Interesting Medical Images; a 52-yr old man with neck and shoulder pain

A 52-yrs old man was admitted to the emergency room with shoulder and left arm cruciating pain after struggling with and being attacked by a person at home. He was suffering from hypertension for a few years. There was not any evidence of diabetes mellitus in his past medical record. No dizziness and syncope occurred. EKG, troponin and CPK-MB tests were within normal limits. The patient complained of the left arm pain when the arm was abducted and the hand was put behind the head. Although there were some pain triggering points over the shoulder and trapezius muscle along the posterior part of the second and third ribs and over the biceps tendon which were ameliorated with lidocaine and intratendon injection of corticosteroid by our pain specialist the dull pain in the shoulder area subsided by reducing the blood pressure with administering antihypertensive drugs and aspirin 40mg/day.

The patient was a chemical warfare victim and his respiratory system was sensitive to many drugs specially radiologic contrast media. Contrast enhanced CT or MRI images could not be requested. Plain chest lung CT-scan did not show aortic aneurysmal changes. MRA without contrast media enhancement with the aim of ruling out dissection or anurysmal changes in the vertebral arteries showed three stenotic areas along the first segment of the left vertebral artery while the right vertebral artery was intact. It was an incidental finding. Ultrasonographic study of carotid arteries showed no stenosis in the ateries. MRI of the neck spinal cord revealed discal hernia in C5-C6 region.

It is recommended that pathological changes in the vertebral arteries be kept in mind in hypertensive patients and in patients with neck pain.

Thanks to CT-scan and MRI department of Bazarganan Hospital, Tehran, Iran, specially to Mr. Etlaby; MRI technician.

Stenosis of V1 segment of the left vertebral artery (yellow arrows). Right vertebral artery is intact (white arrow).

Stenosis of V1 segment of the left vertebral artery (yellow arrows). Right vertebral artery is intact (white arrow).

MRI of spinal cord in the neck. The arrow shows the lesion in C5-C6 intervertebral disc.

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