DENTAL PROCEDURES AND STROKE:
Did you know that dental procedures can cause you to suffer a stroke or put you at increased risk of heart attack? Seemingly minor trauma, such as prolonged extension of the neck during dental procedures, may cause arterial dissections and ischemic strokes. This is the conclusion of a team of researchers at the department of clinical neurosciences, Calgary Stroke Program, University of Calgary, Calgary, Alberta.
The researchers state that as vertebral artery dissection may cause stroke, they must be identified and treated promptly. The association of arterial dissection with dental procedures has been previously observed. They report that a patient with posterior circulation stroke secondary to vertebral artery dissection following a dental procedure.
Dissection of a vessel is a process in which a tear leads to blood entering the wall of the artery under pressure and splitting its layers. This results in either acute narrowing of the vessel lumen leading to obstruction or stenosis or dilatation of the vessel wall at the site of weakening leading to formation of an aneurysm. If the tear is subintimal, the dissection leads to luminal narrowing and occlusion.
Vertebral artery dissection (VAD) resulting from trauma is an important cause of stroke in otherwise healthy people with no known stroke risk factors. The average annual incidence of VAD is 1.0–1.1 per 100 000.1 Dental procedures that involve prolonged neck posturing may cause VAD. Diagnosis is based on clinical and radiologic findings. In this article, we describe a patient presenting with VAD and posterior circulation stroke following a dental procedure.
A CASE STUDY
A 63-year-old, previously healthy man underwent a dental filling procedure during which his neck remained in an extended and rotated position for about 1.5 hours. Although the procedure was uneventful, that night he experienced the acute onset of diffuse, severe throbbing headache and pain on the left side of his neck associated with several bouts of vomiting. The symptoms were aggravated with neck turning to either side. About 5 hours later, the patient noted imbalance and incoordination while walking. The following morning, he attended the emergency department, where neurologic examination revealed a conscious, alert patient with gait ataxia and no other neurologic deficits. General physical examination and systemic examination were normal.
A computed tomography (CT) scan of the brain did not reveal any abnormality. However, CT angiography of the head and neck showed a long-segment thrombus in the vertebral artery reaching from its origin to the mid-V4 segment. The thrombus also extended into the proximal subclavian artery. The patient had no risk factors for an atherosclerotic vascular disease, e.g., hypertension, diabetes mellitus, coronary artery disease, dyslipidemia or smoking. There was no family history of dissections. In view of his neck pain, headache and the temporal relation of symptoms to the prolonged neck posturing during the dental procedure, a diagnosis of VAD leading to a posterior circulation ischemic stroke was made. His blood parameters—hemogram, lipid panel, thrombophilia profile, homocysteine and other biochemistry—were normal and electrocardiogram and echocardiogram were unremarkable.
The patient was started on continuous intravenous heparin using a standard protocol of the stroke unit. The following day, he developed increased headache, vomiting and left-side numbness and incoordination. Examination revealed normal cranial nerves, inability to perform left finger-to-nose and heel-to-shin tests, a reduction in sense of touch and joint position on the left side and reduced appreciation of pinprick on the right side. Magnetic resonance imaging of the brain revealed a left posterior inferior cerebellar artery territory infarction, appearing bright on a diffusion-weighted image. Magnetic resonance angiography (MRA) revealed an occluded left vertebral artery.
Seemingly trivial trauma, such as prolonged extension of the neck during dental procedures, may cause arterial dissections and ischemic strokes. A high degree of suspicion is necessary to ensure prompt diagnosis, especially in the setting of headache, neck pain and recurrent vomiting. A delay in diagnosis or in the institution of appropriate therapy in symptomatic patients could cause extensive ischemia due to embolism from the thrombus in the vessel wall or extension of the thrombus distally with a resultant potential catastrophe. With therapy, the prognosis for this condition is generally good.
Call The Baxter Law Firm. If you believe that you may have suffered a stroke or heart attack following a dental procedure contact George Baxter, Esq. simply call us (201) 254-0596 to speak with an experienced dental malpractice lawyer. Mr. Baxter has recovered from hundreds of thousands of dollars for clients in dental malpractice cases.