Abstract
Case A 29-year-old man presented with one week of severe left upper limb weakness preceded by a two-week history of atraumatic left neck and shoulder pain. Previous history significant only for hypertension diagnosed in the preceding year. This was untreated and systolic blood pressure was consistently above 200mmHg at presentation. Examination revealed severe sensorimotor deficit localized to the left C5/C6 dermatome and myotome. Chest X-ray showed elevation of left hemidiaphragm. Initially diagnosis was of an inflammatory left brachial plexopathy.
MR Brachial Plexus revealed bilateral vertebral artery dissection. On the left, the expanded dissected vertebral artery caused displacement and flattening of the left C5 and C6 nerves at the lateral margin of the foramina; the nerves appearing thickened and edematous. CT Angiogram confirmed bilateral non-occlusive vertebral artery dissection extending from C7 to C2 which normalized in appearances at follow-up scan 8 weeks later. Nerve conduction studies supported left C5 and C6 neuropathy localizing at or proximal to upper trunk of brachial plexus.
Management/Outcome Investigations are ongoing into secondary causes for hypertension. The patient will be on lifelong Aspirin and his hypertension is now controlled on three anti-hypertensive agents. His sensorimotor deficits resolved within 6 weeks.
Discussion Severe hypertension was deemed to be the cause of the spontaneous bilateral vertebral artery dissections, with the neuropathy resulting from compressive and ischemic factors. Although rare, vertebral artery dissection should be considered as a differential in the workup of patients whose presentation is suggestive of a brachial plexopathy or cervical radiculopathy.
