Dr. Fox is an emergency medicine resident at Wexner Medical Center at the Ohio State University and the Ohio State University Medical Center East. Dr. King is an assistant professor-clinical at Wexner Medical Center at the Ohio State University and the Ohio State University Medical Center East.
CrossFit has become a workout phenomenon with more than 5,500 gyms and millions of staunch followers. Developed by Greg Glassman, CrossFit defines itself as “that which optimizes fitness, constantly varied functional movements performed at relatively high intensity.” The craze has been embraced by fitness enthusiasts and weekend warriors alike.
These intense workouts can be dangerous for those with less experience who do not have trainers to help ease them into the routine. A 2005 New York Times article, “Getting Fit, Even If It Kills You,” criticized CrossFit for placing emphasis on speed and weight hoisted instead of technique. (Dec. 22, 2005; http://nyti.ms/1mOt86Z.) The article later quoted Wayne Winnick, a sports medicine specialist, as saying, “There's no way inexperienced people doing this are not going to hurt themselves.” Mr. Glassman backs up the risk by stating, “It can kill you. … I've always been completely honest about that.”
Our patient was a 33-year-old man with a past medical history of migraine headaches and attention deficit hyperactivity disorder, who presented with a left temporal headache and neck tightness for one month. The headache began suddenly during an intense CrossFit regimen. He was doing heavy lifting at the time of acute onset, and was exerting himself more than his normal limits. He developed severe, throbbing pain in the left side of his head that was accompanied by neck tightness, which was different from his migraines in severity and character. He saw his primary care physician, who prescribed him a medication for migraines, but the drug proved ineffective. The headache was constant and intense for the entire month before his emergency department visit, and he only slightly responded to ibuprofen and acetaminophen. He returned to his primary physician a week before his ED visit, and his physician performed a CT head scan that was negative. Given the persistence of pain, he presented for further evaluation. The patient denied any associated neurologic sequelae including paresthesias, weakness, vision changes, and tinnitus.
Vital signs revealed tachycardia at a rate of 112 bpm, but his other vital signs were normal. His pupils were also equal, round, and reactive to light, and the extraocular muscles were intact. Cranial nerve examination involving nerves II-XII was normal. Strength and sensory testing in the upper and lower extremities was normal and symmetric. Cerebellar testing also was entirely normal. The patient exhibited a normal, brisk gait. Laboratory testing showed a normal CBC, PT/INR, and PTT. Given the persistence of his symptoms and the negative outpatient head CT, a brain and neck MRI/MRA was ordered to delineate the cause of his headache. He received intravenous prochlorperazine and diphenhydramine, which lessened his symptoms. The neck MRA revealed dissection of the distal left cervical internal carotid artery as it entered the skull base with an associated 50 percent stenosis.
The patient was started on a heparin drip, and the EP consulted a neurologist, who recommended that aspirin also be administered. The patient was admitted to the neurology service, where the heparin was discontinued. He was later discharged on Plavix and Lipitor, and given clear instructions to refrain from strenuous exercise, heavy lifting, and golf. The neurologists determined that long-term anticoagulation was not necessary, and no procedure was performed during his inpatient admission. Coagulation studies were also negative. The patient remains well with no headache or neurologic sequelae.
Our case was difficult because the patient had a known history of migraines, which could have initially explained his headache. If advanced imaging had not been pursued, a correct diagnosis was unlikely, and the patient would have been at risk for a catastrophic outcome.
Carotid dissections occur when an arterial wall loses its structural integrity, allowing blood to flow and collect between layers, usually in the subintimal plane. (Neurology 2000;54:442.) Many triggers are associated as etiologies for dissection, such as minor trauma and intense physical activities. The high amount of stress placed on the body by CrossFit combined with inexperience puts lifters at risk for a carotid artery dissection.
Headache and neck pain are the most common symptoms for carotid artery dissection, occurring in 80 percent of patients. (Neurology 2000;54:442.) More than the 56 percent of patients present with TIA symptoms and another 25 percent present with Horner's syndrome, both of which would lead a practitioner to consider vascular etiologies.
Spontaneous carotid dissection accounts for 20 percent of ischemic strokes in young adults, occurring in approximately 2.6 per 100,000. (Neurology 2006;67:1809.) The diagnosis of our patient was clinched by the MRA of the head and neck. The pathognomonic sign to look for is the crescent sign of intramural hematoma, which forms because of an eccentric rim of hyperintensity surrounding a hypointense arterial lumen. (See Figures 1 and 2.)
The crescent sign is typically found on MRI T1-weighted sequences, but can be seen on MRI diffusion-weighted imaging or CT angiography. (J Neurol Sci 2007;253:81.) A 2009 systematic review showed the diagnostic sensitivity and specificity of MRI, MRA, and CT-angio to be similar in carotid artery dissection. (AJR Am J Roentgenol 2009;193:1167.) Carotid artery duplex Dopplers are a quick and cheaper bedside tool for diagnosing dissection, but sensitivity is only 70 percent in patients with a headache and no signs of ischemia. (Front Neurol Neurosci 2006;21:70.)
Our patient was stable for a month, but he could have had a devastating outcome. The emergency provider must always remember that intense physical exertion is a risk factor for carotid artery dissection and vascular headache, and that a head CT for a persistent headache will miss pathology in the neck, which could reveal the etiology. Consider obtaining imaging of the neck to rule out carotid artery dissection for patients who recently had an intense CrossFit workout presenting with a headache, neckache, or neurologic symptoms.