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research-article2014

SPHXXX10.1177/1941738114547347Mas Rodriguez et alSports Health

vol. 8 • no. 1

SPORTS HEALTH

[ Orthopaedic Surgery ]

Spontaneous Bilateral Vertebral
Artery Dissection During a Basketball
Game: A Case Report
Manuel F. Mas Rodriguez, MD,*† Rafael Arias Berrios, MD,†
and Edwardo Ramos, MD†
Spontaneous vertebral artery dissection accounts for 2% of all ischemic strokes and can occur as a consequence of sports
events. We present an unusual case of spontaneous bilateral vertebral artery dissection in a 30-year-old male patient during
a basketball game. He developed severe dysphagia, right hemiparesis, and balance dysfunction. We also present a review of
the pathology, diagnosis, symptomatology, treatment, prognosis, and occurrence of this entity in sports.
Keywords: spontaneous bilateral vertebral artery dissection; stroke; basketball; sports

S

troke is a rare condition in the young adult population,
with fewer than 5% of all strokes occurring in adults
younger than 45 years. Vertebral artery dissection (VAD)
accounts for 20% of these cases and is a possible result of
trauma or chiropractic neck maneuvers. Spontaneous
occurrence is rare.

Case Report
A 30-year-old man with an unremarkable medical history was
admitted to the emergency room after experiencing numbness
on the right side of his face and dizziness while playing
basketball. He recounts that he quickly had a transient cold
sensation on the right side of his face extending to his right arm
and leg. These symptoms were followed by a cramp-like
sensation on the right arm and weakness of the right leg.
Afterward, the remaining symptoms were weakness/numbness
on the right side of the face and difficulty with speech and
swallowing. The patient recently had an uneventful upper
respiratory tract infection and had no toxic habits. Family
history was unremarkable.
In the emergency room, he had right facial asymmetry with
tongue deviation to the right and right hemiparesis. Laboratory
values and the initial head computed tomography scan were
unremarkable. Forty-eight hours later, magnetic resonance

imaging (MRI) of the brain showed multiple recent infarcts at
both cerebellar hemispheres, suggestive of a VAD (Figure 1).
Magnetic resonance angiography (MRA) showed bilateral VAD
(Figure 2). He was anticoagulated and required gastrostomy for
severe dysphagia.
The patient was admitted to an inpatient rehabilitation facility
where he scored 81 on the Functional Independence Measure17
at initial evaluation. He was discharged after 16 days, with a
score of 107. At 6 months, he was asymptomatic, and continues
to work as a security guard.

Discussion
Spontaneous vertebral artery dissection (SVAD) is a
nontraumatic tear or disruption in the wall of the vertebral
artery.4 It is a rare cause of ischemic stroke, comprising 2% of
all ischemic strokes.30 However, in patients younger than 45
years, SVAD accounts for 20% of all ischemic strokes, with an
annual incidence of 2.6 to 5 in 100,000.3 Recently, the incidence
of SVAD has increased, in part because of the higher use of
modern diagnostic imaging studies rather than a true increase.18
There is no clear sex predominance; however, women tend to
develop this condition 5 years earlier than men.4 Simultaneous
damage of multiple vessels can occur in 30% of cases.3 A recent
multicenter study evaluating spontaneous cervicocranial

From the †Department of Physical Medicine, Rehabilitation & Sports Medicine, School of Medicine, University of Puerto Rico, Guaynabo, Puerto Rico
*Address correspondence to Manuel F. Mas Rodriguez, MD, Physical Medicine and Rehabilitation, School of Medicine, University of Puerto Rico, PO box 365067, San Juan,
Puerto Rico, 00969 (e-mail: manuelmasrodriguez@gmail.com).
The authors report the following potential conflicts of interest in the development and publication of this article: Editorial support was provided by grants from the National
Center for Research Resources (U54 RR 026139-01A1) and the National Institute on Minority Health and Health Disparities (8U54 MD 007587-03) from the National Institutes
of Health.
DOI: 10.1177/1941738114547347
© 2014 The Author(s)

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Mas Rodriguez et al

Figure 1. Axial diffusion-weighted image (DWI)
demonstrating focal areas of restricted diffusion in both
cerebellar lobes, compatible with acute infarcts.

