible, to differentiate mechanical neck pain from symptomatic VAD. Perhaps employing a careful distinction between visceral tissue damage-mediated pain and mechanical pain, which should respond significantly to movement or position, might help. But the vascular structures in question will certainly be prone to movement and positional stresses that are similar to the mechanical tissues, so I'm not sure that this distinction will be helpful here. I suppose some VBI tests might be employed, although they haven't been shown to be very sensitive, and there may be some unnecessary risks associated with performing them. If the patient does not respond to careful manual and movement therapies within a reasonable time frame, then, rather than proceed with more aggressive techniques (which is what some clinicians will do), then the prudent course might be to refer back for more medical work up to rule out VAD. __________________ John Ware, PT Fellow of the American Academy of Orthopedic Manual Physical Therapists "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

19-11-2010, 05:09 PM	#7
Bas Asselbergs Physiotherapist Join Date: Jul 2004 Location: Canada Age: 61 Posts: 3,693 Thanks: 835 Thanked 484 Times in 233 Posts	Sorry Anders. I considered pain a neurological sign and symptom. I agree with John - not a heck of a lot to be sure beforehand. __________________ We don't see things as they are, we see things as WE are - Anais Nin Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

19-11-2010, 08:58 PM	#8
nari NeuroNut Evangelist Join Date: Mar 2004 Location: ACT Aust Posts: 7,678 Thanks: 704 Thanked 233 Times in 167 Posts	I think it would be impossible to determine the difference between a potential VAD and the more usual pain and stiffness presentation. Even if there was a subtle sign of a VAD about to occur, it is not worth the risk of doing anything which stresses the cervical spine in any way. Which is where DNM comes in, it cannot stress or harm in any way. If there's no positive response, I'd consider a referral back for more information on the matter. Come to think of it, we all must have done stressful things to patients whose VA was at borderline patency and got away with it. Particularly the chiros... Nari

19-11-2010, 09:15 PM	#9
kongen Senior Member Join Date: Jul 2006 Location: Sweden Age: 38 Posts: 530 Thanks: 25 Thanked 15 Times in 7 Posts	John, That is my reasoning aswell, and one that I have applied to an ongoing case presentation. The signs, symptoms and lack of response to gentle treatment does not add up in my book. Getting an MD to take my concerns seriously though.. All I can do is refer. I will update this thread. Bas, I see your point about using the correct terminology. __________________ Anders. "There is nothing so practical as a good theory." -Kurt Lewin

22-11-2010, 07:47 PM	#10
kongen Senior Member Join Date: Jul 2006 Location: Sweden Age: 38 Posts: 530 Thanks: 25 Thanked 15 Times in 7 Posts	The patient in question did recieve a thorough medical check up today, all clear. __________________ Anders. "There is nothing so practical as a good theory." -Kurt Lewin

22-11-2010, 11:29 PM	#11
Frédéric Swaying against the breeze Join Date: Sep 2008 Location: Prévost Québec Age: 37 Posts: 1,880 Thanks: 92 Thanked 122 Times in 57 Posts	I had a pt once that could have had the signs and symptoms for a VA issue after a MVA. I even convinced the neurologist at the time to do the angio MRI and another angio test I can't recall. That was some years ago. She had difficulty swallowing, tinnitus, hypoesthesia to the left side of the face, a change in her voice timbre. She had upper neck pain and headaches plus a focal dystonia following the accident. Dizziness was present. The VBI test was increasing some of the symptoms, mostly pain and dizziness. There where severe hypertonia in her sub-occipital muscles and sterno muscles from what I recall. All the tests turned out negative. Her symptoms only started a few days after the accident soon after her family member had told her she could have died in such an accident. (she made a lot of tumbling at hight speed on the highway. Now that I look back, I think she was highly sensitized and perhaps had some disseminated small neuropathies, but no VAD. __________________ Frédéric Wellens, pht «We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.» «Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate. » Friedrich Nietzsche www.physioaxis.ca chroniquesdedouleur blog

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