Bilateral vertebral artery dissection and cerebellar stroke following massage: a case report
Background: Headache and vomiting are common presenting complaints to the emergency department (ED). Whilst the majority of cases have a benign aetiology, stroke is an important diagnostic consideration.
Case: A 39-year-old male with a past history of migraine presented to the ED with one day of headache. He had associated vomiting, which was atypical for his usual migraines. He also described generalised posterior neck pain that preceded his other symptoms. The vital signs were within normal limits. The physical examination was only remarkable for left-sided past-pointing and an ataxic gait. A retaking of the history revealed that the neck pain had started abruptly during a Thai massage two days prior to presentation. Investigation with computed tomography (CT) angiography revealed bilateral vertebral artery dissection. CT brain showed evolving infarction of the cerebellar hemisphere. These findings were confirmed on magnetic resonance imaging (MRI), and the patient referred for admission under a stroke unit.
Discussion: Massage is a common alternative medicine in Australia. We believe that this is the first case of vertebral artery dissection (VAD) and subsequent stroke to be associated with massage. VAD is a significant cause of stroke in young patients, and can be caused by a broad range of trauma. We postulate that this may include straining of the vertebral arteries in certain massage techniques. Our case highlights the importance of history taking in young patients presenting with a stroke syndrome. Any recent trauma or pain affecting the neck should be identified to guide investigation. If suspicious for VAD, clinicians should proceed to early CT angiography.
Conclusion: Vertebral artery dissection is an important consideration in young patients who present with a stroke syndrome, especially in the presence of neck pain. Massage may be a previously unrecognized cause of this pathology. Alternative medicine is commonly used, and should be given consideration as a potential source of patient harm.
