Departments of Neurology,
New York Medical College,
Valhalla, NY,
Phelps Memorial Hospital Center,
Sleepy Hollow, NY
To the Editor:
The recent article by Barinagarrementeria and colleagues,1
dealing with the causes and mechanisms of cerebellar infarction in
young patients, is not only informative but also
provocative. The finding that 67% were caused by vertebral
artery dissection raises several questions. Specifically, the
pathogenesis of spontaneous vertebral artery dissection remains
unknown, yet several independent factors exist that may provide clues.
Did any of the individuals have chiropractic therapy,2
shampooing in a beauty parlor,3 or sustained neck
angulation activity4 within a week prior to their stroke?
It is well known that the mechanism of injury may be acute but also can
be delayed, with intimal damage evolving over hours or days. Thus, the
precipitating cause may be missed since physicians seldom ask about
antecedent neck activities or prolonged angulation postures.
It is also well established that individuals harboring a hypoplastic
vertebral artery are at augmented risk for brain stem
stroke.4 Did any of the cohort have this congenital
anomaly, since its presence imposes specific
hemodynamic stresses? Last, a recent
report5 implicated acute infectious disease as a cause of
vascular injury and dissection. Did any of the cohort experience an
infection within one week of onset?
In conclusion, physicians generally assume that the mechanisms of
stroke are acute, yet intimal-medial defects or cumulative response to
trivial traumas or infections need to be explored as part of a detailed
neurological history.
References
1.
Barinagarrementeria F, Amaya LE, Cantu C.
Causes and mechanisms of cerebellar infarction in young
patients. Stroke.. 1997;28:2400–2404.
2.
Mueller S, Sahs AL. Brain-stem dysfunction
related to cervical manipulation: report of three cases.
Neurology.. 1976;26:547–550.
3.
Weintraub MI. Beauty parlor stroke syndrome:
report of five cases. JAMA.. 1993;269:2085–2086.
4.
Weintraub MI, Khoury A. Critical neck positions
as an independent risk factor for posterior circulation stroke: a
magnetic resonance angiographic analysis. J
Neuroimaging.. 1995;5:16–22.[Medline]
[Order article via Infotrieve]
5.
Grau AJ, Brandt T, Forsting M, Winter R, Hacke W.
Infection-associated cervical artery dissection; three
cases. Stroke.. 1997;28:453–455.
Stroke Clinic,
Instituto Nacional de Neurologia y Neurocirugía,
Manuel Velasco Suárez,
Mexico City, Mexico
We have read with interest the comments of Dr Weintraub. The
frequency of vertebral artery dissection as cause of cerebellar
infarction was 27%, explaining 10 of 15 cases (67%) with cerebellar
infarction in territorial (PICA) distribution. There were no cases of
dissection with history of chiropractic therapy, but two of our
patients had a history of neck hyperextension with cervical pain in the
week prior to stroke onset. As pointed out by Dr Weintraub, dissection
may follow a variety of predisposing factors, including neck flexion or
extension,1 2 peritonsillar trauma, and strangulation. We
agree that these types of activities should be routinely researched in
young patients with cerebral infarction.
In our series there were no cases with evidence of congenital anomalies
in the vertebrobasilar system; neither was there a history of acute
infectious disease in those patients with vertebral artery
dissection.
Is well known that arterial dissection produce delayed
ischemic symptoms. Many patients have headache or neck pain as
first manifestation and develop ischemic symptoms hours or days
later. Pain could be the only manifestation of arterial
dissection.3
References
1.
Herr RD, Call G, Banks D.
Vertebral artery dissection from neck flexion during paroxysmal
coughing. Ann Emerg Med.. 1992;21:88–91.[Medline]
[Order article via Infotrieve]
2.
Mourad JJ, Girerd X, Safar M. Carotid-artery
dissection after a prolonged telephone call. N Engl
J Med.. 1997;336:516.
3.
Biousse V, Woimant F, Amarenco P, Touboul PJ, Bousser
MG. Pain as the only manifestation of internal carotid artery
dissection. Cephalalgia.. 1992;12:314–317.[Medline]
[Order article via Infotrieve]
© 1998 American Heart Association, Inc.
Letters to the Editor
Causes and Mechanisms of Cerebellar Infarction in Young Patients
Response
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