dissections reported that 7% have bilateral vertebral artery
involvement.14 Bilateral VAD has been linked to chiropractic
maneuvers of the cervical spine, yet has also been reported as a
result of a volleyball game, basketball match, swimming,
dancing, or even episodes of mild exertion such as lifting a dog
or coughing.14,28 Sudden neck movements and stretching can
cause arterial tears.4
Pathophysiology
The extracranial vertebral artery is vulnerable to dissection in 3
segments throughout its course: at its origin from the subclavian
artery, through the spine within the intervertebral foramina, and
at the dura when penetrating the cranium.3 This last segment is
the most common location for dissection.4 Extracranial VAD can
extend intracranially in 10% of cases.4
Clinical Features
Headaches occur in 50% to 75% of patients who experience
SVAD.12,18 Pain is often localized at the occipital area
unilaterally, yet can occur bilaterally as well. Posterior neck pain
can be the initial symptom.9 Tinnitus, vertigo, nausea, unilateral
facial numbness, and balance disturbance can all be
accompanying symptoms.18
Neurologic sequelae after an SVAD depend largely on the site
of brain ischemia. Frequent patterns of ischemic brain damage
are cerebellar infarction in the posterior inferior cerebellar artery
territory and lateral medullary infarction.4 Lateral medullary
syndrome (Wallenberg syndrome)11 can manifest as contralateral
loss of pain and temperature sensation on the trunk with similar
symptoms on the ipsilateral side of the face.5 Other findings can
include ipsilateral Horner syndrome as well as limb ataxia,
54

Jan • Feb 2016

Figure 2. Magnetic resonance angiography image showing
almost complete thrombosis of the basilar artery (arrow).
This is an extension from the vertebral artery dissection and
thrombosis.

vertigo, nystagmus, nausea, vomiting, and dysarthria.38
Dysphagia occurs in 50% to 100% of patients with this
syndrome.27
Diagnosis
Diagnosis of SVAD should be considered with symptoms
consistent with a cerebrovascular event accompanied by neck
and/or occipital pain. Younger patients with no previous risk
factors experiencing symptoms after strenuous activities or
chiropractic maneuvers should further increase the
consideration of SVAD on the differential diagnosis.4 Digital
subtraction angiography is the gold standard for diagnosis.2,3,12,18
The most common findings are an eccentric, smooth, or
irregularly tapered stenosis.12
MRI and MRA are viable alternatives to digital subtraction
angiography for cerebral artery dissection, with a reported
sensitivity of 60%.4,12,18 More recently, computed tomography
angiography is more sensitive (100%) and specific (98%) in the
diagnosis of VAD.12 Color duplex ultrasound is an adjuvant
diagnostic tool with MRI and MRA,15,32 with a sensitivity of
75% to 86% efficacy. It is now a follow-up examination
tool.12,17
The current recommended initial imaging studies are MRI or
MRA followed by computed tomography angiography if
diagnosis is still in question.4,12,18
Treatment
Management of SVAD focuses on antithrombotic therapy.3,4,12,18
Intravenous heparin infusion is commonly used in the acute
phase followed by oral anticoagulation with warfarin for the
next 3 months.3 If follow-up imaging is unremarkable,
anticoagulation can be switched to oral antiplatelet therapy for
3 additional months.12 A risk factor for anticoagulation is
increased bleeding, but several studies have proven no
additional risk of hemorrhage with heparin or any other

vol. 8 • no. 1

SPORTS HEALTH

anticoagulant.3,4,12 Controversy exists in the selection of the
treatment for SVAD. A Cochrane review found no increased risk
of ischemic events or intracranial bleeding with the use of either
anticoagulants or antiplatelet agents.22

