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Article in Press 159 Clinical Practice and Cases in Emergency Medicine
Kathryn Sulkowski, MD*
Georgina Grant, MD*
Thomas Brodie, MD†
Section Editor: R. Wilkerson, MD
Submission History: Submitted January 10, 2022; Revision received February 9, 2022; Accepted February 10, 2022
Electronically published April 6, 2022
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
DOI: 10.5811/cpcem.2022.2.56046
Introduction: Arterial dissection is well known as a potential cause of stroke in young patients.
Vertebral artery dissection occurs most commonly in the setting of minor trauma but has been seen in
cases of cervical manipulation. With advances in at-home therapeutic modalities for neck pain came
the advent of handheld massage guns. These massage guns have gained considerable popularity in
recent years, but their safety for use in the cervical region has not been well studied.
Case report: In this case report, we discuss a 27-year-old female who presented with headache, neck
pain, and dizziness who was found to have vertebral artery dissection after repetitive use of a handheld
massage gun.
Conclusion: In young patients presenting with headache, neck pain, and vague neurologic symptoms
it is important to consider vertebral artery dissection as a cause of symptoms as it can lead to serious
morbidity. When considering an inciting event such as minor trauma, it may also be important to assess
whether there has been use of a handheld massage gun. Although causality is dicult to establish,
with the increase in use of handheld massage guns we may nd more frequent association between
their use and vertebral artery dissection. [Clin Pract Cases Emerg Med. 2022;6(2):159-161.]
Keywords: vertebral artery dissection; handheld massage gun.
The reported incidence of vertebral artery dissection (VAD)
is estimated to be 2.6-3/100,000.1 Vertebral artery dissection is
a known cause of stroke in patients younger than 45 years of
age. Unfortunately, because its clinical features and symptoms
tend to be vague and/or nonspecic, diagnosis may not even be
considered. Upon close review of the literature, we found very
few cases reported of VAD secondary to neck massage and none
related to the use of a handheld massage gun. Given the increase
in popularity of at-home, handheld massage, the importance of
safety while using these devices is of the utmost importance. In
this report we describe a case of VAD in a young woman after the
use of a handheld massage gun. She was treated with aspirin and
discharged with no residual neurological decits.
University of Nevada, Las Vegas, Emergency Medicine Residency Program, Las
Vegas, Nevada
Mike O’Callaghan Federal Medical Center, Department of Emergency Medicine, Las
Vegas, Nevada
*
†
A 27-year-old female presented to the emergency
department (ED) with a two-week history of progressively
worsening dizziness. She described the dizziness as a
combination of vertiginous symptoms as well as disequilibrium.
Over the prior four days she noticed a headache and neck pain.
She denied any recent trauma but had recently begun using a
handheld massage gun on her neck over the preceding three
weeks. The patient denied any past medical history and used no
medications regularly, except for occasional over-the- counter
ibuprofen, which did not alleviate her symptoms. She had a
family history signicant for migraine headaches. She endorsed
occasional alcohol and daily tobacco use but denied any
illicit substance use. She denied fever, diplopia, blurry vision,
Clinical Practice and Cases in Emergency Medicine 160 Volume 6, no. 2: May 2022
Vertebral Artery Dissection After Use of Handheld Massage Gun Sulkowski et al.
CPC-EM Capsule
What do we already know about this clinical
entity?
Arterial dissection is a potential cause of stroke
in young patients. Vertebral artery dissection
(VAD) usually occurs with minor trauma but has
been seen with cervical manipulation.
What makes this presentation of disease
reportable?
We could nd no prior reported cases of VAD
associated with use of a handheld massage gun.
What is the major learning point?
In young patients presenting with headache,
neck pain, and vague neurologic symptoms, it is
important to consider VAD as a cause of symptoms.
How might this improve emergency medicine
practice?
Given the rising popularity of handheld massage
guns, emergencv physicians should be aware of
the evaluation and management of VAD.
photophobia, phonophobia, or vomiting but endorsed mild
associated nausea.
Physical examination revealed a young female resting
comfortably. Vital signs were all within normal limits. On
examination, she demonstrated full range of motion of the
neck without pain. She had no audible carotid bruit, no notable
swelling, ecchymosis, or midline cervical spinal tenderness to
palpation. On a detailed neurologic examination, the patient
had a Glasgow Coma Scale of 15 and was alert and oriented to
person, place, and time. She had a normal cranial nerve exam,
full strength in the upper and lower extremities, normal reexes,
and no ataxia. She had a negative Romberg test and normal,
rapid alternating movement testing and nger-to-nose testing.
Initial diagnostic evaluation demonstrated a normal
complete blood count. Comprehensive metabolic panel
demonstrated no abnormalities, and all electrolytes were
within normal limits. Beta human chorionic gonadotropin
was undetectable. She was administered 25 milligrams (mg)
meclizine orally, 1000 mg acetaminophen intravenously, 10
mg prochlorperazine intravenously, and a one-liter bolus of
lactated Ringer’s solution for her symptoms.
Because the patient had prolonged symptoms and endorsed
a history of massage gun use, both a computed tomography
(CT) without contrast of the head and a CT angiogram (CTA)
with intravenous contrast of the head and neck were obtained.
The CT of the head without contrast demonstrated no notable
abnormalities. The CTA of the head and neck revealed a long
segment of irregular stenosis of the right vertebral artery
extending from the second to the fth cervical vertebra, most
compatible with a vertebral artery dissection (VAD).
