Working Diagnosis:
The patient's final diagnosis was a right extracranial and intracranial vertebral artery dissection secondary to air embolism. This dissection resulted in an MRI imaging negative lateral medullary infarct with residual right facial sensory loss and residual ataxia.

Based on the patient's imaging and the evolution of her clinical presentation, it was suspected that the mural thrombus at the dissection site threw off small emboli which caused transient ischemic attacks then progressed into a cerebrovascular accident.

Treatment:
The patient was not eligible for reperfusion therapy as it may have caused a worsening hematoma. Once stable, the patient was discharged with stroke rehabilitation, neck precautions, aspirin for stroke prevention, and Lyrica for neck pain. Neck precautions included avoidance of heavy lifting, deep tissue massage, and hyperextension of the neck.

Outcome:
The patient completed physical therapy at an acute rehabilitation facility and ophthalmology clinic due to residual loss of balance and abnormal depth perception. Four months later, a repeat MRA Head/Neck showed a resolving right vertebral artery dissection. She returned to work as a primary care physician six months after the cerebrovascular accident, but never returned to full-time practice and discontinued her surgical obstetrics practice.

Author's Comments:
This case demonstrated a vertebral artery dissection and resultant stroke that presented as neck pain after ascending quickly while diving. Initially, the exam was consistent with a benign cervical strain. When it evolved into episodes of numbness, tachycardia, and diaphoresis, it was presumed she was having panic attacks given her symptoms resolved with breathing exercises. Once transient ataxia and vision changes occurred, the differential expanded to include neurologic etiologies. It highlights that a serious and uncommon diagnosis can present with a common musculoskeletal complaint thus confirming the importance of taking a thorough history and starting with a broad differential diagnosis.

The association between scuba diving and vessel dissections is known but not fully understood. There has been an increase in number of case studies reporting a connection between dissection of the cervical vasculature and scuba diving over the past 20 years. Most of these cases were identified immediately following or within two weeks of the diving episode.1 In contrast, in the presented case study, it took four weeks for the dissection to be discovered. Per the literature, it is thought that the main factors related to scuba diving that may lead to vessel dissection include exaggerated cervical movements while in the water, the heavy weight of diving gear putting mechanical stress on the body, the demanding physical exercise required during immersion/emersion, the temperature changes of the water, and the exposure to gas that can influence the regulation of the vessel wall. Likely a combination of these factors, rather than just one factor, leads to a greater risk of dissection.

Editor's Comments:
This case demonstrates the importance of follow-up for even problems that appear to be simple so as not to miss something more drastic. Follow up visits assess healing or progression of symptoms which would indicate further investigation may be needed.

The most common symptom of vertebral artery dissection is neck pain. Ischemic symptoms usually result from TIA of the medulla or cerebellum and include dizziness/vertigo, loss of balance, veering to one side and ataxia. Most vertebral artery dissections are caused by mechanical events or trauma that may be mild or trivial in nature. Many different sports including scuba diving have been reported as causes.

In this case, she developed Wallenberg Syndrome as a result of the vertebral artery dissection causing either loss of blood flow or embolism to the posterior inferior cerebellar artery causing infarction of the lateral medulla. Symptoms and signs of Wallenberg syndrome include vertigo and disequilibrium, ipsilateral limb ataxia, ipsilateral Horner's syndrome, nystagmus or abnormal eye movements, loss of pain and temperature sensation on ipsilateral face and contralateral trunk though some may have decreased sensation to painful stimuli (hypalgesia). Hoarseness and dysphagia may also occur.

References:
1. Brajkovic S, Riboldi G, Govoni A, Corti S, Bresolin N, Comi G. Growing Evidence about the Relationship between Vessel Dissection and Scuba Diving. Case Rep Neurol. 2013;5(3):155-161. doi:10.1159/000354979.

2. Wasik M, Stewart C, Norris J. Delayed recognition of Horner syndrome secondary to internal carotid artery dissection after scuba diving. Clin Exp Ophthalmol. 2017;45(5):551-553. doi:10.1111/ceo.12931.

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