Acknowledgment

Prognosis

References

Persistent neurologic symptoms after discharge were seen in
42% of patients with this condition.6,12 In a prospective study of
169 patients with SVAD, outcome was favorable (modified
Rankin scale of 0 or 1) in 82% of patients presenting with
ischemic symptoms.1 Low baseline score on the National
Institute of Health Score Scale (NIHSS) and younger age were
independent predictors of a favorable outcome. Bilateral SVAD
was not a factor related to poor clinical outcome.1 Patients with
SVAD have a significantly better modified Rankin scale when
compared with those with spontaneous internal carotid artery
dissection (sICAD). Recurrent transient ischemic attacks and
ischemic strokes were more common in patients with SVAD
when compared with those with sICAD. Only higher NIHSS
score was seen as a risk factor for increased mortality and poor
outcome in this study.35
In general, SVAD has a relatively benign prognosis, with
low risk of recurrence of ischemic and/or aneurysmal
symptoms.18

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Dis. 2005;19:281-282.
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cervicocranial dissections: a multicenter study. J Stroke Cerebrovasc Dis.
2013;22:389-396.
15. Hoffmann M, Sacco RL, Chan S, Mohr JP. Noninvasive detection of vertebral
artery dissection. Stroke. 1993;24:815-819.
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Vertebral Artery Dissection in Sports
To our knowledge, SVAD has only been reported once during
or after a basketball game. A professional basketball player
developed symptoms of stroke and died 7 days later.8 Similar
sequelae have been seen after playing golf, including unilateral
vertebral artery occlusion, dissection, and/or aneurysm
formation.13,24,33,37 The proposed mechanism in all these cases
coincides to be a mechanical stretch on the vertebral artery
caused by sudden neck movement while playing golf,
especially during a golf swing. VAD occurs in contact sports
such as judo,20 mixed martial arts,31 and kickboxing.23 In these
cases, symptoms do not necessarily occur during a match yet
are linked to sport contact including grappling or kick to the
jaw. Of these, only the judoka suffered immediate neurologic
symptoms during contact sports participation. VAD has
occurred in Australian football,25 rugby,25 tennis,25,29 and
soccer.26,34 VAD has also been seen in horse racing,10 weight
lifting,21 scuba diving,19 inline skating,16 trampoline jumping,36
and gymnastics.7

Conclusion
Although uncommon in the general population, VAD is an
important cause of ischemic stroke in young adults, and
spontaneous occurrence is rare. However, VAD can occur
during sports events and should be considered as a differential
diagnosis in young patients with spontaneous occurrence of
ischemic stroke symptomatology.

The authors thank Gory Ballester-Ortiz, MD, University of
Puerto Rico School of Medicine for imaging study analysis.

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28. Prabhakar S, Bhatia R, Khandelwal N, Lal V, Das CP. Vertebral artery dissection due
to indirect neck trauma: an underrecognised entity. Neurol India. 2001;49:384-390.
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vertebral artery after a tennis match [in French]. Presse Med. 1985;14:2108.
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vertebral arterial dissection. Case report. Interv Neuroradiol. 2009;15:203-208.
31. Slowey M, Maw G, Furyk J. Case report on vertebral artery dissection in mixed
martial arts. Emerg Med Australas. 2012;24:203-206.
32. Sturzenegger M, Mattle HP, Rivoir A, Rihs F, Schmid C. Ultrasound findings in
spontaneous extracranial vertebral artery dissection. Stroke. 1993;24:1910-1921.
33. Taniguchi A, Wako K, Naito Y, Kuzuhara S. Wallenberg syndrome and vertebral
artery dissection probably due to trivial trauma during golf exercise [in Japanese].
Rinsho Shinkeigaku. 1993;33:338-340.

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34. Tekin S, Aykut-Bingol C, Aktan S. Case of intracranial vertebral artery dissection
in young age. Pediatr Neurol. 1997;16:67-70.
35. von Babo M, De Marchis GM, Sarikaya H, et al. Differences and similarities
between spontaneous dissections of the internal carotid artery and the vertebral
artery. Stroke. 2013;44:1537-1542.
36. Wechsler B, Kim H, Hunter J. Trampolines, children, and strokes. Am J Phys Med
Rehabil. 2001;80:608-613.
37. Yamada SM, Goto Y, Murakami M, Hoya K, Matsuno A. Vertebral artery
dissection caused by swinging a golf club: case report and literature review. Clin
J Sport Med. 2014;24:155-157.
38. Zorowitz R, Baerga E, Cuccurullo S. Types of stroke. In: Cuccurullo S, ed.
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