Red flags for extracranial vertebral artery dissections in patients with neck pain: a scoping review

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OBJECTIVES: Neck pain is common and generally benign, but in rare cases it may be the early symptom of vertebral artery dissection (VAD). To date, no published secondary analysis addressing red flags for VADs in patients whose primary complaint is neck pain, nor any describing the typical clinical presentation, demographic characteristics, and common risk factors of VAD, has been published. Therefore, this scoping review addresses that gap by systematically mapping available evidence on red flags, predisposing risk factors, clinical features at presentation, and demographic profiles in patients presenting primarily with neck pain due to extracranial vertebral artery dissection. METHODS: A systematic search was conducted in MEDLINE, Embase, Web of Science, and CINAHL. Primary studies on adults with extracranial VAD and neck pain were included. Two authors independently selected studies and extracted data on clinical predictors. RESULTS: Forty-six studies (38 case reports, 8 case series) involving 58 patients were included. Most patients (63.8%) were female, with a mean age of 36.8 years. Neck pain was typically unilateral, severe, and poorly responsive to analgesics, often radiating to the head, upper limb, or shoulder; in half of the cases no identifiable cause of onset could be determined, while trauma or sudden neck movements accounted for another third. Risk factors were inconsistently reported, with current smoking and hypertension the most commonly documented. Neurological symptoms were present in two-thirds of cases, most frequently upper limb weakness and dizziness, while systemic symptoms (mainly nausea and vomiting) occurred in 24.1%. Physical examination findings were also inconsistently reported: motor deficits, sensory loss, and reflex abnormalities were each documented in roughly 40-47% of cases, and cranial nerve examination was described in only 25.9% of cases and was unremarkable in most of these. CONCLUSION: Symptoms and demographic features in extracranial VAD cases with neck pain are highly variable. Due to limited diagnostic accuracy data and inconsistent reporting, the clinical utility of red flags remains uncertain. Until more robust evidence becomes available, clinicians should adhere to expert recommendations for screening for VAD while maintaining a high level of vigilance. Further large-scale observational studies are needed to assess the diagnostic value of red flags in this context.

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