The Use of Tissue Plasminogen Activator in the Treatment of Wallenberg Syndrome Caused by Vertebral Artery Dissection

• Published in: The Journal of emergency medicine Vol. 52; no. 5; pp. 738 - 740
• Main Authors: Salerno, Alexis, MD, Cotter, Bradford V., MD, Winters, Michael E., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-05-2017
• Subjects: Adult; Ataxia - etiology; Computed Tomography Angiography - methods; Emergency; Emergency Service, Hospital - organization & administration; Fibrinolytic Agents - pharmacology; Fibrinolytic Agents - therapeutic use; Headache - etiology; Humans; ischemic stroke; Lateral Medullary Syndrome - complications; Lateral Medullary Syndrome - drug therapy; Male; Neck Pain - etiology; Nystagmus, Pathologic - etiology; Stroke - drug therapy; Stroke - etiology; Tissue Plasminogen Activator - pharmacology; Tissue Plasminogen Activator - therapeutic use; vertebral artery dissection; Vertebral Artery Dissection - complications; Vertebral Artery Dissection - drug therapy; Vomiting - etiology; Wallenberg syndrome; vertebral artery dissection; Wallenberg syndrome; ischemic stroke
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2017.01.025

Abstract Background Acute cerebrovascular accident (CVA) is a devastating cause of patient morbidity and mortality. Up to 10% of acute CVAs in young patients are caused by dissection of the vertebral or carotid artery. Wallenberg syndrome results from a CVA in the vertebral or posterior inferior artery of the cerebellum and manifests as various degrees of cerebellar dysfunction. The administration of a thrombolytic medication has been recommended in the treatment of patients with stroke caused by cervical artery dissection. Surprisingly, there is scant literature on the use of this medication in the treatment of this condition. Case Report We describe a 42-year-old man with the sudden onset of headache, left-sided neck pain, vomiting, nystagmus, and ataxia 1 h after completing a weightlifting routine. Computed tomography angiography revealed a grade IV left vertebral artery injury with a dissection flap extending distally and resulting in complete occlusion. Subsequent magnetic resonance imaging and angiography demonstrated acute left cerebellar and lateral medullary infarcts, consistent with Wallenberg syndrome. The patient was treated with tissue plasminogen activator, which failed to resolve his symptoms. Why Should an Emergency Physician Be Aware of This? Emergency physicians frequently manage patients with acute CVAs. For select patients, the administration of tissue plasminogen activator can improve outcomes. However, the risk of major hemorrhage with this medication is significant. Cervical artery dissection is an important cause of acute stroke in young patients and is often missed on initial presentation. It is imperative for the emergency physician to consider acute cervical artery dissection as a cause of stroke and to be knowledgeable regarding the efficacy of thrombolytic medications for this condition.