I read with interest the article by Brukner and colleagues1 on traumatic cricket-related fatalities in Australia, which describes two autopsy-confirmed deaths due to subarachnoid haemorrhage following vertebral artery dissection, with a further 11 deaths suspected to be secondary to this condition. Two recent articles described a total of 230 cases of carotid or vertebral artery dissection temporally related to 45 different sports or recreational activities.2,3 The majority of episodes of arterial dissection were related to non-contact sports, including jogging, walking, swimming, golf, basketball, tennis and scuba diving. The mean age of patients was 35 years. The mechanism of non-traumatic dissection is thought to relate to shearing stress on the arterial wall with sudden neck rotation. Thus arterial dissection in golfers affected the right side in 11 of 14 patients (79%), and involved the posterior circulation in 12 of 14 patients (86%).4 Controversy regarding the association between neck manipulation and arterial dissection persists, although a retrospective case–control study found an odds ratio of 12.8 for prior neck manual therapy in individuals aged 55 years or less presenting with craniocervical arterial dissection.5 Arterial dissection may also occur spontaneously, the risk being increased in the setting of systemic lupus erythematosus, other connective tissue disorders, migraine and in the postpartum period. It is important that health professionals recognise that arterial dissection may occur spontaneously or as a result of non-contact sports and activities, and that persons of any age presenting with symptoms suggestive of anterior or posterior circulation ischaemia require urgent review and neuroimaging.
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