Vertebral Artery Dissection with Subsequent Medullary Hemorrhaging

Abstract

A 45-year-old man was admitted due to sensory disturbance of the left side of the body, right-sided dyshidrosis, dysarthria, and right eye blepharoptosis. Eight days earlier, the patient had developed persistent throbbing occipital pain. Subsequently, two days before admission, he developed the neurological symptoms. The right vertebral artery (VA) was poorly depicted in its intracranial region (V4) on brain magnetic resonance angiography and computed tomography (CT) angiography. It was slightly dilated compared to the left VA on basiparallel anatomical scanning (Picture 1). Intramural hematoma was observed on T1-weighted imaging (T1WI), which was highly suggestive of arterial dissection (1). Brain CT showed a hematoma in the right lateral medulla oblongata on admission, which was identified as isointense on T1WI. Six days after admission, the patient developed intractable hiccups and sick sinus syndrome, which were treated with oral medication and a temporary pacemaker, respectively. The hematoma was depicted as hyperintense on fat-suppressed T1WI (Picture 2). We diagnosed the patient with radiologically confirmed VA dissection and subsequent medullary hemorrhaging. Medullary infarction and subarachnoid hemorrhaging are common complications of VA dissection, whereas medullary hemorrhaging has not been reported, except for one suspected but not radiologically confirmed case (2). Based on the absence of any other vascular malformations, intramural hematoma propagation into the medullary supplying arteries and subsequent vessel wall rupture was most likely, as suspected in