VAD accounts for only 2% of ischaemic strokes but is the leading cause of ischaemic stroke in people under 45 years of age[8]. The mechanisms of ischaemic stroke induced by VAD include the following: 1) tearing of the blood vessel wall, which compresses the surrounding tissue and leads to ischaemia, 2) lumen stenosis and occlusion caused by dissection, 3) detached embolism after secondary thrombosis, and 4) haemodynamic disorders[9].
The patient presented a moderate headache, and then developed severe head and neck pain, ataxia, dizziness, nausea, and vomiting the following day. The symptoms of VAD were in accordance with a previous report[10]. Brain MRI examination revealed multiple and sporadic acute cerebral infarction lesions in the brain. No distal vascular occlusion was found on the examination. The formation of a thrombus in the interlayer, which broke off and embolized the circulating vessels, was considered to be the underlying cause[11].
Typical imaging features of VAD through DSA include eccentric stenosis with external duct dilatation, beaded or segmental stenosis, intramural haematoma, double-lumen sign, intimal valve, and formation of dissecting aneurysm. Among them, the double-lumen sign and intimal flaps are the symptoms of a direct diagnosis of arterial dissection[12]. It has also been reported that irregular lumen stenosis or occlusion, thin line sign, rat tail sign, and pseudoaneurysm in DSA are the diagnostic signs of arterial dissection[13]. In this case, the DSA presented irregular luminal stenosis, clear distal vascular dilatation and an obvious right-angled vascular notch at the distal end of the vessel, which is not typical imaging features but is expected to provide a new imaging manifestation for arterial dissection.
Since the vertebral artery runs through the intervertebral foramen, VAD is often caused by mild mechanical stimulation, such as neck hyperextension or hyperflexion, or even head-turning[14]. The patient in the case was a young female with symptoms that appeared after neck massage with the pulling method. There is rarely a clear relationship between neck massage and VAD, but some studieiques, especially the incorrect, oblique angle in cervical pulling manipulation, can lead to acute intimal damage and dissection of the vertebral artery. Some studies have also found that there are three segments of the vertebral artery that can easily peel off to form a dissection[15]: the origin of the subclavian artery, the area where it penetrates the intervertebral foramen, and the area where it passes through the dura of the skull base (the most common area, which is consistent with this case)[16]. The risk of carotid artery dissection and stroke during neck massage is related to cervical spine manipulation and the strength of neck rotation in pulling manipulation[17], but there is currently no clinical recommendation on the range of rotation angle and strength of cervical spine ms have found that improper technanipulation, which requires further investigation.
There are only a few reports about VAD related to neck massage in the literature. Six previously reported cases are summarized in Table 1[18–22]. Among the 6 patients, 5 patients had acute cerebral infarction with neurological deficits r emaining. One patient had no cerebral infarction with bilateral carotid artery and bilateral vertebral artery dissection. Only one patient received emergency endovascular therapy due to acute vertebral artery occlusion[22], while the others received drug treatment. The symptoms and prognosis are shown in Table 1.
Table 1
Cases of vertebral artery dissection related to neck massage.
| Case | Trigger | Symptoms | Vessel | Cerebral infarction lesions | Treatment options | Outcome |
| M.Bashar Katirji, et al.[18] | Chiropractic manipulation | Neck pain, vertigo, vomiting, hemiparesis, ataxia | Right vertebral artery dissection | Right cerebellum | Low molecular weight heparin for anticoagulation | Ataxia and hypoesthesia remained after 20 months |
| M.Bashar Katirji, et al.[18] | Chiropractic manipulation | Neck pain, nausea, vomiting, vertigo, left hand numbness, slurred speech, difficulty swallowing | Right vertebral artery dissection | Right medulla | | Speech disorders, dysphagia and ataxia remained after 3 months |
| Stephen J. Phillips, et al.[19] | Chiropractic manipulation | Dizziness, speech disturbance, left-sided hemiplegia | Bilateral vertebral artery dissection | Right pons | Medicine treatment | Hemiplegia of left side remained after 16 days |
| R N Nadgir, et al.[20] | Chiropractic manipulation | Headache, ataxia, dysarthria, hypoesthesia | Left vertebral artery dissection | Right thalamus | Low molecular weight heparin for anticoagulation | Hemianesthesia of left side remained after 1 month |
| Andrea L. Chakrapani, et al.[21] | Chiropractic manipulation | Neck pain, ptosis | Bilateral internal carotid arteries Bilateral vertebral artery dissection | None | Warfarin Clopidogrel, aspirin• | Improved completely after 4 weeks; recovered completely after 1 year of follow-up |
| Jiang-Qiong Ke, et al.[22] | Chiropractic manipulation | Complete quadriplegia, complete facial and bulbar palsy, dyspnoea | Bilateral vertebral artery dissection | Bilateral pons | Emergency endovascular therapy | Hemiplegia of both sides remained after 27 days |
The treatment of VAD should take into account the condition of stroke and arterial dissection. According to the AHA/ASA Guidelines for the Early Management of Acute Ischaemic Stroke published in 2019, intravenous thrombolysis using alteplase within 4.5 h of onset is safe and reasonable in patients with acute ischaemic stroke with suspected carotid artery dissection[23]. For the occurrence outside of the intravenous thrombolysis therapy window (more than 4.5 h), antithrombotic therapy, including antiplatelet aggregation and anticoagulant therapy, is mainly recommended for treating ischaemic stroke and transient ischaemic attack and preventing the recurrence of artery dissection[24]. Studies have shown that 14% of patients with VAD experience an exacerbation of symptoms within 1 month, and most of them are alleviated at least 6 months later[25].
Endovascular therapy has become an important choice for the treatment of carotid and vertebral artery dissection in recent years but has mostly been evaluated in small samples[26]. The Chinese Guidelines for the Diagnosis and Treatment of Carotid Artery Dissection (2015) recommended that endovascular therapy could be chosen for carotid artery dissection, while stroke events were not controlled by drug therapy[27]. In this case, the patient was a young female with an acute onset and aggravated progression. Considering the critical condition, we adopted emergency endovascular therapy by placing a self-dilating Solitaire AB stent at the VAD and then applied aspirin and clopidogrel. The treatment process, in this case, can provide clinical ideas for endovascular treatment of stroke events caused by acute VAD so that the patients can receive more timely and effective treatment and more quickly achieve remission. However, additional cases and longer periods of follow-up are needed.
In conclusion, it is particularly important to collect the patient’s previous medical history to determine some special pathogens for the diagnosis of VAD. Endovascular therapy may be an effective way to quickly relieve clinical symptoms and reduce serious complications in patients with acute VAD. In our experience, the timely diagnosis and emergency endovascular therapy for the young female patient resulted in the rapid relief of symptoms and effective prevention of progression, in addition to reducing the possibility of permanent disability or even death from VAD.