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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282XOn-line version ISSN 1678-4227

Arq. Neuro-Psiquiatr. vol.74 no.4 São Paulo Apr. 2016  Epub Oct 06, 2015

http://dx.doi.org/10.1590/0004-282X20150150 

Articles

Cerebrum-cervical arterial dissection in adults during sports and recreation

Dissecção arterial cérebro-cervical em adultos durante prática de esportes e recreação

Yara Dadalti Fragoso1 

Tarso Adoni2 

Lazaro Luiz Faria do Amaral3 

Flavio Tulio Braga4 

Joseph Bruno Bidin Brooks1 

Christiane Siqueira Campos3 

Elizabeth Regina Comini-Frota5 

Nelson Paes Fortes Diniz Ferreira4 

Luciano Marcus Tirotti Giacon6 

Sidney Gomes3  6 

Marcus Vinicius Magno Goncalves7 

Pedro Silva Correa Magalhaes8 

Andre Palma da Cunha Matta9 

Francisco Tomaz Meneses de Oliveira3 

Joao Felipe de Oliveira10 

Marco Antonio Pierucettti6 

Samira Luísa dos Apostolos Pereira11 

Maciel Eduardo Pontes12 

Fabio Siquineli10 

Carlos Bernardo Tauil12 

Guilherme Navarro Troaini1 

1Universidade Metropolitana de Santos, Santos SP, Brazil;

2Hospital Sírio-Libanês de São Paulo, Sao Paulo SP, Brazil;

3Hospital Beneficência Portuguesa de São Paulo, Sao Paulo SP, Brazil;

4Hospital do Coracão, Sao Paulo SP, Brazil;

5Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil;

6Hospital Paulistano, Sao Paulo SP, Brazil;

7Centro Hospitalar UNIMED, Joiville SC, Brazil;

8Clinica Neurológica Joinville, Joinville SC, Brazil;

9Universidade Federal Fluminense, Niteroi RJ, Brazil;

10Universidade Regional de Blumenau, Blumenau SC, Brazil;

11Universidade de São Paulo, Sao Paulo SP, Brazil;

12Hospital de Base de Brasília, Brasilia DF, Brazil.

ABSTRACT

Dissection of cervical arteries constitutes a medical emergency. Although relatively rarely, activities classified as sports and recreation may be a cause of arterial dissection independently of neck or head trauma. The purpose of the present paper was to present a series of cases of cerebrum-cervical arterial dissection in individuals during or soon after the practice of these sports activities.

Methods

Retrospective data on patients with arterial dissection related to sports and recreation.

Results

Forty-one cases were identified. The most frequently affected vessel was the vertebral artery. A large variety of activities had a temporal relationship to arterial dissection, and jogging was the most frequent of these. This is the largest case series in the literature.

Conclusion

Arterial dissection may be a complication from practicing sports.

Key words: dissection; carotid artery; vertebral arterial; stroke

RESUMO

A dissecção das artérias cervicais é uma emergência médica. Embora de forma relativamente rara, certas atividades descritas como esportes e recreação podem ser a causa de dissecção arterial independentemente de trauma de crânio ou cervical. O propósito do presente estudo é apresentar uma série de casos de dissecção de artérias cérebro-cervicais em indivíduos durante ou logo após a prática destas atividades desportivas.

Métodos

Dados retrospectivos de pacientes com dissecção arterial relacionada à prática de esportes e recreação.

Resultados

Quarenta e um casos foram identificados. A artéria mais frequentemente afetada foi a vertebral. Uma grande variedade de atividades teve relação temporal com a dissecção arterial, sendo a corrida a mais frequente delas. Esta é a maior série de casos da literatura.

Conclusão

Dissecção arterial pode ser uma complicação da prática de esportes.

Palavras-Chave: dissecção; artéria carótida; artéria vertebral; acidente vascular cerebral

Dissection of cervical arteries can lead to severe sequelae and constitutes a medical emergency. Among the causes of this dissection, trauma to the neck rates high in importance. When trauma is extensive, such as in motor vehicle accidents, the risk of dissection is clear and most doctors attending these patients at the scene or at the time of hospital admission will consider this possibility1. However, when trauma occurs during sports or recreation, it may be more difficult to recognize the clinical manifestations of the arterial injury. In addition, the trauma may be minimal and not be perceived as such, thus making the diagnosis more difficult. The possible influence of these sport-related traumatic events may be further underestimated if longer intervals between vessel dissection and ischemia occur.

