Sun28November0440PM 49

A 28-year-old man was admitted to the Emergency department after attending his weekly judo club meeting.

He had felt well and had been participating actively. Within a few minutes of his final fight, he developed pain in his neck, vertigo, blurred vision and diplopia. He had difficulty in balancing himself with a tendency to fall to the right and incoordination of right upper and lower limbs.

There was accompanying facial asymmetry, decreased hearing from right side, difficulty in swallowing, and associated weakness of right side of body.

There was no past medical history of note and he was a non-smoker.

On examination, a right sided Horner's syndrome was noted. There was nystagmus (fast phase to the right), sensorineural hearing loss in the right ear and paresis of soft palate on right side. There was reduced tone and power in upper and lower limbs on the right. Deep tendon reflexes were brisk on the right side and plantar response was extensor.

Sensory examination revealed a crossed hemianaesthesia with involvement of the face on the right side.

What is the most likely diagnosis?

(Please select 1 option)

Atlanto-axial dislocation

Vertebral artery dissection Correct

Posterior communicating artery aneurysm

Posterior inferior cerebellar artery infarction

Cavernous sinus thrombosis

Explanation

Vertebral artery dissection is well-recognised cause of stroke in patients under 45 years and is associated with a 10% mortality rate in the acute phase.

Death may occur due to intracranial dissection, brainstem infarction or subarachnoid haemorrhage.

Common causes include:

Structural defects of the arterial wall

Connective tissue disease

Trauma (for example, road traffic accident, sporting injury), and

Chiropractic manipulation of the neck.

The typical clinical presentation is with severe occipital headache followed by focal neurological signs attributable to ischaemia of brainstem or cerebellum.

Other less likely differential diagnoses of stroke in this age group include:

focal seizure

migraine with prolonged aura and migraine variants

multiple sclerosis, and

conversion disorders.