Clinical Practice and Cases in Emergency Medicine

Introduction: Vertebral artery dissection is a rare but life-threatening complication of strangulation.  Symptoms are often nonspecific and may not manifest immediately, complicating diagnosis. If prior neck trauma is not elicited during assessment, clinicians may miss a mechanistic link to prompt vascular imaging, leaving patients at risk for irreversible outcomes, as illustrated in this case.

Case Report: A 24-year-old woman presented to a critical access emergency department (ED) with nonspecific neurological symptoms that had largely resolved upon arrival. Her only reported history was vague head and neck pain, which she attributed to stress after leaving an abusive relationship several weeks earlier.  Hours later, while still in the ED, the patient experienced abrupt neurological deterioration. She was transferred to a regional medical center, where magnetic resonance imaging eventually revealed vertebral artery dissection with basilar artery hypoperfusion and extensive pontine infarction. Collateral history obtained from family revealed a preceding strangulation event.  Police at the scene had documented neck injury, but the patient declined their offer of a medical assessment. By the time vertebral artery dissection was diagnosed, she had developed irreversible neurological damage leading to locked-in syndrome. She survived in this state for years before succumbing to complications of quadriplegia. The death was certified as a homicide due to inflicted blunt force neck injury.

Conclusion: This case underscores the importance of timely, skilled medical assessment after strangulation and highlights the need for targeted screening of patients with vague neurological symptoms or disclosure of intimate partner violence.