The literature on the subject is rich in isolated cases or small case series, showing a variety of sports that can be related to cervical arterial dissection. Soccer2, diving3,4, wakeboarding5, golf6, treadmill running7, horse riding8, snowboarding9, physical fitness testing10, triathlon11, heavy weight-lifting12,13, volleyball14, basketball15, skating16, gymnastics17, tennis18 and martial arts19,20,21,22 are examples of these cases found in the literature. Even virtual sports, practiced using the Wii device, have been correlated with arterial dissections of the neck23. There are few case series on sport-related arterial dissection of the cerebrum-cervical system, and the largest and most recent series reports 10 cases24.

The aim of the present study was to report on a large series of patients with cerebrum-cervical arterial dissection during a variety of sport or recreational activities.

METHOD

Neurologists at different units in Brazil were invited (personally and via e-mail) to forward cases of arterial dissection of the neck that had occurred during or immediately after sport or recreational activities. Cases involving motor vehicle accidents were not included, even if they were considered to be a sportive activity (e.g. motocross).

Retrospective data were collected from the medical records of patients who had already signed a consent statement at the time of hospital admission. The present study was approved by the Ethics Committee (Institutional Review Board) of Universidade Metropolitana de Santos, under the number CAAE 37485714.7.0000.5509. Whenever necessary, additional approval was obtained from other institutions.

Analyses of the results were done in an essentially descriptive manner, and no other statistical methods were used.

RESULTS

Forty-one cases of sport-related arterial dissections were identified. A summary of all the cases is presented in Table. A similar same numbers of men and women were affected (21 men and 20 women) and their average age at the time of the dissection was 39.4 years (range: 18 to 68 years of age). Four individuals presented high blood pressure before arterial dissection and one of them had had a previous stroke. These patients were undergoing treatment and were considered fit for physical activity. None of the subjects was a smoker or was using performance-enhancing drugs. None of them had head trauma at the time of the dissection, and only two of the individuals had been subjected to potential neck trauma (direct pressure on the neck in jujitsu practice). Jogging was found to be the most frequent activity preceding arterial dissection, affecting 18 individuals. Six patients correlated their dissection with doing brisk walks. In fact, jogging and brisk walks may not have been the cause of the dissection, but the temporal relationship between the events led us to include these cases in the cohort.

Four patients presented dissection during martial arts practice, three during swimming, two during muscle-building exercises, two during Pilates practice, and one each during scuba diving, soccer, bungee-jumping, gymnastics, belly dancing and tennis. The neurological symptoms occurred up to five days after the sports events.

The vertebral arteries were the most frequently affected vessels (11 cases on the left and 10 on the right side). Dissection of the following carotid arteries was observed: internal (eleven cases), external (four cases) and common (five cases). A list of the arteries affected in each case, along with the clinical manifestations according to the Bamford classification25, is presented in Table.

In nine cases, the dissection occurred in the intracranial segment of the arteries, while in 30 cases it affected the extracranial segment. In two cases, both intra- and extracranial segments were affected. There were three cases of embolism and complete obstruction of cerebral arteries, one of which resulted in death (dissection of both carotid arteries and occlusion of the middle cerebral artery). This was a 40-year-old female who was jogging. One patient (male aged 22 years) who presented left vertebral artery dissection during martial arts practice progressed to brain death. One patient (male aged 42 years) who presented dissection of the left common carotid artery while swimming also remains in a vegetative coma with right hemiplegia. Twenty-one patients (52.5%) present neurological sequelae of the arterial dissection.

Regarding the National Institutes of Health Stroke Scale (NIHSS)26, the patients scored between zero and 24 points (this last being the case of death). There were five cases with NIHSS scores of 16 points or above. On average, the NIHSS score was 8.6 ± 7.0 points. At the time when the patients were released from hospital, the score on the Rankin modified scale27,28 ranged from zero to five points (average 1.7 ± 1.3).

