An Accountant Who Loves Aerobics With Hiccups and Incoordination

Ajith Goonetilleke, MB BS, FRCP

Disclosures

July 02, 2021

Cervical artery dissections (CADs) may involve the carotid or vertebral arteries. They are implicated in 2% of all ischemic strokes but in up to 10%-25% of cases in young and middle-aged patients. CAD may occur spontaneously, and several inheritable connective tissue disorders (eg, Ehlers-Danlos syndrome type IV, Marfan syndrome, autosomal dominant polycystic kidney disease, and osteogenesis imperfecta) are associated with an increased risk. Familial arterial dissections have been associated with generalized lentiginosis, coarctation of the aorta, bicuspid aortic valve, and aortic root dilatation.

Traumatic CAD occurs most frequently following motor vehicle accidents. Less violent forms of trauma have also been implicated in CAD, especially cervical spine chiropractic manipulations. Other forms of trauma implicated in CAD include contact sports, yoga, calisthenics, vigorous aerobic exercise, ceiling painting, tonic-clonic seizures, and riding on roller coasters. The mechanism of stroke in CAD is usually thromboembolic due to disruption of normal blood flow in the region of dissection. Partial or total occlusion of the vessel that then results in low blood flow and watershed ischemia is less common. The presence of a CAD may be confirmed by formal cerebral angiography, but less invasive procedures such as MR angiography, CT angiography, or duplex Doppler studies are diagnostic in a high proportion of patients.

The patient in this case presented acutely to the ED, had a normal CT head scan, and was within the time window to receive treatment with IVT. She was given 0.9 mg/kg of recombinant tPA intravenously 3 hours and 15 minutes after the onset of her stroke. She remained well, and 24 hours later she was started on oral aspirin therapy. Her intractable hiccups were treated with oral chlorpromazine and resolved after 2 weeks. Because she was experiencing an intrusive burning sensation affecting the left side of her body as well as disturbed vision due to persistent nystagmus, she was started on gabapentin therapy. Both of these symptoms were controlled well with gabapentin at 1800 mg per day. The patient's dysphagia and right-sided limb ataxia improved such that she was able to eat a normal diet and walk within 1 week of hospital admission. The patient was discharged to home and was able to return to her employment as an accountant 10 weeks after her stroke.

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