A woman in her 40s presented to the emergency department (ED) complaining of right shoulder and neck pain that started after her car was hit by a truck. She had no other complaints. Plain films of the shoulder and cervical spine were negative and she was sent home.
Eight days later, the patient returned to the ED. Although her pain had improved, she now had severe vertigo and a mild headache. She reported vomiting occasionally, but denied any abdominal pain. A neurologic evaluation and a CT scan of the head found no abnormality. The patient was given a diagnosis of post-concussive syndrome and, again, sent home, with prescriptions for ondansetron and meclizine.
Two days later, the patient returned yet again, with persistent vertigo, but no new symptoms. She stated that the vertigo—a spinning feeling that was nonpositional—had gotten worse. During the examination, the patient kept her eyes closed because it mitigated her symptoms. Her neurologic examination was once again unremarkable except for nystagmus. Romberg test results were normal, and there was no dysmetria. Results of finger-nose-finger, heel-shin, and rapid alternating movement testing were all normal.
The progression of the patient’s symptoms suggested an occult injury. To investigate further, the ED physician at this visit ordered a carotid and vertebral arterial duplex ultrasound examination, the results of which were markedly abnormal. Results of a subsequent magnetic resonance angiography (MRA) study of the neck are shown in Figure 1.
What’s your diagnosis and how would you treat this patient?