A few images from examinations on these patients are shown in Figure. Ischemic lesions of different areas of the brain, brainstem and cerebellum were common, and angiography confirmed and located the arterial dissection.

The treatment consisted of full anticoagulation for 35 patients, two of whom also received a stent. There was one case of stent use without anticoagulation and three cases of treatment with anti-platelet drugs. Four patients underwent craniotomy due to the extensive brain lesion and edema. Details of these cases are also shown in Table.

DISCUSSION

Regular practicing of sports and recreational activities is an important part of a healthy life. Acute and severe accidents or injuries during sports occur infrequently and should never be a deterrent to physical activity. However, it is important to acknowledge that arterial dissection may be a complication from practicing sports. Cervical trauma has been described as an important determinant of cervical arterial dissection, although it is not the only outcome predictor in these patients29. Recognition of this medical emergency is essential and the literature on the subject is, at present, very poor. A comprehensive review of the literature showed that, so far, only isolated cases or small series have been published2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24. Of all the sports potentially related to cerebrum-cervical arterial dissection, scuba diving25and martial arts20,21,22are those that are most often mentioned in the literature. This was not the experience of the authors of the present paper, who found that jogging was the main activity temporally related to arterial dissection among our patients.

The study presents limitations, as it is a pooled cohort from a large number of Neurology Units in Brazil. This was not a systematic collection of cases and no conclusions can be drawn regarding prevalence of arterial dissection, mechanisms for this arterial damage or even whether the activity was indeed the sole cause of vessel dissection. On the other hand, the present study brought in a large series of cases with a variety of sports potentially related to arterial dissection, including some not mentioned before. Failure to suspect a dissection in the context of a sport-related injury and therefore to proceed with the correct therapy can lead to permanent neurological deficits.

Table Summary of all cases reported in this cohort of patients with arterial dissection that occurred in temporal relationship with the practice of sports or recreational activities. 

