Introduction

Present day sees obesity manifest itself as an immense global health challenge. Accordingly, surgical treatment for morbid obesity has gained growing popularity worldwide. Over the last years, sleeve gastrectomy has captured remarkable surgical interest mainly because this technique does not require a gastrointestinal anastomosis or intestinal bypass. The most common complications of sleeve gastrectomy are bleeding, staple line leak, early and late stenosis, GERD, incisional hernia, wound infection, and even nutrient deficiencies [1]. Vomiting, being one of the more frequent issues following laparoscopic sleeve gastrectomy (LSG), is mostly self-limiting if not due to technical problems. At times, this can lead to dangerous and unexpected complications. The incidence of postoperative nausea and vomiting following bariatric surgeries, who did not receive antiemetic prophylaxis, is high almost 70–80% [2].

Vertebral artery dissection is a rare condition that may follow mild neck trauma. The annual incidence of vertebral artery dissection is estimated at 1 to 1.5 per 100,000 and occurs in 0.01–1% of patients sustaining head and neck trauma. The typical mechanism for vertebral artery dissection involves hyperextension or rotation of the neck [3]. The most common ophthalmologic findings include diplopia, nystagmus, blurred vision, and visual field defect [4].

Here, we present a 33-year-old woman with history of LSG, who was admitted due to nausea and vomiting, and neurologic symptoms that occurred later. Following investigations, a rare etiology, vertebral artery dissection, was confirmed.

Case Presentation

A 33-year-old woman with body mass index (BMI) of 43 kg/m2 with a history of LSG 20 days prior arrived at the clinic with fatigue, nausea, and vomiting. These symptoms began a few days after surgery. She denied having had any fever, abdominal pain, or other associated symptoms. At admission, the patient’s vital signs were stable (T, 36.8; PR 100/min; and BP, 100/56 mmHg). She was dehydrated and looked ill. In physical examination, the abdomen was soft, without tenderness. Intravenous (IV) fluids for resuscitation, proton pump inhibitor (PPI), and antiemetic agents were administered. Nutritional complements consisting vitamins, especially thiamine (B1), for preventing Wernicke-Korsakoff syndrome were administered. Laboratory investigation revealed a normal complete blood count, electrolyte and renal function test imbalance such as hypernatremia (Na 171 mEq/dl, K 4.5 mEq/lit), and pre-renal azotemia (BUN 81 mg/dl, Cr 2.6 mg/dl). Additionally, raised hepatic transaminases were found (AST 297 IU/lit, ALT 278 IU/lit, ALKP 209 IU/lit); amylase was 55 IU/ml.

After satisfying fluid resuscitation, an esophagogastroduodenoscopy (EGD) and an upper gastrointestinal fluoroscopy were performed showing normal gastric tube patency without any stricture or twisting (Fig. 1). After a while, the patient’s symptoms improved; nausea and vomiting almost diminished with increasing tolerance for liquid and soft food regimen. Her electrolyte levels slowly balanced and hepatic transaminases decreased. Four days after EGD, she suddenly developed a new onset vertigo, diplopia, blurred vision, and was unable to walk properly. Nausea and vomiting worsened. Hence, a neurology consult was requested. The neurological consult revealed a normal mental state and cranial nerve examinations, but she had a horizontal right-beating nystagmus. Motor and sensory examination and deep tendon reflexes were also normal. Her right side extremities were slightly dys-metric and her gait was ataxic with a preponderance to fall to the right. A brain MRI (magnetic resonance imaging) revealed a small lesion in the right superior cerebellar peduncle on DWI sequence with restricted diffusion in favor of an acute ischemic infarction (Fig. 2a and b).

