vertebral artery dissection vertebral artery dissection vertebral artery dissection (vad) is a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain. after the tear, blood enters the arterial wall and forms a blood clot, thickening the artery wall and often impeding blood flow. the symptoms of vertebral artery dissection include head and neck pain and intermittent or permanent stroke symptoms such as difficulty speaking, impaired coordination and visual loss. it is usually diagnosed with a contrast-enhanced ct or mri scan. vertebral artery dissectionother namesvertebral dissectionarteries of the neck, with arrows indicating the right vertebral arteryspecialtyneurologysymptomsheadache, difficulty speaking, difficulty swallowing, poor coordinationcomplicationsstroke, subarachnoid hemorrhagecausestrauma, ehlers–danlos syndrome, marfan syndromediagnostic methodcomputed tomography angiography, magnetic resonance angiography, invasive angiographytreatmentanticoagulation, angioplasty, surgerymedicationaspirin, heparin, warfarinfrequency1.1 per 100,000 vertebral dissection may occur after physical trauma to the neck, such as a blunt injury (e.g. traffic collision), or strangulation, or after sudden neck movements, i.e. coughing, but may also happen spontaneously. 1–4% of spontaneous cases have a clear underlying connective tissue disorder affecting the blood vessels. treatment is usually with either antiplatelet drugs such as aspirin or with anticoagulants such as heparin or warfarin. vertebral artery dissection is less common than carotid artery dissection (dissection of the large arteries in the front of the neck). the two conditions together account for 10–25% of non-hemorrhagic strokes in young and middle-aged people. over 75% recover completely or with minimal impact on functioning, with the remainder having more severe disability and a very small proportion (about 2%) dying from complications. it was first described in the 1970s by the canadian neurologist c. miller fisher. classification vertebral artery dissection is one of the two types of cervical artery dissection. the other type, carotid artery dissection, involves the carotid arteries. vertebral artery dissection is further classified as being either traumatic (caused by mechanical trauma to the neck) or spontaneous, and it may also be classified by the part of the artery involved: extracranial (the part outside the skull) and intracranial (the part inside the skull). signs and symptoms head pain occurs in 50–75% of all cases of vertebral artery dissection. it tends to be located at the back of the head, either on the affected side or in the middle, and develops gradually. it is either dull or pressure-like in character or throbbing. about half of those with vad consider the headache distinct, while the remainder have had a similar headache before. it is suspected that vad with headache as the only symptom is fairly common; 8% of all cases of vertebral and carotid dissection are diagnosed on the basis of pain alone. obstruction of blood flow through the affected vessel may lead to dysfunction of part of the brain supplied by the artery. this happens in 77–96% of cases. this may be temporary ("transient ischemic attack") in 10–16% of cases, but many (67–85% of cases) end up with a permanent deficit or a stroke. the vertebral artery supplies the part of the brain that lies in the posterior fossa of the skull, and this type of stroke is therefore called a posterior circulation infarct. problems may include difficulty speaking or swallowing (lateral medullary syndrome); this occurs in less than a fifth of cases and occurs due to dysfunction of the brainstem. others may experience unsteadiness or lack of coordination due to involvement of the cerebellum, and still others may develop visual loss (on one side of the visual field) due to involvement of the visual cortex in the occipital lobe. in the event of involvement of the sympathetic tracts in the brainstem, a partial horner's syndrome may develop; this is the combination of a drooping eyelid, constricted pupil, and an apparently sunken eye on one side of the face. if the dissection of the artery extends to the part of the artery that lies inside the skull, subarachnoid hemorrhage may occur (1% of cases). this arises due to rupture of the artery and accumulation of blood in the subarachnoid space. it may be characterized by a different, usually severe headache; it may also cause a range of additional neurological symptoms. 13–16% of all people with vertebral or carotid dissection have dissection in another cervical artery. it is therefore possible for the symptoms to occur on both sides, or for symptoms of carotid artery dissection to occur at the same time as those of vertebral artery dissection. some give a figure of multiple vessel dissection as high as 30%. causes the causes of vertebral artery dissection can be grouped under two main categories, spontaneous and traumatic. spontaneous spontaneous cases are considered to be caused by intrinsic factors that weaken the arterial wall. only a very small proportion (1–4%) have a clear underlying connective tissue disorder, such as ehlers–danlos syndrome type 4 and, more rarely, marfan syndrome. however, ultrastructural abnormalities of the dermal connective tissue components are discernible in two out of three patients with spontaneous dissection. ehlers–danlos syndrome type 4, caused by mutations of the col3a gene, leads to defective production of the collagen, type iii, alpha 1 protein and causes skin fragility as well as weakness of the walls of arteries and internal organs. marfan syndrome results from mutations in the fbn1 gene, defective production of the protein fibrillin-1, and a number of physical abnormalities including aneurysm of the aortic root. there have also been reports in other genetic conditions, such as osteogenesis imperfecta type 1, autosomal dominant polycystic kidney disease and pseudoxanthoma elasticum, α1 antitrypsin deficiency and hereditary hemochromatosis, but evidence for these associations is weaker. genetic studies in other connective tissue-related genes have mostly yielded negative results. other abnormalities to the blood vessels, such as fibromuscular dysplasia, have been reported in a proportion of cases. atherosclerosis does not appear to increase the risk. there have been numerous reports of associated risk factors for vertebral artery dissection; many of these reports suffer from methodological weaknesses, such as selection bias. elevated homocysteine levels, often due to mutations in the mthfr gene, appear to increase the risk of vertebral artery dissection. people with an aneurysm of the aortic root and people with a history of migraine may be predisposed to vertebral artery dissection. vascular tortuosity or redundancy in young patients is associated with an increased risk of spontaneous dissection. traumatic traumatic vertebral dissection may follow blunt trauma to the neck, such as in a traffic collision, direct blow to the neck, strangulation, or whiplash injury. 