Returning To Exercise After Valsalva-induced Carotid Artery Dissection

HISTORY: An 18-year-old male suffered spontaneous left internal carotid artery (ICA) dissection during martial arts, complicated by left temporal lobe stroke and recurrent transient ischemic attacks; treated with angioplasty and stenting. He was diagnosed with vascular Ehlers-Danlos Syndrome with likely pathogenic COL3A1 mutation. Twelve months later, he presented to the emergency department for acute onset right-sided jaw pain, headache, and left-hand numbness after sneezing. He denied fever, visual disturbances, falls, or trauma within prior week. PHYSICAL EXAMINATION: HR 73 bpm, regular rhythm, symmetrical 2+ extremity pulses, BP 125/82 mmHg, temperature 98.2 °F. Alert and well-orientated; NIHSS score 0. DIFFERENTIAL DIAGNOSIS: ICA post-dissection headache, Carotid artery dissection, Cerebral ischemia, Meningitis TEST AND RESULTS: CT angiogram of the neck revealed right cervical ICA dissection with luminal narrowing but without occlusion. MRI brain was negative for acute infarct but demonstrated chronic left temporal lobe infarct. FINAL WORKING DIAGNOSIS: Right ICA dissection. TREATMENT AND OUTCOMES: The ICA dissection was managed with dual antiplatelet therapy, angiotensin receptor blocker, and mineralocorticoid receptor antagonist; surgical intervention was opted against via shared decision making (SDM). Three months post discharge, MR angiogram demonstrated near complete healing of right ICA dissection with restoration of near normal flow. After his first dissection, he was advised to limit strenuous exercise to prevent progression, causing weight loss, deconditioning, anxiety, and medical withdrawal from college. After his second dissection (via SDM), the patient completed 36 sessions of medically supervised cardiac rehabilitation (CR) without complication. At program completion, a typical CR session included ≥35 min of aerobic (HR ≤160 bpm, BP ≤170/62 mmHg, RPE ~13) or ≥ 45 min of isolation and compound resistance exercise (BP 94/62 to 160/60 mmHg). Six-minute walk distance increased 58% (417 to 658 m) and quality of life improved (Dartmouth COOP score, 21 to 15). The patient gained 11 kg, stopped PRN benzodiazepine, and re-enrolled in college. MR angiogram of the neck on CR completion confirmed normal cervical segment of the right ICA with no residual or recurrent dissection.