Last year, my wife and I put our 1-year-old daughter into daycare for the first time. She developed an upper respiratory infection and passed it along to me. Despite Tessalon Perles, albuterol, and a variety of over-the-counter remedies, I had a hacking, bronchospasm-type cough for a few days. At one point, I was at home watching a sitcom and started laughing and coughing at the same time, which resulted in a twinge in the left side of my neck. I didn’t have any pain but noticed that I would reflexively hold my neck whenever I coughed.

Early the next week, I was in a meeting and developed a left occipital headache. Nothing major but enough to make me take some Tylenol when I got home. The next morning, the headache was back and now was associated with a sunburn-like sensation to my left frontal and parietal scalp. I would also develop a headache in that region whenever I pushed on my neck at the base of my scalp. The pain would go away when I stopped. That night at dinner, I noticed that the sniffing position was now quite uncomfortable for me. Tylenol, Motrin, and Robaxin didn’t help, but lying on my side (either side) and either ice or heat did help. I had an early shift the next morning, so figuring I pulled something while coughing, I slapped on some ice and went to bed.

The next day at work, the symptoms persisted. I spoke to one of my colleagues, who commented that his brother had something very similar and it turned out to be shingles. That sounded reasonable, so I started Valtrex and prednisone and went about my business. We were leaving for Hawaii the next morning for a friend’s wedding, so I popped over to the barber after work. The pain from the comb through my hair was quite impressive as was the pain from wearing a baseball cap.

Over night, the headache worsened and settled into a persistent pre-orbital pain along with my neck pain. It was still better when I was on my side. The shingles rash that I was expecting had yet to materialize. I was having no other symptoms. By the afternoon, I was becoming a bit more concerned and called my emergency department and spoke with a doctor. If I came in, based on what I’m saying, would she do any imaging? She didn’t think so, and in her shoes, I wouldn’t either. I still figured I pulled something while coughing, though I couldn’t really link that to the neuralgia symptoms. That evening, I was texting with another emergency physician, and she matter-of-factly diagnosed me with a vertebral artery dissection (VAD). Thanks, I said, but I’ll stick with rash-less shingles and muscle strain with secondary neuralgia.

I actually slept well that night, and things seemed to be getting better. However, by the time I got downstairs in the morning, the pain was back and worse. What worried my wife most was that we needed to be out the door in 15 minutes and I had crawled back into bed. We had a plane to catch, so I slapped on an ice pack and loaded up the car, and we were out the door. About 10 minutes into the car ride, my wife noticed that I had my seat completely reclined, and we both came to the realization that getting on the plane probably wasn’t a great move. She got off the freeway, and we decided to swing by my emergency department to get told everything was fine, and then we’d be on our way.

Emergency Department Workup

At the emergency department, I had a normal exam, and everyone agreed that this was muscular. My colleague even found a nice trigger point that exacerbated my symptoms. He suggested a trigger point injection, which I was agreeable to on the condition that I would get a CT angiogram of my neck if it didn’t help. Deal. I got the injection; it didn’t help. I got the CT angiogram, and about 30 minutes later, I was in an ambulance to our neuro tertiary-care center for my long-segment VAD. No Hawaii for me.

The overnight stay in the neuro ICU was pretty uneventful. I got a little morphine, more for the cough than the pain. I was started on Plavix and aspirin. My MRI of the brain was normal. Transcranial Doppler showed no emboli. I puked up a dose of Norco, but otherwise, the night was uneventful. After seeing the intensivist, neurologist, and neurosurgeon, it was decided that I would lay low for six weeks, continue the antiplatelets, and start lisinopril and Lipitor.

Little did we know that the day I left the hospital was the first day of boating season in Seattle, and our route home was from one side of Lake Washington to the other. After about an hour in the car (for a 10-mile drive), I was carsick and made it to within a half mile of my house before I vomited. This led to a marked increase in the headache that was not improved with position, ice, Zofran, or tramadol. Of course, my wife thought I was doing fine, so she popped over next door to chat with the neighbors. When she got home, apparently I looked like death, so back to the emergency department we went. I guess the nurses agreed with my wife’s assessment; they put me in a resuscitation room. Now my blood pressure was 230/120, and I was dripping in sweat. Fortunately, a repeat CT angiogram showed no change in the dissection, and I did not have a subarachnoid hemorrhage. After about eight hours in a room, two liters of fluid, IV Dilaudid, Zofran, Compazine, Benadryl, and Ativan, I was as good as new.

Long Road to Resolution

Sadly, I spent the next three weeks on my back, needing narcotics and benzos to control the pain. I finally went in to see the neurosurgeon, who wasn’t thrilled that I was incapable of sitting upright in the waiting room. He promptly got the neurointerventionalist from next door, who sent me down to interventional radiology and performed a diagnostic angiogram, which showed a pretty ragged artery with lots of thrombus. The options were: 1) stay on Plavix and hope for the best, or 2) sacrifice the artery that I really didn’t need anyway. I chatted with a few people, but it was pretty clear that the second choice was the best option. The next day, I had a second angiogram and had six platinum coils placed. As an aside, it was noted that I had some extravasation of blood into the soft tissue. I went home that evening with a Medrol dose pack, and by the next morning, I was nearly pain free and have been so since.

I was back at work and feeling great at my six-month follow-up for angiogram number three. To my dismay, this showed that the extravasated blood had managed to work itself into a dural arteriovenous fistula (AVF). The recommendation was to do a fourth angiogram and squirt a little surgical glue (Onyx) in there and just be done with it. The downside of a persistent dural AVF is myelopathy, which is obviously best avoided. This sounded like a fantastic plan until the physician told me that the risk of the procedure was the glue going where it shouldn’t, causing an immediate spinal artery stroke and quadriplegia. I spoke to my neurosurgeon and then a colleague neurosurgeon, who both thought an open approach, if even needed, was better, so I got an MRI (normal) and saw a specialist outside of the system who did these for a living. He wanted to wait another six months, repeat the MRI, and then do his own angiogram. The repeat MRI was normal. His angiogram showed decreased blood flow through the AVF. Apparently, a few of these just slow down and shut off on their own. It was decided to wait a year and repeat the angiogram. If the flow remains low, then there won’t be much more to do. If there is still a problem, then the next step would be a multilevel spinal fusion—which definitely beats a spinal artery stroke!

In the meantime, I feel great and have no symptoms. I’ve diagnosed a good number of VADs in the meantime, and my group’s CT utilization rate has skyrocketed. I have come to the conclusion that VADs are not that uncommon.

Dr. Christianson is program director of emergency services at Group Health Permanente in Seattle.