Fig. 1
figure 1

Normal gastric tube patency in fluoroscopy

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Fig. 2
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Lesion in the right superior cerebellar peduncle in brain MRI which is hyper signal in DWI (diffusion-weighted imaging) (a) and hyposignal in ADC (apparent diffusion coefficient) map (b). Cervical MRA showing a narrow and irregular left vertebral artery (c)

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An extensive workup to find the cause of the infarction was performed: cardiac evaluation and Holter monitoring for arrhythmia were all normal. Blood tests for vasculitis and hypercoagulative state including antithrombin level, homocysteine, factor V Leiden, antiphospholipid antibody, and anti-cardiolipin were all also normal. The brain MRA (magnetic resonance angiography) did not elicit any pathology or vascular malformation, but cervical MRA revealed a narrowed irregular left vertebral artery (Fig. 2c). A cervical Doppler study revealed a pre-stenotic flow in the left vertebral artery in favor of left vertebral artery dissection. Thiamine level, for Wernicke-Korsakoff syndrome evaluation, was also checked and was in normal range.

A diagnosis of acute ischemic stroke was thus made. Since all other evaluations were irrelevant, we concluded that a vertebral artery dissection was the cause of stroke. Dual antiplatelet therapy was administered (aspirin 80 mg and clopidogrel 75 mg daily). She was discharged after partial recovery in neurological and gastrointestinal symptoms. In 3-month follow-up, she experienced normal food regimen tolerance and marked improvement in ataxia and gait.

Discussion

We presented a young lady with acute ischemic stroke 25 days post LSG due to vertebral artery dissection. LSG, due to its technical simplicity and safety, is the most popular bariatric surgery worldwide. With an increase in the number of operations, complications have become more prevalent [1]. One of the most common symptoms occurring in early postoperative time following sleeve gastrectomy is nausea and vomiting, which is reported up to 70–80% after bariatric surgeries [2]. Management of these symptoms includes fluid resuscitation and electrolyte imbalance correction. The investigation should be done by EGD or upper GI contrast study [5], which did not demonstrate any pathologic evidences in our patient. In this case, hypernatremia and azotemia were corrected in standard manner. Wernicke-Korsakov syndrome is one of the differential diagnoses in post bariatric patients with neurological symptoms following vomiting and insufficient complement compliance [6]. Because of neurological symptoms that occurred few days after endoscopy, we also checked her vitamin B1 level which was in normal range. Cervico-cephalic arterial dissection is the cause of a quarter of strokes under the age of 45 [7]. A small intimal tear in the vessel wall results in the formation of a sub-intimal false lumen. The mechanism of a stroke in arterial dissection is more often thromboembolic rather than hemodynamic [8], and therefore, a left vertebral artery dissection, for instance, can result in an embolic infarct in the left or right side of the cerebellum or brainstem. We believe that in our case, a left vertebral artery dissection resulted in a thromboembolic infarction of the right superior cerebellar peduncle.

In this case, dissection was implied based on cervical MRA and the Doppler study showing an irregular narrowing in the left vertebral artery with pre-stenotic flow pattern. Cervical gadolinium-enhanced fat-suppressed T1 MRI or DSA angiography was not performed in our case.

Iatrogenic causes such as endotracheal intubation, positioning of neck during anesthesia, and EGD procedure may have led to stretching and injury of the left vertebral artery dissection in our patient. However, we did not find any unintended maneuver or difficulties during these procedures.

Trauma is a major etiologic cause of cervico-cephalic arterial dissection. Even minor trauma due to regular sport activities, rigorous sneezing, coughing, and vomiting has been implied [9, 10]. We believe that recurrent severe vomiting in our case resulted in vertebral artery dissection. However, we should also consider hypovolemia as an attributing factor, since it results in a hypercoagulative state.

As far as we know, this is the first case of vertebral artery dissection following bariatric surgery reported in the literature.

Conclusion

Neurologic symptoms after LSG can occur occasionally and should be noticed and evaluated. Despite being a rare complication; vertebral artery dissection needs to be kept in mind in the confrontation of neurological symptoms following LSG, especially in patients who suffer from severe recurring vomiting after surgery.