Images in clinical medicine: vertebral artery dissection

T his is a case of a 47-year-old German lorry driver with very limited English who presented with sudden onset of a neck pain followed by an occipital headache while he was on the motorway. The pain forced him to stop his vehicle and call a friend who brought him to accident and emergency department. On examination, he had unsteady gait, slight dysarthria and subtle horizontal nystagmus on extreme left gauze. There was slight incoordination and dysdiadokinesis in his left upper limb. Lumbar puncture showed high CSF protein with normal cells and glucose. MRI scan showed a left cerebellar infarction (Fig. 1). On angiogram (Fig. 2), there was evidence of some irregularity of the superior vertebral arteries bilaterally, particularly on the left side. There was some high signal in the vessel wall on the left side. These findings are consistent with vertebral arteries dissection predominantly on the left side.