The patient was administered 324 mg aspirin orally and
was transferred and admitted overnight to a tertiary accepting
center with vascular surgery capability. Vascular surgery was
consulted and recommended non-operative management
and suggested consultation with interventional radiology.
Interventional radiology was consulted and recommended
continuing aspirin, and admission for observation with
neurological checks every four hours. The patient was
neurologically stable during the admission and was discharged
with prescriptions for 324 mg aspirin orally daily as well as 25
mg meclizine orally as needed. She was given follow-up with
neuro-interventional radiology in two weeks as an outpatient.
The patient did not re-present to our hospital for follow-up.
Dissection of the vertebral arteries related to handheld
massage devices is not well documented, and we found no
case reports in the literature of handheld massage devices
potentially leading to VAD. When considering the anatomy of
the extracranial vertebral artery, it is susceptible to dissection
in three segments: its origin at the subclavian artery; as it
traverses the intervertebral foramen; or at the site of entry into
the cranium.2 Neurologic sequelae of VAD vary widely based
on the location of the dissection and the amount of ischemic
damage to the posterior circulation territory (cerebellum,
brainstem, and posterior cerebrum). Early identication of
VAD is crucial to improving outcomes; thus, it is imperative
to maintain a high index of suspicion.
Headache, neck pain, and dizziness are very common
chief complaints that are evaluated in the ED and outpatient
clinics. The clinician must make a distinction between patients
who have benign conditions and patients with life-threatening
conditions. Much of this determination rests upon clinical
suspicion based on a patient’s history as well as the use of
imaging modalities.
Handheld massage guns have risen in popularity and
become more accessible to the everyday user. There are many
new handheld massage guns on the market, ranging in price
from $50 to over $1000 for higher end models.4 Most of
these devices rely on percussive motion (low amplitude, high
frequency) to relieve tension in muscles. On many models,
pulses per minute can be adjusted. While most user instruction
manuals caution against holding the device in one place or
using the device on the neck, they do advertise its use on the
posterior neck, trapezius, and shoulder muscles.
Unfortunately, despite the increase of popularity, proper
use is not clearly demonstrated. In website image searches
for these devices, many ads show models using the device
around the upper and lateral neck as well as on more anterior
Volume 6, no. 2: May 2022 161 Clinical Practice and Cases in Emergency Medicine
Sulkowski et al. Vertebral Artery Dissection After Use of Handheld Massage Gun
muscle tissues. Users with either no background in medicine
or knowledge of the underlying anatomy may not realize the
signicance of the vasculature beneath these tissues and how
they may be damaged with the use of handheld massage guns.
While the patient in our case did not suer any long-lasting
decits, this may not always be the case. If handheld massage
guns pose a risk when used in improper locations, consumers
must be made aware of these potential consequences.
Management options for VAD are varied and based on
numerous factors such as presentation, time of onset, and
imaging results. Options include antiplatelet or anticoagulation
medications, endovascular management, or vascular surgery.3 In
patients with severe decits, reperfusion therapy is an option to
more immediately restore blood ow to areas of the brain that
can be salvaged. These options include alteplase, tenecteplase, or
mechanical thrombectomy. These therapies are not without risk
as they have the potential to increase the size of the intramural
hematoma. These therapeutic modalities have been studied much
more thoroughly in cases of cervical artery dissections with
minimal literature to support their use in cases of VAD.5,6,7
Anticoagulation or antiplatelet therapy is more widely
used for VAD. 8,9 Medically stable patients, like our patient,
can be started on low molecular weight heparin, direct oral
anticoagulants or antiplatelet therapy based on the ABCD2
score, similar to the risk stratication performed on other
transient ischemic attack/stroke patients. Those deemed
low risk by the ABCD2 score are started on 324 mg of
aspirin daily, whereas high-risk patients are placed on dual
antiplatelet therapy with both aspirin and clopidogrel.10 Most
cases of nontraumatic VAD are shown to heal within the rst
few months of the inciting event. In one study of patients with
VAD, 62% of cases showed complete healing of the dissection
at six months.11
We report the case of a 27-year-old female who presented
with two weeks of worsening dizziness and four days
of neck pain who had recently used a handheld massage
device and was subsequently found to have vertebral artery
dissection. Although rare, VAD is a known cause of stroke,
particularly in young patients. In this patient population with
presenting symptoms of dizziness, headache, and/or neck
pain it is important to consider VAD as early diagnosis is
imperative in improving outcomes. It is also crucial to take a
complete social history to determine whether there were any
provoking factors, such as the use of a handheld massage
device. Treatment with antiplatelet or anticoagulation may be
appropriate in the correct patient population.
With the rise in popularity of handheld massage guns, more
research must be performed in evaluating their safety. Although
causality is dicult to establish, we may nd an increase in
incidence of VAD as popularity of these devices continues to rise.
In some circumstances we may ultimately discover that the use of
handheld massage guns may be implicated as a cause of VAD.
The Institutional Review Board approval has been documented
and led for publication of this case report.
Address for Correspondence: Kathryn Sulkowski, MD, University
of Nevada, Las Vegas, Emergency Medicine Residency Program,
901 Rancho Lane, STE 135, Las Vegas, NV 89106. Email:
kathryn.sulkowski@unlv.edu.
Conicts of Interest: By the CPC-EM article submission
agreement, all authors are required to disclose all aliations,
funding sources and nancial or management relationships that
could be perceived as potential sources of bias. The authors
disclosed none.
Copyright: © 2022 Sulkowski. This is an open access article
distributed in accordance with the terms of the Creative Commons
Attribution (CC BY 4.0) License. See: http://creativecommons.org/
licenses/by/4.0/
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