Svårbedömda symtom och behov av särskild utredning. Risk för fördröjd handläggning vid vertebralisdissektion
Engelsk titel: Difficult-to-asses symptoms and need of special investigation. Risk of delayed management of vertebral artery dissection
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Författare:
Larsson D
;
Sigstedt B
;
Bruhn H
Email: daniellarsson@telia.com
Språk: Swe
Antal referenser: 18
Dokumenttyp:
Fallbeskrivning
UI-nummer: 08081716
Sammanfattning
The case report describes a previously healthy 45 year old male presenting in the emergency room with severe headache, nausea and vomiting after an intense game of badminton. Neurological examination shows discrete findings such as minor horizontal and vertical nystagmus at the end stages of eye movement and a slightly pathological finger–nose test. Cardiac examination shows a systolic murmur and changes on ECG specific for cardiac stress. The patient was taken to the Heart Intensive Care Unit and investigated further for endocarditis with septic brain embolism. Neither brain and pulmonary CT scans nor ultrasonography of the carotid artery detected any embolic material. Transesophageal ultrasonography showed a bicuspid aortic valve but no source of embolism. Consultants of infectious diseases and ENT found no ground for endocarditis or peripheral genesis for the nausea. Further investigations with magnetic resonance imaging (MRI) showed a cerebellar infarction measuring 6x4 cm in the left hemisphere. Simultaneous intracranial angio sequence without contrast was normal. Further investigation with magnetic resonance angiography without contrast (MRA) showed proximal occlusion of the left vertebral artery with signs consistent with proximal intimal dissection. Dissection of cerebral arteries is together with cardiac embolism the most common causes of ischemic stroke in young adults. This case illustrates that the patient can present with unspecific symptoms without known previous risk factors. It also illustrates that diagnostics can be difficult and requires specific investigations. This can lead to an unnecessary delay in diagnosis and anticoagulant treatment with risk of further brain damage and even death. We conclude that dissection of the vertebral arteries is an important differential diagnosis in young patients with signs of a cerebrovascular disorder even after minor trauma, and that MRA, if available, is the best alternative for imaging the lower vertebral arteries.