A 45-year-old man developed sudden vertigo while riding a snowmobile. He attributed his symptoms to a cold, stayed home from work, and did not seek medical care. During the next 3 weeks, he had additional symptoms, including horizontal diplopia, dysarthria, and left arm clumsiness. When he developed left face and arm paresthesias, he came to the emergency department. Neuroimaging revealed chronic left proximal cerebellar and acute bilateral distal cerebellar infarctions (Figure 1), raising suspicion for embolism from the left vertebral artery.1,2 A cardiac source for embolism was not found. A curved reconstruction image from computed tomographic angiography of the neck showed a possible dissection flap in the V3 segment of the left vertebral artery (Figure 2A) that was most apparent on 1.25-mm axial source images (Figure 2B). Anticoagulation was started. On repeated computed tomographic angiography 1 month later, the dissection flap was resolving, but a pseudoaneurysm was apparent (Figure 2C). He had no further cerebrovascular events.
Goddeau RP, Caplan LR, Hackney DB, Alhazzani AA, Searls DE. A Very Small but Very Symptomatic Vertebral Artery Dissection. Arch Neurol. 2010;67(2):248-249. doi:10.1001/archneurol.2009.318