Engelter, S.

Haller, S.

Hardmeier, M.

Lyrer, P.

Renaud, S.

Steck, A.

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M. HardmeierS. HallerA. SteckP. LyrerS. EngelterS. RenaudVertebral arterydissection presenting withfifth cervical root (C5)radiculopathyReceived: 4 February 2006Received in revised form: 26 March 2006Accepted: 28 March 2006Published online: 11 April 2007Sirs: Peripheral motor deficits inthe upper limb are rare manifesta-tions of vertebral artery dissection(VAD) [1–6]. In cervical spine MRIsigns of VAD may remain unrec-ognised. The case reported herehighlights the need to excludeVAD in otherwise unexplainedradiculopathies of the uppercervical cord.A white 52-year-old waiterpresented with severe proximalweakness of the left arm. Threeweeks prior to presentation he hadsustained minor trauma withbruises to the right chest and tendays later developed left-sidedneck pain without radiation to thearms. Three days before presen-tation he noticed difficulties atwork when serving his guests,because he could neither elevatenor rotate the left shoulder. Hispast medical history was signifi-cant only for vaccinations (polio,hepatitis A and tetanus) threemonths before. He has no familyhistory of neuromuscular diseases.On admission severe weaknessof the following muscles was ob-served on the left: deltoid (2/5),supraspinatus (2/5), infraspinatus(2/5) and biceps (3/5). Biceps andbrachioradialis reflexes were ab-sent and no sensory deficit wasdetected. The remainder of theneurological and physical examwas unremarkable. A C5 radicul-opathy was suspected on clinicalgrounds, probably due to a discherniation. Since there was neitherradiating pain nor a sensory defi-cit infectious radiculopathy andidiopathic plexus neuritis wereconsidered in the differentialdiagnosis.In the CSF, however, cell countand protein were within normallimits and the Lyme serology wasnegative. Cervical MRI (Fig. 1 Aand B) showed no relevant disc-opathy, but revealed a dissectionof the left vertebral artery from C7to C2 indicated by an intramuralhaematoma (open and thin ar-rows) in close relationship to thenerve root (filled arrows). MR-angiography (Fig. 1 C) demon-strated a narrowed lumen of theextracranial left vertebral artery.Neurosonography revealed en-larged vessel diameter and nar-rowed vessel lumen of the V2-segment of the left vertebral arterywithout intimal flap or haemody-namic changes. Diagnosis of leftsubadventitial extracranial VADcompressing the C5 nerve root wasmade. Electromyography con-firmed an isolated acute denerva-tion process of the C5 innervatedmuscles of the left arm. Therapywith acetylsalicylic acid (100 mg)was started [7]. The weakness re-solved within four weeks.We found eight other publishedcases of VAD with severe weak-ness of C5 and C6 innervatedmuscles as the only presentingsymptom [1–6]. Patients wereyoung (mean age 35.4 years), thedelay between initial pain andoccurrence of weakness rangedfrom three to ten days (mean7.2 days). Neck pain was reportedin eight patients, local pain in theshoulder or arm in four. Weaknesswas most prominent in the deltoidmuscle in all cases, slight numb-ness in the upper arm occurred infive. All had a full recovery afterone to five months. None sufferedfrom stroke or TIA during follow-up.Cases of VAD presenting onlywith peripheral motor deficitsmay be underdiagnosed due to amore benign clinical course andthe difficulties in establishing thediagnosis. MRI is the preferredtechnique for spine imaging, butsubtle signs of VAD may bemissed in the first few days, be-cause the hyperintensity of theintramural haematoma on T1weighted images is not visibleuntil the formation of methae-moglobin [8, 9]. Here, neuroso-nography may provide usefulinformation about altered verte-brobasilar perfusion and non-atherosclerotic arterial wall alter-ations.The close anatomical relation-ship between the vertebral arteryin the intraforaminal part and theanterior motor part of the nerveroots suggests a compressive aeti-ology due to mural haematoma inthe vessel wall [1, 2, 5]. Alterna-tively, VAD may compromise theperfusion in the vasa nervorumand result in nerve root ischaemia.The C5 root seems to be the mostsusceptible root.M. Hardmeier (&) Æ A. Steck Æ P. LyrerS. Engelter Æ S. RenaudDept. of NeurologyUniversity Hospital BaselPetersgraben 44031 Basel, SwitzerlandTel.: +41-61/265-4151Fax: +41-61/265-4100E-Mail: mhardmeier@uhbs.chS. HallerDivision of NeuroradiologyDept. of DiagnosticRadiology, University Hospital BaselBasel, SwitzerlandLETTER TO THE EDITORSJ Neurol (2007) 254:672–673DOI 10.1007/s00415-006-0331-8References1. Dubard T, Pouchot J, Lamy C, Hier D,Caplan LR, Mas JL (1994) Upper limbperipheral motor deficits due to extra-cranial vertebral artery dissection.Cerebrovasc Dis 4:88–912. Hetzel A, Berger W, Schumacher M,Luecking CH (1996) Dissection of thevertebral artery with cervical root le-sions. J Neurol 243:121–1253. De Bray JM, Penisson-Besnier I, GiroudM, Klein J, Tanguy JY, Pasco A, Dubas F(1998) Peripheral motor deficit andthree vertebral artery dissections. RevNeurol (Paris) 154:762–7664. Aggarwal A, Burton K (1999) Cervicalroot injury caused by vertebral arterydissection. J Clin Neurosci 2:166–1685. Fournier JY, Amsler U, Weder B, Hei-lbronner R, Hildebrandt G (2000)Extracranial vertebral artery dissectioncausing cervical root lesion. J Neuroi-maging 10:125–1286. Crum B, Mokri B, Fulgham J (2000)Spinal manifestations of vertebral arterydissection. Neurology 55:304–3067. Lyrer P, Engelter S (2003) Antithrom-botic drugs for carotid artery dissection.Cochrane database Syst Rev 3:CD0002558. Tay KW, U-King-Im JM, Trivedi RA,Higgins NJ, Cross JJ, Davies JR, Weiss-berg PL, Antoun NM, Gillard JH (2005)Imaging the vertebral artery. Eur Radiol15:1329–13439. Paciaroni M, Caso V, Agnelli G (2005)Magnetic Resonance Imaging, MagneticResonance and Catheter Angiographyfor Diagnosis of Cervical Artery Dissec-tion. In: Baumgartner RW, Bogousslav-sky J, Caso V, Paciaroni (eds) Handbookon Cerebral Artery Dissection. FrontNeurol Neurosci. Karger, Basel, vol 20,pp 102–118Fig. 1 Axial MRI at the level of C5, T1weighted sequence with fat and flowsuppression (A) shows intramuralhaematoma of the left vertebral artery(open arrows) in close relationship tothe nerve root (filled arrows). CoronalT1 weighted MRI with fat suppression(B) shows intramural haematoma(arrows) of the entire transforaminalV2-segment of the left vertebral arteryranging from C7 to C2. Contrastenhanced MR-angiography (C) showsmarked longitudinal narrowing of theleft vertebral artery lumen (arrows)673

Vertebral artery dissection presenting with fifth cervical root (C5) radiculopathy

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Vertebral artery dissection presenting with fifth cervical root (C5) radiculopathy

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