VA occlusion

[bedrock]

Have a patient with moderate cervical stenosis and clear radicular pain. Had planned to do a CESI.

His c spine MRI and later CT angiogram revealed a major blockage of the entire left VA as it passes through the neck.

He didn’t have any CN deficits when I saw him last month.

Thoughts on him ? No acute neurological deficits so I was thinking of sending him to neurology but they have a 2 month wait.

Maybe just send him to ER in major city so he can get a same day neurology consult?

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[Ducttape]

he is at risk of stroking out.

no symptoms tho - hard to argue for ER visit. not sure what they would do. probably just discharge him.


vascular surgery consultation as soon as conceivable.

low dose aspirin.

ask PCP if he can start anticoagulation.


inform patient of risks of stroke and what symptoms to watch out for.

 

[pmrmd]

I’d have done the CESI anyway because no symptoms and before anticoagulation but that’s me.

 

[SSdoc33]

I’d have done the CESI anyway because no symptoms and before anticoagulation but that’s me.

Same

 

[hyperalgesia]

For me this would be an incidental finding that would not interfere with planned care.

On a non-urgent basis, I would defer to PCP or get a vasc surg consult.

 

[callmeanesthesia]

Agree with vascular surgery referral and see PCP for risk factor modification, but proceed with CESI before he starts thinners.

When I was in med school rotating at the VA, we saw a guy with both carotids and one vertebral artery that were chronically occluded. Still neurologically intact.

 

[mdo1738]

When I was in med school rotating at the VA, we saw a guy with both carotids and one vertebral artery that were chronically occluded. Still neurologically intact.

The circle of Willis saving him from the circle of life

 

[Ducttape]

i would be hesitant myself with steroid injection.

there is known risk of anabolic steroids increasing risk of ischemic stroke. the data doesnt seem to suggest that low dose steroids have any effect, but seems equivocal that high dose steroids may.

id also be concerned about positioning him for the injection.

at the very least, i would include potential for stroke in the consent process.

 

[nvrsumr]

I wouldn’t poke either.

 

[painfree23]

what prompted the CTA order?

 

[hyperalgesia]

The real question about this case is the OTHER VA. That's what will determine the management. If one VA is 100% blocked and the pt is asymptomatic, that side is stable at this point, not a stroke risk.

 

[Ducttape]

in the OP, bedrock wrote "major blockage of the entire left VA".i took that to mean that it was not 100% occluded.

 

[Doctodd]

He probably has collateral circulation that will show up on MRA. My dad had CA dissection and occlusion after XRT years prior and he is alive without a CVA thanks to lots of collateral circulation on that side.

 

[bedrock]

Now, another patient cervical mri yesterday showed “abnormal signal void in right vertebral artery, raising suspicion for vertebral artery dissection”. Could be further evaluated with CT or MR angiogram.

Patient also has moderate cervical stenosis and no neurological deficits other that what is well explained by their moderate cervical stenosis in their early forties.

Anyone feel differently about dealing with a potential VA dissection vs blockage of the VA?

 

[lobelsteve]

Now, another patient cervical mri yesterday showed “abnormal signal void in right vertebral artery, raising suspicion for vertebral artery dissection”. Could be further evaluated with CT or MR angiogram.

Patient also has moderate cervical stenosis and no neurological deficits other that what is well explained by their moderate cervical stenosis in their early forties.

Anyone feel differently about dealing with a potential VA dissection vs blockage of the VA?

Is there a history of recent chiropractic manipulation or head and neck trauma? Are there symptoms consistent with radiculopathy or vertebral artery dissection? Radiologist look at a picture and tell you what they see. Nothing more and nothing nothing less.

 

[MitchLevi]

Is there a history of recent chiropractic manipulation or head and neck trauma? Are there symptoms consistent with radiculopathy or vertebral artery dissection? Radiologist look at a picture and tell you what they see. Nothing more and nothing nothing less.

I've seen two women under 30 yo with massive carotid dissections from chiropractic adjustments. Both with hemiplegia.

 

[lobelsteve]

I've seen two women under 30 yo with massive carotid dissections from chiropractic adjustments. Both with hemiplegia.

Same Chiro?

 

[MitchLevi]

Same Chiro?

No. At least, I highly doubt it. One was Shepherd Center and I think the other was Emory Rehab, but they may have both been SC pts. Young. Terrible.

 

[bedrock]

I’ve seen 3 VA dissections/CVA from chiropractic cervical HVLA.

Sad cases all of them.

 

[paindoc007]

Do the chiros ever get massive lawsuits for it??

 

[hyperalgesia]

Now, another patient cervical mri yesterday showed “abnormal signal void in right vertebral artery, raising suspicion for vertebral artery dissection”. Could be further evaluated with CT or MR angiogram.

Patient also has moderate cervical stenosis and no neurological deficits other that what is well explained by their moderate cervical stenosis in their early forties.

Anyone feel differently about dealing with a potential VA dissection vs blockage of the VA?

Would be the same mgmt for me. I would notify the patient and the PCP of the incidental findings and that's it.

Some vasc surgeon in the future might see this post and say, "we could have wrapped that VA in synthetic graphene vascomesh and saved the patient!!"

 

[Ducttape]

anticoagulation is not the prophylactic treatment.

vascular surgery again but not the same level of acuity. acute dissection is pretty obvious. i would not hesitate to do the epidural. would clearly advise to never see chiro or do any rapid movements of the neck.

neurologists would not be helpful.