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 Swedenbengt.firstname.lastname@example.org
Date of Submission: 02-Feb-2011
Code Number: ni11141
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.  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, , vertebral artery aneurysm,  carotid artery dissection,  whiplash injury,  odontoid fracture,  and vertebral artery dissection with vertebrobasilar ischemia or infarction.  It is believed that Terry Balsamo, the guitarist from the heavy metal band Evanescence, experienced a stroke from head banging.  In the young, the causes of ischemic stroke may be other than atherothrombosis and hypertension.  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. , 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. ,,, 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.
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