1–2% of those with major trauma may have an injury to the carotid or vertebral arteries. in many cases of vertebral dissection, people report recent very mild trauma to the neck or sudden neck movements, e.g. in the context of playing sports. others report a recent infection, particularly respiratory tract infections associated with coughing. trauma has been reported to have occurred within a month of dissection in 40% with nearly 90% of the traumas being minor. it has been difficult to prove the association of vertebral artery dissection with mild trauma and infections statistically. it is likely that many "spontaneous" cases may in fact have been caused by such relatively minor insults in someone predisposed by other structural problems to the vessels. a more likely theory, also as yet unproven, is that the low-energy traumatic dissections are actually spontaneous dissections brought to medical attention by the onset of neurological symptoms. these neurological events represent embolic phenomena due to loosening or breakdown of the clot at the site of the dissection, which can be triggered by low energy trauma or even occur spontaneously. the fragments travel within the arterial system downstream to the brain to cause stroke or stroke-like symptoms. vertebral artery dissection has also been reported in association with some forms of neck manipulation. there is significant controversy about the level of risk of stroke from neck manipulation. it may be that manipulation can cause dissection, or it may be that the dissection is already present in some people who seek manipulative treatment. at this time, conclusive evidence does not exist to support either a strong association between neck manipulation and stroke, or no association. however, the two most authoritative articles on the subject, recent literature reviews and analyses, conclude that although there exists an association between stroke from vertebral artery dissection and chiropractic adjustment, there is insufficient evidence to indicate that the adjustment caused the dissection. a recent meta-analysis of the published data on the topic also looked to apply hill's criteria for assigning causation in biological systems to the relationship between chiropractic adjustment and cervical artery dissection, finding that the relationship did not fulfill the required criteria for causality. mechanism a reconstruction of the vertebral arteries from a ct scan, seen from the front. from the bottom, v1 is from the subclavian artery to the foramina, v2 is from the foramina to the second vertebra, v3 is between the foramina until entry into the skull, and v4 is inside the skull embedded in the dura mater. they merge into the basilar artery, which then divides into the posterior cerebral artery. the vertebral arteries arise from the subclavian artery, and run through the transverse foramen of the upper six vertebrae of the neck. after exiting at the level of the first cervical vertebra, its course changes from vertical to horizontal, and then enters the skull through the foramen magnum. inside the skull, the arteries merge to form the basilar artery, which joins the circle of willis. in total, three quarters of the artery are outside the skull; it has a high mobility in this area due to rotational movement in the neck and is therefore vulnerable to trauma. most dissections happen at the level of the first and second vertebrae. the vertebral artery supplies a number of vital structures in the posterior cranial fossa, such as the brainstem, the cerebellum and the occipital lobes. the brainstem harbors a number of vital functions (such as respiration) and controls the nerves of the face and neck. the cerebellum is part of the diffuse system that coordinates movement. finally, the occipital lobes participate in the sense of vision. dissection occurs when blood accumulates in the wall of the blood vessel. this is most likely due to a tear in the tunica intima (the inner layer), allowing blood to enter the tunica media, although other lines of evidence have suggested that the blood may instead arise from the vasa vasorum, the small blood vessels that supply the outer layer of larger blood vessels. various theories exist as to whether people who sustain carotid and vertebral artery dissection, even if they do not have a connective tissue disorder, have an underlying vulnerability. biopsy samples of skin and other arteries has indicated that this might be a possibility, but no genetic defect in collagen or elastin genes has been convincingly proven. other studies have indicated inflammation of the blood vessels, as measured by highly sensitive c-reactive protein (hscrp, a marker of inflammation) in the blood. once dissection has occurred, two mechanisms contribute to the development of stroke symptoms. firstly, the flow through the blood vessel may be disrupted due to the accumulation of blood under the vessel wall, leading to ischemia (insufficient blood supply). secondly, irregularities in the vessel wall and turbulence increase the risk of thrombosis (the formation of blood clots) and embolism (migration) of these clots of the brain. from various lines of evidence, it appears that thrombosis and embolism is the predominant problem. subarachnoid hemorrhage due to arterial rupture typically occurs if the dissection extends into the v4 section of the artery. this may be explained by the fact that the arterial wall is thinner and lacks a number of structural supports in this section. diagnosis magnetic resonance angiogram of the neck vessels in a person with ehlers-danlos syndrome type iv; it shows a dissection of the left internal carotid artery, dissection of both vertebral arteries in their v1 and v2 segments and a dissection of the middle and distal third of the right subclavian artery. such striking episodes of dissection are typical for this "vascular" subtype of ehlers-danlos syndrome. various diagnostic modalities exist to demonstrate blood flow or absence thereof in the vertebral arteries. the gold standard is cerebral angiography (with or without digital subtraction angiography). this involves puncture of a large artery (usually