During head rotation, neck hyperextension and other provocative manoeuvres of the neck, the vertebral artery may be compressed at various sites along its course.1 A 63-year-old man with a history of type 2 diabetes, hypertension and ischemic heart disease presented with symptoms of slurred speech, unsteadiness and left-side weakness immediately after a 56-minute telephone conversation. Physical examination revealed left facial droop with mild weakness of the left arm and hand grip of 4/5. Electrocardiography showed sinus rhythm. CT of the head (Fig. 2) showed calcification of the right vertebral artery and a small right pontine infarct. Duplex Doppler ultrasonography showed small atherosclerotic plaques at the distal common carotid arteries. The echocardiogram was normal.
Fig. 2: CT of the head, showing calcification of the right vertebral artery (black arrow) and a right pontine infarct (white arrow).
Ischemia and infarction of the brain stem can occur if an abnormal posture of the neck is sustained for more than 10 minutes.2 These problems have been reported after chiropractic neck manipulation,3 protracted dental work, intubation, perimetry and x-ray positioning2 and have been described in “beauty parlour stroke syndrome.”4 Given the temporal relation between the prolonged telephone conversation and the stroke, and exclusion of other causes, this man's right pontine infarct was probably the result of compression of the ipsilateral vertebral artery during the phone call. He had kept his neck bent to the right side throughout the conversation, which caused compression of the already calcified right vertebral artery and resulted in stroke.
This case illustrates another situation in which a person may unconsciously keep the neck in an abnormal position that could cause compression or occlusion of the vertebral circulation. Anyone who talks on the telephone for prolonged periods, especially elderly people, should consider changing sides frequently or using a hands-free telephone to avoid sustained provocative neck positions.
Malvinder S. Parmar Medical Director, Medical Program Timmins and District Hospital Timmins, Ont.
References
- 1.Grossman RI, Davis KR. Positional occlusion of the vertebral artery: a rare cause of embolic stroke. Neuroradiology 1982;23:227-30. [DOI] [PubMed]
- 2.Fogelholm R, Karli P. “Iatrogenic” brainstem infarction: a complication of x-ray examination of the cervical spine and following posterior tamponation of the nose. Eur Neurol 1975;13:6-12. [DOI] [PubMed]
- 3.Krueger BR, Okazaki H. Vertebrobasilar distribution infarction following chiropractic cervical manipulation. Mayo Clin Proc 1980;55:322-32. [PubMed]
- 4.Weintraub MI. Beauty parlor stroke syndrome: report of five cases. JAMA 1993;269:2085-6. [DOI] [PubMed]