Causes and Mechanisms of Cerebellar Infarction in Young Patients
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.
- Copyright © 1998 by American Heart Association
Barinagarrementeria F, Amaya LE, Cantu C. Causes and mechanisms of cerebellar infarction in young patients. Stroke.. 1997;28:2400–2404.
Mueller S, Sahs AL. Brain-stem dysfunction related to cervical manipulation: report of three cases. Neurology.. 1976;26:547–550.
Grau AJ, Brandt T, Forsting M, Winter R, Hacke W. Infection-associated cervical artery dissection; three cases. Stroke.. 1997;28:453–455.
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,R1 R2 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.R3