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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 59, Num. 3, 2011, pp. 478-479

Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 478-479

Letter to Editor

Head banging associated with basilar artery thrombosis

Bengt Edvardsson, Staffan Persson

Department of Neurology, Faculty of Medicine, Lund University Hospital, Lund, Sweden

Correspondence Address: Bengt Edvardsson Department of Neurology, Faculty of Medicine, Lund University Hospital, Lund

Date of Submission: 02-Feb-2011
Date of Decision: 02-Feb-2011
Date of Acceptance: 04-Feb-2011

Code Number: ni11141

PMID: 21743194

DOI: 10.4103/0028-3886.82756


Head banging is a type of dance which involves violently shaking head in time with music, most commonly heavy metal music. Head banging can be up-down, circular swing, full body, or side-to-side. It is considered that head banging to loud music, while "making you more metal," has associated risks other than acquired hearing loss. Several case reports have indicated the inherent risk in this activity, especially of head and neck injury. [1] We describe a patient with a history of intensive head banging and basilar artery thrombosis (BAT).

A 20-year-old man presented with neck and head pain and vertigo of three weeks duration. His medical history was otherwise normal including drug exposure or abuse. He was a musician and had a history of intensive head banging. He had sought medical help for these symptoms at other facility, but was not worked up to establish the diagnosis. The symptoms progressed in severity and he had intermittent loss of consciousness. On physical examination, vitals were normal and neurological examination revealed left hemiplegia with dysarthria. Computer tomography of brain, electrocardiogram, electroencephalogram, complete blood picture, and blood biochemistry were essentially normal. Magnetic resonance imaging including angiography could not be performed as he was very anxious. Possible diagnosis of BAT was suspected and he underwent cerebral digital subtraction angiography under general anesthesia, which revealed BAT [Figure - 1]. No underlying dissection or vascular malformation could be detected. He was treated with intra-arterial fibrinolytic agents. However, the outcome was complicated by a locked-in state and no obvious improvement has been observed during the follow-up.

The neurological complications described in association with intensive head banging include subdural hematoma, [2],[3] vertebral artery aneurysm, [4] carotid artery dissection, [5] whiplash injury, [6] odontoid fracture, [7] and vertebral artery dissection with vertebrobasilar ischemia or infarction. [8] It is believed that Terry Balsamo, the guitarist from the heavy metal band Evanescence, experienced a stroke from head banging. [1] In the young, the causes of ischemic stroke may be other than atherothrombosis and hypertension. [9] A high index of suspicion of vascular injury in young persons presenting with persistent unilateral head or neck pain even after a minor trauma should be maintained. This index of suspicion should be even higher in patients with posterior circulation symptoms with antecedent trauma. Examples of trivial blunt trauma to the head and neck resulting in vertebral artery dissection include chiropractic manipulation, tennis, seat belt use, yoga, and head banging. [8],[10] Literature survey did not reveal incidence of BAT associated with head banging. Vertebrobasilar ischemia or infarction as a result of extremes of cervical motion is probably due to the fact that the vertebral arteries are fixed in the transverse foramina, rendering them susceptible to occlusion or shearing from extremes of neck motion. Rotation occurs first at the atlantoaxial joint before any rotation occurs in the cervical spine, leading to stretching and compression of the vertebral artery. Occlusion and spasm of the artery has been documented. An intimal tear can occur with formation of an intraluminal clot, which may result in embolization in the posterior circulation. [4],[9],[10],[11] Probably this might have been the mechanism of ischemic stroke in our patient. It remains unclear whether head banging and BAT in this single case is just coincidental or causally related. However, the temporal relationship between intensive head banging and the posterior circulation stroke is striking, suggesting a possible causal relation between the two and also no other risk factor could be found. Unfortunately, in our patient, the therapeutic intervention had resulted in significant neurological disability.


1.Patton D, McIntosh A. Head and neck injury risks in heavy metal: head bangers stuck between rock and a hard bass. BMJ 2008;337:a2825.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Neyaz Z, Kandpal H, Sharma R, Kale S. 'Head banging' during rock show causing subdural hematoma. Neurol India 2006;54:319-20.  Back to cited text no. 2  [PUBMED]  Medknow Journal
3.De Cauwer H, Van Giel R, Mortelmans L, van den Hauwe L. An uncommon cause of headache after head banging at a party. Eur J Emerg Med 2009;16:212-3.   Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Egnor MR, Page LK, David C. Vertebral artery aneurysm-a unique hazard of head banging by heavy metal rockers. Case report. Pediatr Neurosurg 1991-1992;17:135-8.  Back to cited text no. 4    
5.Jackson MA, Hughes RC, Ward SP, McInnes EG. "Head banging" and carotid dissection. Br Med J (Clin Res Ed) 1983;287:1262.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Kassirer MR, Manon N. Head banger's whiplash. Clin J Pain 1993;9:138-41.  Back to cited text no. 6  [PUBMED]  
7.Zijlstra WP, van Raay JJ. A 65-year-old patient with an odontoid fracture caused by 'head banging'. Ned Tijdschr Geneeskd 2008;152:1743-5.   Back to cited text no. 7  [PUBMED]  
8.Malek AM, Halbach VV, Phatouros CC, Meyers PM, Dowd CF, Higashida RT. Endovascular treatment of a ruptured intracranial dissecting vertebral aneurysm in a kickboxer. J Trauma 2000;48:143-5.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Hilton-Jones D, Warlow CP. Non-penetrating arterial trauma and cerebral infarction in the young. Lancet 1985;1:1435-8.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Showalter W, Esekogwu V, Newton KI, Henderson SO. Vertebral artery dissection. Acad Emerg Med 1997;4:991-5.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Bakay L, Sweet WH. Intra-arterial pressures in the neck and brain; late changes after carotid closure, acute measurements after vertebral closure. J Neurosurg 1953;10:353-9.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]

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