Gender Age Comorbidities Smoking Sport Head/neck trauma? Affected arteries Extra or intracranial? Bamford Main symptoms NIHSS Treatment Sequela Rankin modificado
F 18 Bungee-jumping RECA Extra TACS Headache 22 Anticoagulation + craniotomy Left hemiparesia 2
M 22 Jiujitsu Neck LVA Extra POCS Coma, right hemiplegia 21 Craniotomy Brain death death
F 22 Jogging LVA Extra POCS Headache, nausea, vomiting 0 Anticoagulation 0
F 26 Jogging LVA Extra POCS Headache, nausea, vomiting 0 Anticoagulation 0
F 28 Jogging LVA Intra POCS Headache and vertigo 0 Stent 0
F 29 Belly dance RVA Extra LACS Dysarthria, dysmetria, nystagmus 1 Anticoagulation 0
M 30 Swimming LVA Extra POCS Ataxia, vertigo, dysarthria 3 Anticoagulation 0
F 31 Jogging RVA Extra POCS Right hemiparesis, aphasia 4 Anticoagulation 0
M 32 Jiujitsu Neck RECA Extra PACS Left hemiparesis, hemihyposthesia 4 Anticoagulation 0
M 32 Jogging LVA Extra POCS Neck pain 8 Anticoagulation Roomberg 1
M 32 Jogging RVA Extra POCS Headache and dizziness 8 Anticoagulation gait ataxia 2
M 32 Jogging LECA Intra TACS Neck pain 10 Anticoagulation 1
M 34 Jiujitsu Neck (very slight) LICA Intra PACS Hemiparesis and dysphasia 14 Anticoagulation hemiparesis 3
M 34 Jiujitsu Neck LECA Both PACS Aphasia 2 Anticoagulation diyphasia 2
F 35 Gymnastics LICA Extra PACS (+Horner) Horner and headache 0 Anticoagulation 0
F 35 Jogging RVA Extra POCS Headache, neck pain 0 Anticoagulation 0
F 36 Jogging LICA Intra PACS Headache and neck pain 0 Double anti-aggregation + stent 0
M 38 HBP Pilates Neck (very slight) RVA Intra POCS Ataxia, dizziness, left hemihyposthesia, dysarthria 5 Double anti-aggregation dysarthria 2
M 38 Football LVA Extra PACS Right hemiparesis, aphasia 8 Anticoagulation 0
F 40 Jogging LVA Extra POCS Neck pain 0 Anticoagulation 1
F 40 Jogging BILAT CCA Intra TACS Seizures 24 Anticoagulation death death
M 40 Jogging RVA Extra POCS Headache, neck pain 8 Anticoagulation 0
M 42 Swimming Neck (very slight) LCCA Extra TACS Coma, right hemiplegia, seizures 18 Craniotomy coma 5
F 42 Weight lifing ACID Both TACS Coma, right hemiplegia, VII nerve palsy 18 Anticoagulation + stent dysphasia 1
M 42 Swimming Neck (very slight) LCCA Extra TACS Coma, right hemiplegia, seizures 18 Craniotomy coma 5
M 43 Football RICA Extra PACS Left hemiparesis, blurred vision 2 Anticoagulation hemianopsia 2
F 43 Jogging LICA Intra TACS Headache 8 Anticoagulation hemiparesis 1
F 44 HBP Brisk walk LVA Intra POCS Headache, neck pain 16 Anticoagulation hemiparesis 2
F 44 Weight lifing RICA Extra PACS Left hemiparesis, VII nerve palsy 6 Anticoagulation 0
F 45 HBP Tennis LVA Extra POCS Dysarthria, dysmetria, nystagmus 8 Anticoagulation 0
M 45 Jogging RICA Intra TACS Headache 10 Anticoagulation hemiparesis 2
M 46 Scuba diving BILAT CCA Extra (only Horner) Headache 0 Anticoagulation 0
M 46 Brisk walk RVA Extra POCS Headache 18 Anticoagulation + stent hemiparesis 2
F 47 Jogging RVA Extra POCS Headache, neck pain 10 Anticoagulation gait ataxia 2
F 47 Jogging RVA Extra POCS Headache, neck pain 10 Anticoagulation ptoses 1
F 49 Jogging LVA Extra POCS Left hemiparesis, dizziness 8 Anticoagulation hemiparesis 2
F 50 Brisk walk LICA Extra TACS Headache, blurred vision 14 Anticoagulation 1
M 53 Jogging BILAT ICA Extra TACS Headache, XII nerve palsy 8 Anticoagulation XII nerve palsy 2
F 56 Brisk walk LICA Extra TACS Headache, right hemiplegia 14 Anticoagulation hemiparesis 2
M 59 Brisk walk LICA Extra TACS Aphasia 12 Anticoagulation hemiparesis 2
M 68 HBP, stroke Brisk walk RVA Extra POCS Headache, blurred vision, left hemiparesis 12 Anticoagulation hemiparesis 2

CCA: common carotid artery; RECA: right external carotid artery; LECA: left external carotid artery; RICA: right internal carotid artery; LICA: left internal carotid artery; RVA: right vertebral artery; LVA: left vertebral artery; TACS: total anterior circulation infarct syndrome; PACS: partial anterior circulation infarct syndrome; LACS: lacunar infarct syndrome; POCs: posterior circulation infarct syndrome.

Figure Images of angiography in cerebrum-cervical arterial dissection. A: bilateral internal carotid arterial dissection; B: left internal carotid artery; C and D: two cases of dissection of the left vertebral artery; E: right vertebral artery. 

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Erratum

The original Table with report of individual cases in the on line version of the article “Cerebrum-cervical arterial dissection in adults during sports and recreation” contained some mistakes. We have now provided the corrected version of the Table, removing the column with the Bamford classification, as per decision of all authors of the paper.

Received: December 16, 2014; Revised: July 17, 2015; Accepted: August 06, 2015

Correspondence

:Yara Dadalti Fragoso; Departamento de Neurologia, Faculdade de Medicina - UNIMES; Rua da Constituicao, 374; 11015-470 Santos SP, Brasil; E-mail: yara@bsnet.com.br

Conflict of interest:There is no conflict of interest to declare.

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